Fairburn Heights Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairburn, Georgia.
- Location
- 178 West Campbellton Street, Fairburn, Georgia 30213
- CMS Provider Number
- 115298
- Inspections on file
- 22
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Fairburn Heights Of Journey Llc during CMS and state inspections, most recent first.
The facility did not ensure menus were prepared in advance with required details such as serving sizes and diet-specific modifications. After a kitchen fire, staff relied on emergency menus but failed to provide clear documentation or guidance for dietary modifications and portion sizes. Residents received meals that did not match planned menus, and dietary staff lacked instructions for preparing meals according to individual diet orders, placing all residents at risk of nutritional issues and dissatisfaction.
The facility did not maintain required infection control surveillance documentation for the previous year, as confirmed by the DON. A resident was treated for a UTI during this period, but no surveillance records were available to track or monitor infections as outlined in the facility's policy.
Surveyors observed that multiple resident rooms and the main dining room had significant maintenance issues, including damaged drywall, missing or broken tiles, worn furniture, and broken window blinds. Facility staff confirmed awareness of some of these problems, and incomplete repairs were noted during the inspection.
The facility failed to maintain proper food safety and sanitation practices, with unlabeled and expired food items found in storage, and a lack of temperature logs for kitchen equipment. The kitchen environment was unsanitary, with appliances and preparation areas covered in grime. Staff interviews revealed a lack of awareness and adherence to food safety protocols.
The facility failed to maintain a medication error rate below five percent, resulting in an 8.57% error rate. Three residents received incorrect dosages of medications, as confirmed by an LPN. The DON expects staff to follow physician orders and monitors compliance through audits and observations.
The facility failed to provide meals that were palatable, appetizing, and attractive, affecting 97 residents. Observations showed meals deviated from the planned menu, such as serving a meatless hotdog bun with cheese and chicken noodle soup. The Dietary Manager cited ingredient shortages as the reason for substitutions, while the Registered Dietitian noted that alternate menu choices should be available but had not verified their posting.
The facility failed to properly label and store bath basins, bedpans, and urinals in several rooms, as required by their infection control policy. Observations showed these items were not bagged or labeled, which was confirmed by staff interviews, including a CNA, an LPN, and the DON. This deficiency highlights a lapse in maintaining a sanitary environment to prevent cross-contamination.
The facility failed to assess the ability of four residents to self-administer medications, resulting in medications being left at their bedside without proper authorization. Despite the facility's policy requiring secure storage of medications, observations revealed that medications were left at the bedside for residents with various diagnoses, including lupus, Alzheimer's, and diabetes, without documented assessments for self-administration. The DON confirmed that no residents had self-administration orders, and all medications should be administered under supervision.
The facility failed to honor residents' meal preferences and provide snacks, affecting 108 residents. Residents reported not receiving snacks, cold food, and lack of assistance to the dining room. The Dietary Manager admitted to substituting meals due to menu changes, and the Registered Dietitian noted gaps in providing alternatives and missing menu cards on trays, crucial for dietary communication.
A facility failed to provide a resident and their representative with written bed hold information at the time of hospital transfer or within 24 hours, as required by policy. Despite multiple hospitalizations, there was no evidence of compliance with this requirement. Interviews with staff confirmed the oversight, and the Administrator was unaware of the lapse.
A facility failed to complete a PASARR Level 2 assessment for a resident with schizophrenia and other medical conditions, who was admitted with only a Level 1 assessment from the hospital. Despite the resident's complex needs and use of psychoactive medications, the necessary Level 2 review was not conducted. Interviews revealed that the hospital did not complete the Level 2 assessment in 2021, and the facility did not initiate it upon admission.
A resident with multiple diagnoses was discharged without proper medication reconciliation and documentation. The discharge summary lacked a complete list of medications and necessary signatures, and there was a discrepancy in the resident's code status. Interviews revealed that the resident did not receive all medications, and specific information about their functional level was missing. The LPN admitted to not making a copy of the medication form for the medical record.
The facility failed to ensure a safe environment for three residents, who were found with hazardous items like nail polish remover, isopropyl alcohol, and Hibiclens Antiseptic in their rooms. Despite efforts to declutter and inform residents about prohibited items, these hazards were present. The DON acknowledged the issue of clutter and inappropriate items in resident rooms.
