Glenwood Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Glenwood, Georgia.
- Location
- 41 North Fifth Street, Glenwood, Georgia 30428
- CMS Provider Number
- 115703
- Inspections on file
- 19
- Latest survey
- March 8, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Glenwood Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to prevent resident-to-resident abuse when a resident with schizoaffective disorder, bipolar type, traumatic brain injury, and a known history of aggressive behaviors escalated from yelling profanities at staff to verbally and physically assaulting another resident with Alzheimer's disease and associated psychotic and mood disturbances. While the victim was ambulating in the hallway, the aggressive resident struck him repeatedly in the head, causing a fall and head impact on the ground, after which nursing documented bruising to the victim's cheek and his inability to recall the event.
Staff failed to properly hold and monitor hot food temperatures prior to meal service, with items such as creamed corn and mechanically chopped ham with pineapple being held at insufficient temperatures and without required checks. Additionally, decayed tomatoes and oranges with visible mold were found in the walk-in refrigerator, indicating a lapse in daily inspection and removal of expired items. The Dietary Manager and Registered Dietician confirmed that food safety protocols were not consistently followed, and the DON and Administrator acknowledged the need for improved staff education and oversight.
Two residents with intact cognition who filed grievances did not receive written decision responses as required by facility policy and federal regulations. Instead, the Social Services Director provided only verbal notifications of grievance outcomes, and both the DON and Administrator were unaware of the written response requirement. Documentation for multiple grievances confirmed the absence of written responses.
The facility failed to follow its food storage and sanitation policies, resulting in several deficiencies. Observations showed that food items were not removed by discard dates, and opened items lacked labels and dates. A dented can was improperly stored, and cases of bottled water were on the floor. Additionally, food on the steam table was not maintained at the required temperatures, with several items below 135 degrees. The Dietary Manager and staff acknowledged these issues.
The facility failed to ensure a clean and safe environment, with deficiencies observed in resident rooms and shower areas. Seven rooms on the 100 hall had issues like missing tiles, baseboards, and brown water from faucets. Shower rooms were cluttered with equipment, leaving limited access for residents. The Maintenance Director was unaware of these issues, and the facility's water system was managed by the city. The Administrator expected cleanliness and proper storage, highlighting a disconnect between expectations and reality.
The facility failed to secure the medication storage room and remove expired medications. Nurses accessed the room without a key, and expired medications were found, contrary to policy. The DON confirmed the room was unlocked during the surveyor's visit.
A facility failed to submit a PASRR Level II for a resident after a new mental health diagnosis and the development of aggressive behaviors. The Social Services Director did not update the PASRR, despite the resident's diagnosis of unspecified psychosis and use of psychotropic medications. Interviews confirmed the oversight, which had the potential to impact the resident's care.
A facility failed to properly clean and store a nebulizer mask for a resident with respiratory issues, as required by their policy. The mask was found uncleaned, unbagged, and unlabeled on the bedside table, contrary to the facility's guidelines. This deficiency was confirmed through observations and staff interviews.
A facility failed to ensure dietary staff followed recipes and measured ingredients for pureed meals, affecting a resident on a pureed diet. Dietary cook BB added unmeasured milk to pureed chicken tenders, resulting in a soup-like consistency, and used milk instead of pea juices for pureed peas. The Dietary Manager confirmed the improper preparation and noted the absence of recipes for these items.
Failure to Prevent Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by another resident, contrary to its policy titled "Abuse, Neglect and Exploitation." On the date of the incident, one resident with Alzheimer's disease with late onset, psychotic disturbance, mood disturbance, and anxiety (R38) was ambulating in the hallway when another resident (R44) began yelling profanities at staff and then became aggressive toward R38. According to the facility incident report and progress notes, R44 verbally and physically assaulted R38, striking him repeatedly in the head, which caused R38 to fall and hit his head on the ground. Nursing assessment documented bruising to R38's left cheek, and R38 was unable to recall what had happened. Record review showed that R44 had been admitted with schizoaffective disorder, bipolar type, and an unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, and had a documented history of behaviors related to schizophrenia, including a prior altercation with another resident and verbal and physical aggression toward staff. On the day of the incident, R44 was attempting to get into a bathroom near the nurse station and was being redirected by nursing staff when R38 was walking up the hall, at which point R44 escalated from yelling profanities at staff to physically attacking R38. The incident demonstrates that the facility did not prevent resident-to-resident abuse, resulting in one resident being verbally and physically assaulted by another resident with a known history of aggressive behaviors.
