Evergreen Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rome, Georgia.
- Location
- 139 Moran Lake Road, Ne, Rome, Georgia 30161
- CMS Provider Number
- 115720
- Inspections on file
- 19
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Evergreen Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that several facility areas, including the clean linen room, overflow linen room, biohazard room, and medication room, were not maintained in a clean, orderly, or sanitary manner. Observations included clutter, debris, dirty floors, improperly stored supplies, and unsanitary conditions in refrigerators and laundry areas. The Housekeeping Director confirmed the poor condition of the clean linen room.
Surveyors found that the facility failed to maintain a clean, safe, and homelike environment, with observations of soiled and cluttered hallways, resident rooms, shower rooms, and the dining area. Multiple mobility chairs had torn upholstery, and resident equipment and furniture were dirty or in disrepair. Housekeeping practices did not ensure adequate cleaning, as evidenced by dirty mop water and persistent debris in resident and common areas.
Expired insulin pens and vials were found on two medication carts, with some lacking proper labeling and others past their expiration dates. Medication room refrigerators were left unlocked, and narcotic lock boxes containing lorazepam were not affixed to shelving as required. Additionally, one refrigerator was found dirty. LPNs and the ADON confirmed these deficiencies and acknowledged that storage and labeling practices did not meet facility policy.
A resident with severe cognitive impairment and a need for assistance with personal hygiene was observed to have long, jagged, and dirty fingernails over multiple days, despite documentation indicating care was provided and no recorded refusals. The care plan addressed general refusals but did not specifically address nail care, leading to inadequate hygiene for the resident.
A resident with severe cognitive impairment and a history of wandering eloped from the facility when an LPN opened a secured door for a recreational therapist, who then held the door open, allowing the resident to exit unsupervised. The therapist was unaware the individual was a resident, and staff did not alert him to prevent the exit. The resident was later found off facility property and returned without injury. The incident was captured on video, confirming lapses in supervision and monitoring.
A resident with mental health diagnoses was not referred for a required PASARR Level II screening due to a communication breakdown among staff. The facility's policy mandates coordination with the PASARR program, but the Social Service Director was not informed of the resident's schizoaffective disorder diagnosis, which should have prompted the screening. This oversight could result in the resident not receiving necessary specialized services.
The facility failed to follow care plans for residents receiving oxygen therapy, administering incorrect oxygen rates and neglecting to clean oxygen concentrators as required. Observations and staff interviews confirmed these deficiencies, with discrepancies in medical records and unclean equipment noted. The care plans included specific interventions that were not consistently adhered to, leading to these issues.
The facility failed to maintain respiratory equipment and administer oxygen as per physician orders for several residents. Observations revealed unclean oxygen concentrators and incorrect oxygen flow rates, with staff acknowledging these issues. Residents with severe cognitive impairment and chronic conditions were affected, highlighting lapses in equipment maintenance and adherence to medical orders.
Failure to Maintain Sanitary and Orderly Environment in Multiple Facility Areas
Penalty
Summary
Surveyors observed multiple areas of the facility that were not maintained in a clean, orderly, or sanitary manner. At the nurse's station near the South Hall shower room, empty cardboard boxes, a plastic cup, and scattered debris including a cotton ball and paper were found on the floor. Between the supplement room and the locked medication room, opened and unopened boxes of nutritional supplements were stacked on the floor. Inside the medication room, items were cluttered on the counter, a medication box was overfilled, and debris and crumbs were present on the floor and under cabinets. The nourishment room refrigerator was in disarray, with sticky substances and a need for cleaning noted inside both the refrigerator and freezer. In the Biohazard Room, a hopper contained standing dark gray water and had a black substance around the rim, and was not secured to the structure. Trash, debris, and an accumulation of dirt and grime were present on the floor and baseboards. Chemicals, sharps containers, and biohazard bags were stored on the floor, and the entire floor had a buildup of dark grime. An attached overflow laundry room had laundry on the floor, dirt and grime buildup, dead bugs, cobwebs, and light coming in around the exit door. The clean laundry room also had laundry on the floor, some with brown stains, plastic bags of laundry, IV poles and other equipment stored on the floor, and a brownish buildup of grime. The Housekeeping Director confirmed the condition of the clean linen room and accepted responsibility during an interview.