The facility failed to provide effective oxygen therapy for four residents, with issues such as improper storage of equipment, lack of physician orders, and inadequate documentation. One resident with a tracheostomy had essential equipment on the floor, while another received oxygen without an order. Two other residents experienced inconsistencies in oxygen flow rates and documentation, indicating systemic issues in respiratory care management.
A facility failed to document communication between its staff and a dialysis center for a resident with end-stage renal disease. The facility's policy requires ongoing assessment and communication, but several dialysis communication forms were incomplete or missing. Interviews with staff, including an LPN and the DON, confirmed the lack of documentation, which was not addressed until highlighted during a survey.
The facility did not provide meals and snacks according to residents' needs and preferences, affecting 97 out of 112 residents. Despite a policy requiring adjustment of menus to meet individual needs, residents reported not receiving snacks at night. The Dietary Manager admitted to limiting snacks due to concerns about food going missing, and an LPN confirmed that snacks were not offered. The Administrator was unaware of the limited snack provision.
Failure to Prepare and Follow Advance Menus with Diet-Specific Modifications
Penalty
Summary
The facility failed to ensure that menus were prepared in advance and included necessary details such as serving sizes and diet-specific modifications for residents' diet orders. During the survey, the facility was unable to provide complete menu cycles and menu extensions for all diets, and the available documentation did not specify which foods were appropriate for various modified diets, including soft, bite-sized, potassium-restricted, finger food, reduced sodium, no added salt (NAS), and renal diets. Observations revealed that meals served did not always match the planned emergency menus, and handwritten instructions for meal preparation lacked information on portion sizes and diet accommodations. Staff interviews confirmed that, following a kitchen fire, the facility relied on emergency menus but did not consistently provide documentation or guidance for dietary modifications or portion sizes. Residents reported receiving meals that differed from the emergency menu, and dietary staff were observed preparing meals without clear instructions on the amount of food to serve or how to modify meals for specific diets. The Registered Dietician stated that the food service vendor provided menus and recipes for all diets, but these were not fully utilized by the dietary manager during the emergency period. The facility was unable to provide a dietary policy regarding menu preparation and documentation before the survey exit, and the lack of clear, advance menu planning and documentation placed all residents receiving oral meals at risk of nutritional problems and dissatisfaction.
Missing Infection Control Surveillance Documentation
Penalty
Summary
The facility failed to maintain infection control surveillance documentation for the year 2024, as required by its own policy. Review of the facility's Infection Surveillance policy indicated the purpose was to identify and monitor infections to reduce and prevent their spread. However, the only available surveillance documentation was for January through June 2025, with no records for 2024. This deficiency was confirmed during an interview with the DON, who was unable to provide any infection control surveillance records for 2024. Additionally, a resident was treated for a urinary tract infection in December 2024, with supporting documentation in the medical record, but there was no corresponding infection surveillance documentation for that period.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as required by its own policy. Observations conducted across four units revealed multiple deficiencies in 13 resident rooms and the main dining room. Specific issues included gouged and marred drywall, missing or broken tiles, dark discoloration around baseboards, worn laminate on tables, splintered wood on doors, and missing or damaged window blinds. Additional findings included holes in bathroom doors, unsanded and unpainted wall patches, separated drywall seams, missing base molding, and missing drawers in closets. Interviews with the Maintenance Director and Regional Maintenance Director confirmed awareness of some of these issues, with the Maintenance Director acknowledging incomplete repairs, such as unsanded and unpainted drywall patches. The Regional Maintenance Director indicated he was new to the corporation and unaware of the extent of the repair needs. These conditions were directly observed and documented by surveyors during their inspection.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation practices, as observed during a kitchen tour. Several food items in the walk-in cooler and freezer were not labeled or dated, including a container of tea, shredded lettuce, cooked sausage patties, and hot dog buns. Additionally, expired food items such as yogurt and relish were found. The facility also lacked records of daily temperature logs for the freezers, cooler, dishwasher, steam table, and sanitizing solution in the three-compartment sink. This lack of monitoring and documentation could potentially affect 97 of the 112 residents receiving an oral diet. The kitchen environment was found to be unsanitary, with appliances such as the oven, fryer, and convection oven coated in grease and grime. Food preparation areas, countertops, and floors were soiled with food crumbs, dirt, and debris. The ice machine contained a black substance, and the sanitizing sink was surrounded by debris and food particles. The facility's maintenance worker confirmed that the ice machine is cleaned every three months, but there were no logs or manufacturer's cleaning recommendations available. Interviews with the Dietary Manager, Administrator, and kitchen staff revealed a lack of awareness and adherence to food safety protocols. The Dietary Manager confirmed the absence of temperature logs and acknowledged the environmental concerns in the kitchen. The day shift cook was unaware of the requirement to log steam table temperatures, and the Dietary Aid mentioned the absence of a cleaning list. The Administrator recognized the need for a deep clean of the kitchen and acknowledged the potential risk of illness from a dirty ice machine.