Failure to Maintain Safe Food Storage and Preparation Practices
Penalty
Summary
The facility failed to prepare and store food in accordance with professional standards of food service safety, as evidenced by improper hot holding of foods, lack of temperature monitoring, and failure to remove decayed foods from refrigeration. Observations revealed that creamed corn was removed from the oven and placed on a steam table well before meal service without checking its temperature, and then transferred to an oven set at only 100 degrees F for hot holding, which is below the required temperature. Mechanically chopped ham with pineapple was also held in the oven at 100 degrees F without temperature checks before or during holding. Additionally, green beans were left uncovered in a stock pot on a stove that was turned off, rather than being transferred to a proper hot holding unit at the correct temperature. Interviews with dietary staff and the Dietary Manager (DM) confirmed that food temperatures were not checked as required, and that the practice of using an oven set to 100 degrees F for hot holding was routine, despite not meeting the facility's policy or professional standards. The DM and Registered Dietician (RD) both acknowledged that hot foods should be held at a minimum of 135-140 degrees F and that the steam table should only be used shortly before meal service. The DM also stated that she expected cooks to follow recipe guidance and food safety protocols, but these were not consistently followed. Further deficiencies were observed in the facility's walk-in refrigerator, where multiple tomatoes and oranges with visible mold and discoloration were found stored in cardboard boxes. The DM stated that she checked the refrigerated storage daily but admitted to missing these spoiled items during her most recent inspection. The RD reiterated the expectation for daily checks and removal of expired items. The Director of Nursing (DON) and Administrator (ADM) both acknowledged the need for improved education and oversight regarding kitchen sanitation and safe food handling practices.
Failure to Provide Written Grievance Responses
Penalty
Summary
The facility failed to provide written grievance decision responses to two residents who had filed grievances, as required by both facility policy and federal regulations. The policy in place specified that residents or their representatives must receive a written decision at the conclusion of a grievance investigation, including details such as the date received, investigative steps, findings, confirmation status, corrective actions, and the date the decision was issued. However, documentation for multiple grievances showed that only verbal notifications were given, and there was no evidence that written responses were provided. One resident, admitted with intact cognition, filed a grievance regarding another resident and was verbally informed of the resolution by the Social Services Director (SSD). The resident confirmed during an interview that they had not received a written response and were unaware that such documentation could be provided, expressing a desire to receive written outcomes for their grievances. Similarly, another resident with intact cognition filed several grievances, including dietary concerns and issues involving other residents. In each instance, the documentation indicated verbal notification only, with no written decision provided to the resident. Interviews with the SSD, DON, and Administrator revealed a lack of awareness regarding the requirement to provide written grievance responses. The SSD, who had been responsible for investigating and resolving grievances, stated she was not aware of the written response requirement and had only provided verbal updates. Both the DON and Administrator also indicated they were unaware of this requirement, though they expected the grievance official to follow facility policy.
Deficiencies in Food Storage and Temperature Maintenance
Penalty
Summary
The facility failed to adhere to its policies on food storage and sanitation, leading to several deficiencies. Observations revealed that food items were not removed by their discard dates, with sandwich meat remaining in the refrigerator past its discard date. Additionally, opened food items such as BBQ sauce and gravy mix were not labeled or dated, and cut onions were stored without labels or dates. The facility's dietary staff, including the Dietary Manager (DM) and dietary cook, acknowledged these oversights, indicating a lapse in following the established procedures for labeling and dating food items. Further deficiencies were noted in the storage and handling of food items. A dented can of fruit cocktail was found among other canned goods, contrary to the facility's practice of segregating dented cans. Cases of bottled water were stored directly on the floor in both the dry storage area and a kitchen closet, which is against the facility's policy of keeping food items elevated. Additionally, food temperatures on the steam table were not maintained at the required levels, with several items, including chicken tenders and puree peas, being served at temperatures below 135 degrees. The DM confirmed these temperature discrepancies, although the facility had not previously experienced issues with maintaining appropriate food temperatures.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by several deficiencies observed in the living areas and shower rooms. Specifically, seven out of fourteen rooms on the 100 hall had issues such as missing floor tiles, missing baseboards, and brown rust-colored water coming from bathroom faucets. Additionally, some rooms had slow-draining sinks and a strong urine odor. The Maintenance Director was unaware of these issues, suggesting a lack of regular inspections and maintenance. Furthermore, both shower rooms in the facility were cluttered with various items, including wheelchairs, mattresses, IV poles, and other equipment, leaving only one stall available for resident use in each room. The Maintenance Director acknowledged that these items had been stored in the shower rooms since he started working at the facility three months ago. Interviews with the Corporate Maintenance Director and the VP of Environmental Services revealed that the facility's water system was managed by the city, and there had been no reported issues with water or sewage problems. The Administrator expected the facility to be clean and in good repair, with supplies stored outside the facility, indicating a disconnect between expectations and the current state of the facility.