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, comfortable, and homelike environment as required by policy. Observations included soiled and debris-laden areas in both the North and South hallways, resident rooms, shower rooms, and the main dining room. Specific findings included dirty blinds, windowsills with cobwebs and dead insects, soiled stop sign banners on resident room doors, and missing floor tiles with debris in the shower room. The shower room was also cluttered with boxes and storage units, and bathtubs contained debris and trash. Ceiling tiles above the nurse's station were stained and discolored, with one tile showing a large area of black substance. The dining room had scattered debris, food splatters on tables and walls, dirty blinds, and chairs with accumulated grime and dust. In resident rooms, several deficiencies were noted. One resident's wheelchair had a torn cushion with exposed foam and accumulated dirt and food particles on the wheel spokes and bed frame. The bedside table contained an empty pickle jar, a can of squirt cheese without a lid, and crumbs, while the drawers were heavily soiled with food and spillage. Another resident's overbed table had open snack items and soda bottles, with crumbs and debris around and under the bed. A third resident's bed control had exposed wires and was nonfunctional, and a urinal three-fourths full of urine was left on the bedside table. The overbed table was sticky with dried brown substances, and the floor had a buildup of dirt, grime, and food debris. Additional observations included soiled banners on room doors and a plastic bag left at the base of a hallway door. Resident equipment was also found in poor condition. Multiple mobility chairs, including Broda and geri chairs, had torn vinyl armrests with exposed foam, and debris was observed in the seat of one chair. The maintenance director confirmed responsibility for repairs, and the night shift was reportedly responsible for cleaning wheelchairs. Housekeeping practices were questioned, as mop water was observed to be dirty, and the frequency of changing mop heads and water did not align with observed conditions. Deep cleaning schedules and checklists were in place, but actual cleaning did not meet the standards outlined, as evidenced by the persistent dirt and debris in resident rooms and common areas.
Expired Medications and Improper Storage of Controlled Substances
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as evidenced by the presence of expired insulin pens and vials on two of four medication carts reviewed. Observations revealed that some insulin pens were missing resident names, open dates, and expiration dates, and some vials were past their expiration dates but remained in use. Additionally, some insulin vials were not labeled with the date they were opened, and unopened vials that required refrigeration were not stored as directed. Staff interviews confirmed that these insulins were expired and should not have been used, and that labeling and storage practices did not align with facility policy. Further deficiencies were identified in the medication rooms, where both the North Hall and South Hall medication room refrigerators were found unlocked, and the narcotic lock boxes inside were not affixed to the shelving as required. The narcotic lock boxes contained multiple vials of lorazepam, a Schedule IV controlled substance. The South Hall medication room refrigerator was also noted to be dirty, with debris and a yellowish sticky substance present. Staff confirmed these findings and acknowledged that the refrigerators should have been locked and the narcotic boxes properly secured.
Failure to Provide Nail Care for Cognitively Impaired Resident
Penalty
Summary
Staff failed to provide adequate nail care for a resident who was severely cognitively impaired and required partial to moderate assistance with personal hygiene. The resident was admitted with diagnoses including major depression and had a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment. Documentation in the electronic medical record showed that the resident received varying levels of assistance with personal hygiene, and there was no documentation of refusal of care during the period reviewed. Despite this, observations on multiple occasions revealed that the resident's fingernails were long, jagged, and had a brown substance underneath. The care plan for the resident addressed general refusals of care but did not specifically address personal hygiene or nail care. Interviews with facility staff confirmed that the care plan was not specific to nail care, and staff were notified of the resident's nail condition. The lack of specific interventions and failure to provide necessary nail care resulted in the resident having dirty, untrimmed, and unclean nails over an extended period.