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration, resulting in an error rate of 8.57%. This deficiency was identified through observation, record review, and staff interviews. Three residents were involved in the medication errors. Resident 44, diagnosed with Alzheimer's Disease and urinary retention, was administered Cranberry 450mg instead of the ordered Cranberry 425mg. Similarly, Resident 46, with Type 2 Diabetes Mellitus and a history of cerebral infarction, received Cranberry 450mg instead of the prescribed Cranberry 425mg. Resident 61, who has a history of cerebral infarction and prediabetes, was given Vitamin D3 125mcg instead of the ordered Vitamin D3 25mcg. The errors were confirmed during an interview with an LPN, who acknowledged the discrepancies between the medications given and the physician's orders. The Director of Nursing (DON) expressed an expectation for staff to adhere to physician orders and indicated that her role includes monitoring staff through audits and observations to ensure compliance. Despite these expectations, the facility's failure to ensure accurate medication administration led to a medication error rate exceeding the acceptable threshold.
Deficiency in Meal Quality and Menu Adherence
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, appetizing, and attractive, affecting 97 of 112 residents on an oral diet. The facility's policy required that menus meet nutritional needs, be prepared in advance, and deviations be documented and approved by a dietitian. However, observations revealed that meals served did not adhere to these standards. For instance, a meal consisting of a meatless hotdog bun with a slice of cheese, chicken noodle soup, and a side of lettuce was deemed unacceptable by the Administrator and Regional Nurse Consultant. Interviews with the Dietary Manager (DM) and Registered Dietitian (RD) highlighted issues with menu adherence and food availability. The DM admitted to substituting menu items due to a lack of ingredients, such as using a hotdog bun instead of bread and omitting meat from salads due to a shortage of deli meats. The RD confirmed that alternate menu choices should be available and communicated to residents, but acknowledged that she had not verified if these were posted. The facility's menu was on a 30-day cycle, but frequent changes led to inconsistencies in meal offerings.
Failure to Properly Store and Label Personal Care Items
Penalty
Summary
The facility failed to ensure a safe, sanitary, and comfortable environment by not labeling and properly storing bath basins, bedpans, and urinals in eight of 49 rooms. Observations revealed that in several rooms on the 300 hall, including rooms 309, 313, 315, 402, 404, 405, 407, and 408, bath basins and bedpans were not labeled or bagged as required by the facility's policy. The policy, dated 2/12/2022, mandates that bedpans and urinals are for single resident use only, should be labeled with the resident's name, and stored in a plastic bag in the resident's bedside cabinet or drawer. Interviews with staff, including a CNA, an LPN, and the Director of Nursing, confirmed that all urinals and bath basins should be bagged and labeled to prevent cross-contamination. The CNA stated that all basins and urinals should be cleaned after each use and changed out every night. Despite these guidelines, the observations indicated a failure to comply with the policy, leading to a deficiency in infection prevention and control within the facility.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess the ability of four residents to self-administer medications before leaving medications at their bedside, contrary to the facility's policy on medication storage. The policy mandates that all medications should be stored securely and not left at the bedside unless a clinical assessment deems it appropriate for self-administration. However, observations revealed that medications were left at the bedside for residents R56, R44, R41, and R21 without documented assessments for self-administration. Resident R56, diagnosed with lupus erythematosus, asthma, and other conditions, had several medications, including Trelegy Ellipta Inhaler and Zinc Oxide Ointment, left at the bedside. The Director of Nursing (DON) and the Infection Control Nurse confirmed the presence of these medications, which were not supposed to be there. Similarly, Resident R44, with Alzheimer's Disease and other diagnoses, had Triamcinolone cream at the bedside, which was discontinued earlier in the year. The LPN confirmed the presence of the discontinued medication but was unaware of who left it there. Resident R41, who was cognitively intact, had nasal spray and eye drops at the bedside without an order for self-administration. The LPN confirmed that these medications should not have been left at the bedside. Resident R21, with a BIMS score indicating no cognitive impairment, had diclofenac sodium gel at the bedside without an order for self-administration. The DON confirmed that no residents in the facility had self-administration orders, and all medications should be administered under supervision, ensuring residents take their medications before staff leave the room.