Medication Storage Room Security and Expired Medications
Penalty
Summary
The facility failed to ensure that the medication storage room was secure and only accessible to licensed staff, as well as to remove expired medications from the storage. Observations on two separate occasions revealed that nurses were able to enter the medication storage room without using a key, indicating that the room was not kept locked as required by the facility's policy. This was confirmed by a Registered Nurse (RN) during the time of discovery. Further observations identified expired medications stored in the floor stock medication cabinet, including two boxes of Bisacodyl suppositories, four bottles of zinc 50 mg, and four bottles of Vitamin B6 50 mg, all of which had expiration dates prior to the observation. The Director of Nursing (DON) confirmed that the drug storage room door was not locked during the surveyor's observation, which is contrary to the facility's policy that medication rooms should be locked at all times and expired medications should be properly destroyed.
Failure to Submit PASRR Level II for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a PASRR Level II for a resident after a new mental health diagnosis was added and behaviors developed. The facility's policy requires a PASRR Level II review when there is a change in diagnosis or status that may necessitate specialized services. However, the Social Services Director did not update the PASRR for the resident, who had been diagnosed with unspecified psychosis and exhibited behaviors such as physical and verbal aggression. The resident's care plan included the use of psychotropic medications and noted these behaviors, but the necessary PASRR Level II was not completed. Interviews with facility staff revealed that the Social Services Director was responsible for updating the PASRR but failed to do so, acknowledging that it "slipped through the cracks." The Director of Nursing confirmed the resident's behaviors and the need for a PASRR Level II submission. The resident was receiving behavioral health services, and care plan meetings were held with the resident's sister. Despite these measures, the lack of a PASRR Level II review had the potential to affect the appropriate level of care and services provided to the resident.
Improper Storage and Cleaning of Nebulizer Mask
Penalty
Summary
The facility failed to adhere to its policy on respiratory system management, specifically regarding the cleaning and storage of nebulizer masks. Observations revealed that a resident's nebulizer mask was left on the bedside table, uncleaned, unbagged, and unlabeled with the resident's name and room number. This was contrary to the facility's policy, which requires nebulizer masks to be rinsed, air-dried, and stored in a labeled plastic bag or in the machine if a storage shelf is available. The resident involved had been admitted with diagnoses including pleural effusion and shortness of breath, and was receiving respiratory therapy. The deficiency was confirmed through observations and interviews with the Director of Nursing and the assigned Registered Nurse, who acknowledged the responsibility of ensuring nebulizer masks are cleaned and stored properly after use. The failure to follow the established protocol for nebulizer mask maintenance was identified as a deficiency during the survey.
Improper Preparation of Pureed Meals
Penalty
Summary
The facility failed to ensure that dietary staff followed recipes and measured ingredients when preparing pureed food, compromising the nutritive value and flavor for a resident on a pureed consistency diet. During an observation, dietary cook BB was seen preparing pureed chicken tenders by adding an unmeasured amount of milk, resulting in a soup-like consistency. To correct this, she added a packet of food thickener to achieve the proper consistency. The cook admitted to not measuring the milk and acknowledged that she sometimes measures liquids when pureeing food items. She also revealed uncertainty about the availability of recipes for pureed food items. Further observation showed dietary cook BB preparing pureed peas by adding an unmeasured amount of cooked peas and milk to the blender. The Dietary Manager confirmed that the cook did not properly puree the chicken tenders and peas, adding too much liquid to the chicken tenders and using milk instead of the juices from the cooked peas. The Dietary Manager also noted the absence of recipes for pureed chicken tenders and peas for staff to use, which contributed to the improper preparation of the pureed meals.
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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