Failure to Prevent Elopement of Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia with behavioral disturbance, anxiety disorder, and schizophrenia, eloped from the facility without supervision. The resident had a documented history of wandering, was assessed as being at risk for elopement, and had a care plan in place that included frequent monitoring, use of an elopement risk book, and exit alarms. Despite these interventions, the resident was able to leave the facility unsupervised. The incident took place when an LPN opened a secured side door to admit a recreational therapist. As the LPN walked away, the therapist held the door open, allowing the resident to exit the facility. The therapist was not aware that the individual was a resident and believed they were a family member. No staff member alerted the therapist to the resident's status or the need to prevent their exit. The resident was not noticed missing until later during a medication pass, prompting a facility-wide search and notification of the administrator, police, and family. The resident was eventually found off facility property by an acquaintance of the family and returned to the facility without evidence of physical injury. The facility's video surveillance captured the incident, showing the resident exiting past both staff members, but the video lacked a date and time stamp. Staff interviews confirmed that the required supervision and monitoring were not maintained at the time of the incident, resulting in the resident's unsupervised elopement.
Failure to Conduct PASARR Level II Screening
Penalty
Summary
The facility failed to refer a resident for a pre-admission screening and resident review (PASARR) Level II screening, which is required for individuals with mental disorders or related conditions. The resident in question, identified as R61, was admitted with diagnoses including anxiety disorder, major depressive disorder, and schizoaffective disorder. Despite these diagnoses, the resident's electronic medical record and Minimum Data Set (MDS) assessment indicated that a PASARR Level II evaluation had not been conducted. This oversight was contrary to the facility's policy, which mandates coordination with the PASARR program to ensure appropriate care and services. Interviews with facility staff revealed a breakdown in communication regarding the resident's mental health diagnoses. The Social Service Director (SSD) was not informed of the schizoaffective disorder diagnosis, which should have triggered a PASARR Level II request. The Director of Nursing (DON) and the MDS Coordinator were responsible for notifying the SSD of such diagnoses, but this did not occur. The MDS/Care Plan Coordinator acknowledged the lapse in communication, which could result in the resident not receiving necessary specialized services. The DON confirmed that the lack of communication could lead to adverse outcomes for the resident, such as mental health issues requiring emergency room visits or hospitalization.
Failure to Follow Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to adhere to the care plans for residents receiving oxygen therapy, specifically in administering the correct oxygen rate and maintaining the cleanliness of oxygen concentrators. For two residents, the facility did not follow the physician-ordered rate of oxygen, administering higher levels than prescribed. This discrepancy was observed in the medical records and confirmed through staff interviews, where it was acknowledged that the oxygen was not administered as per the physician's orders. Additionally, the facility did not maintain the oxygen concentrators as required by the care plans. Observations revealed that the concentrators had accumulated dust and dirt, indicating that the filters were not cleaned weekly as ordered by the physicians. Staff interviews confirmed the neglect in cleaning the equipment, and it was noted that the tasks were either documented as refused or completed without actual verification. The care plans for the residents included specific interventions for oxygen therapy, such as cleaning the equipment and administering oxygen at the prescribed rate. However, these interventions were not consistently followed, leading to deficiencies in care. The staff interviews highlighted a lack of awareness and adherence to the care plans, contributing to the observed deficiencies.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner and administer oxygen according to physician orders for several residents. For one resident, the oxygen concentrator was observed to have accumulated dust and dirt on both the external slats and the internal filter, despite a physician's order specifying weekly cleaning. Interviews with nursing staff confirmed the equipment's unclean state and acknowledged the responsibility for its maintenance, yet the necessary cleaning was not documented or performed as required. Another resident, who had severe cognitive impairment and required oxygen therapy, was found to have an oxygen concentrator with a filter vent covered in a gray substance. The resident's treatment administration record indicated that the cleaning and tubing changes were documented as refused on one occasion, but completed on others. However, observations showed the equipment remained unclean, and the responsible nurse could not recall the resident refusing the maintenance tasks, suggesting a lapse in documentation and follow-up. Additionally, two residents were receiving oxygen at a higher flow rate than prescribed by their physicians. One resident with chronic obstructive pulmonary disease was observed receiving oxygen at 3.5 liters per minute, contrary to the physician's order of 2 liters per minute. The nursing staff confirmed the discrepancy and acknowledged the potential adverse effects of excessive oxygen for residents with COPD. Similarly, another resident's oxygen concentrator was set at 3 liters per minute instead of the ordered 2 liters per minute, with staff confirming the incorrect setting and the resident stating that only nurses adjusted the flow rate.
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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