Failure to Honor Resident Meal Preferences and Provide Snacks
Penalty
Summary
The facility failed to honor residents' rights to make choices related to meals and snacks, affecting 108 of 112 residents who can consume meals. The facility's policy stated that the residents' council would be included in menu planning, and alternatives would be provided if a food group was missing from a resident's diet. However, a review of the last six months of resident council meeting minutes revealed complaints about not receiving snacks, cold food, and lack of assistance to the dining room. Observations confirmed that no residents were in the dining room for dinner, and interviews with residents indicated that they were not informed about snack availability and that meal preferences were not honored. Interviews with the Dietary Manager and Registered Dietitian highlighted issues with menu management and communication. The Dietary Manager admitted to substituting meals due to constant menu changes and advised not to rely on the distributed menu. The Registered Dietitian acknowledged gaps in providing alternatives and noted the absence of menu cards on trays, which are crucial for communicating dietary preferences and allergies. These deficiencies in meal service and communication contributed to the failure to support resident choice and self-determination regarding meals and snacks.
Failure to Provide Bed Hold Information
Penalty
Summary
The facility failed to provide written bed hold information to a resident and their representative at the time of transfer to the hospital or within 24 hours, as required by their policy. This deficiency was identified for one resident, R154, out of three sampled residents. The facility's Bed Hold Policy, dated 2/12/22, mandates that written notice specifying the duration of the bed-hold policy and information about the resident's return to the next available bed be provided at the time of transfer for hospitalization or therapeutic leave. However, a review of the clinical and financial records revealed no evidence that such information was provided to the resident or their responsible party during multiple hospitalizations. Interviews with facility staff, including the Business Office Manager and an LPN, confirmed that the responsibility for providing the bed hold form lies with the business office manager and licensed nursing staff. The Business Office Manager admitted to not having any electronic or hard copy documentation to show that the bed hold information was provided during the hospitalizations. The Administrator was also unaware that the forms were not being given, despite expecting the staff to provide them. This lack of documentation and communication led to the deficiency being cited by the surveyors.
Failure to Complete PASARR Level 2 Assessment
Penalty
Summary
The facility failed to identify and submit a Preadmission Screening/Resident Review (PASARR) Level 2 review for a resident with a primary diagnosis of serious mental illness, developmental disability, or a related condition. The resident, who has schizophrenia and other medical diagnoses such as hemiplegia and generalized anxiety disorder, was admitted to the facility with only a PASARR Level 1 assessment completed by the hospital. Despite the resident's complex medical and psychiatric needs, including the use of multiple psychoactive medications, the necessary Level 2 assessment was not conducted upon admission. Interviews with facility staff, including the Social Service Director and the administrator, revealed that the PASARR Level 2 was not completed by the hospital in 2021, and the facility did not initiate it upon the resident's admission. The Social Service Director acknowledged that the hospital typically initiates both Levels 1 and 2, but if not, the facility should take responsibility. However, the Level 2 assessment was overlooked, and the Social Service Director was unsure why it was not initiated, as the resident was admitted before her tenure.
Deficiency in Medication Reconciliation and Documentation at Discharge
Penalty
Summary
The facility failed to properly reconcile and document the medications for a resident at the time of discharge, leading to a deficiency in the discharge process. The resident, who had diagnoses including vascular dementia, Parkinson's disease, and type 2 diabetes mellitus, was discharged without a complete and accurate discharge summary. The discharge summary did not list the medications, nor did it include the necessary signatures from the staff and the resident or their family, which are required to confirm that the medications were provided. Additionally, there was a discrepancy in the resident's code status, as the discharge summary incorrectly listed the resident as a full code, while the medical record indicated a Do Not Resuscitate (DNR) status. Interviews with the family and staff revealed that the resident did not receive all prescribed medications upon discharge, and there was a lack of specific information regarding the resident's capabilities and functional level. The Social Service Worker acknowledged the mistake in the code status, and the Director of Nursing confirmed that the discharge summary should have included care instructions, functional level, and medication documentation. The LPN involved admitted to not making a copy of the medication form with the necessary signatures for the resident's medical record, leaving the facility without proof that the medications were given to the resident or their family.
Facility Fails to Prevent Accident Hazards in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for three residents. Resident 41, who has a history of major depressive disorder, hoarding disorder, and uses a wheelchair, was observed with nail polish remover on their bedside table. The Licensed Practical Nurse (LPN) acknowledged the presence of hazardous items and noted that some rooms have clutter, despite efforts to declutter and inform residents about prohibited items. Resident 9, who is alert and oriented with a history of heart failure and chronic kidney disease, was found with a bottle of isopropyl alcohol on their bedside table. The resident stated they purchased it themselves, and the LPN confirmed its presence, noting that residents and families are informed about restricted items. Resident 24, with hemiplegia and paranoid schizophrenia, had four bottles of Hibiclens Antiseptic on their bedside table. The resident received the bottles from another resident and was educated by a Certified Nursing Assistant (CNA) about not keeping certain chemicals. The Director of Nursing (DON) confirmed awareness of clutter and inappropriate items in residents' rooms.
Deficiencies in Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide effective oxygen therapy for four residents, as observed through various deficiencies in the administration and management of respiratory care. For one resident with a tracheostomy and chronic respiratory failure, essential equipment such as an Ambu bag and suction device were found on the floor, and respiratory tubing was improperly stored, indicating a lack of adherence to infection control measures. This resident's care plan included specific orders for tracheostomy care and oxygen therapy, yet the observed conditions did not align with these requirements. Another resident, who was dependent on supplemental oxygen due to chronic respiratory failure and other conditions, was observed receiving oxygen therapy without a physician's order. Despite being on hospice care and having a care plan that highlighted the need for oxygen, the resident's oxygen therapy was not documented in the Medication Administration Record (MAR), and staff interviews confirmed the absence of an official order. This lack of documentation and oversight suggests a failure in maintaining proper records and ensuring physician-directed care. For two additional residents, discrepancies were noted in the administration of oxygen therapy. One resident had a PRN order for oxygen, but observations revealed inconsistencies in the oxygen flow rate and improper storage of equipment, such as dirty filters and unbagged tubing. Another resident was receiving continuous oxygen therapy without a physician's order or documentation in the MAR, and the care plan lacked any mention of oxygen therapy. Interviews with nursing staff and the Director of Nursing confirmed these oversights, highlighting a systemic issue in the facility's management of respiratory care.
Failure to Document Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure proper communication and documentation between its staff and the dialysis center for a resident receiving dialysis. The facility's policy on hemodialysis requires ongoing assessment and communication with the dialysis center, including monitoring the resident's condition before, during, and after dialysis treatments. However, the review of the resident's medical records revealed missing dialysis communication forms for several dates, indicating a lack of documentation of vital signs, assessment of the dialysis access site, and other necessary information. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the forms were incomplete and not properly uploaded into the electronic medical records system. The resident in question had a history of hypertensive chronic kidney disease, end-stage renal disease, legal blindness, and cerebellar stroke syndrome. Despite physician orders for dialysis on specific days, the facility failed to document the necessary information on the dialysis communication forms. The DON acknowledged that the forms were not being completed as required by policy and was unaware of the issue until it was highlighted during the survey. The lack of documentation and communication could potentially impact the resident's care and treatment, as the facility did not ensure that the necessary information was communicated to and from the dialysis center.
Failure to Provide Snacks According to Resident Preferences
Penalty
Summary
The facility failed to ensure that meals and snacks were served according to the residents' needs, preferences, and requests, as required by their policy. The policy, dated April 2024, stated that menus and available snacks should be adjusted to meet individual caloric and nutrient-intake needs. However, during a Resident Council meeting, residents expressed concerns about not receiving snacks at night. Observations revealed that the pantry contained only a limited selection of snacks, such as chocolate sandwich cookies, graham crackers, and chocolate wafer bars. The Dietary Manager admitted to providing only a limited number of snacks due to concerns about food going missing at night and confirmed the lack of ingredients to prepare sandwiches. Interviews with staff further highlighted the deficiency. The Administrator was aware of the issue of food going missing but was unaware of the limited snack provision. An LPN stated that snacks were not offered to residents, and only some received a snack bag. This deficiency affected 97 out of 112 residents, as they were not provided with nourishing alternative snacks at non-traditional times or outside of scheduled mealtimes, contrary to the facility's policy and the residents' expressed needs.
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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