Gold City Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Dahlonega, Georgia.
- Location
- 222 Moore Drive, Dahlonega, Georgia 30533
- CMS Provider Number
- 115689
- Inspections on file
- 23
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Gold City Health And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment but intact limb function, care planned to use a wheelchair and not to have restraints, was observed early one morning by two dietary staff seated or reclined in a Broda chair near the nurses’ station, appearing unable to move arms or legs and verbally expressing distress. One dietary aide believed the resident’s wrists were secured with Velcro, while the other reported the resident’s apparent immobility to nursing staff but did not escalate the concern to administration. Later that morning, an Infection Control LPN saw the resident reclined in a Broda chair, recognized it could function as a restraint, and directed transfer to a regular wheelchair, but did not identify or report an abuse allegation at that time. The dietary staff did not report their observations to their supervisor until two days later, at which point administration was notified and the incident was reported to the State Agency, contrary to facility policy and staff expectations that all suspected abuse or restraint use be reported immediately.
A resident with multiple chronic conditions, severe cognitive impairment, and documented use of a manual wheelchair was placed in a Broda chair without a prior PT assessment, despite facility expectations that such devices be evaluated through a therapy referral. The resident’s MDS and care plan reflected wheelchair use, limited mobility with supervision, and no use of restraints or chairs that prevent rising. An LPN admitted the resident had not been assessed for the Broda chair, a restorative CNA was unaware of its use and reported the resident used a regular wheelchair and could stand, and a PTA confirmed there was no PT referral and no observed Broda chair use. Leadership staff acknowledged that, even when used for comfort and positioning, a therapy assessment should have been completed before using the Broda chair.
A resident with severe cognitive impairment and a history of inappropriate sexual behavior was able to have unsupervised access to another resident, resulting in inappropriate physical contact and attempted kissing. The incident occurred when no staff were present at the nurses' station, and the affected resident was unable to disengage without staff intervention. This reflects a failure to prevent resident-to-resident abuse as required by facility policy.
A resident with multiple mental health diagnoses and a history of suicidal ideation did not have a comprehensive, person-centered care plan with specific interventions to ensure psychosocial well-being and safety. Despite documented incidents of self-harm and a care plan outlining certain precautions, observations revealed that potentially harmful items, such as clear trash liners, were accessible, and staff interviews showed inconsistent understanding of safety measures.
A resident with multiple medical and psychiatric diagnoses was provided with a bed rail without documented assessment, attempts at alternative interventions, or informed consent. Staff and administration confirmed that the required evaluation and interdisciplinary review were not completed prior to the installation of the bed rail.
The facility failed to maintain RN coverage for eight consecutive hours daily on specific dates, as revealed by staff interviews and Daily Nursing Staff Reports. The interim Administrator confirmed the requirement for RN coverage and acknowledged the potential for negative outcomes due to the absence of RNs, potentially affecting all 68 residents.
The facility failed to maintain the chemical level of the low temperature dishwasher, resulting in zero parts per million (PPM) concentration of chlorine, potentially affecting all 68 residents. A dietary aide continued to wash dishes without notifying anyone about the issue, and the dishwasher log was incomplete for several days. The Dietary Manager confirmed the sanitizer should have been at 50 PPM.
The facility failed to protect residents from mental, verbal, and physical abuse. A resident with no cognitive decline verbally harassed others, leading to a physical altercation, while another resident made inappropriate comments and was involved in verbal abuse incidents. Despite these issues, care plans were not updated with new interventions. Additionally, a resident with severe cognitive impairment struck another resident, highlighting the facility's failure to prevent abuse.
A resident with severe dementia and aggressive behaviors was involved in multiple altercations with other residents due to inadequate supervision and monitoring. Despite incidents of aggression, the facility failed to update the resident's care plan with new interventions, leading to repeated conflicts. Staff interviews confirmed insufficient monitoring, contributing to the deficiency.
A facility failed to accurately reflect a resident's Do Not Resuscitate (DNR) status in her medical records. Although the resident's paper chart clearly indicated a DNR order, her electronic medical record (EMR) and admission record incorrectly listed her as a full code, meaning CPR should be attempted. The resident was cognitively intact and had signed documents confirming her DNR status, but these were not accurately reflected in the EMR. The Assistant Director of Nursing confirmed the discrepancies during an interview.
The facility failed to report an abuse allegation within the required timeframe. A resident with severe cognitive impairments entered another resident's room, touched her inappropriately, and yelled at her. The incident was reported to a CNA and then to an LPN, but it was not communicated to the abuse coordinator until several hours later, as confirmed by the Administrator.
A resident reported being treated roughly by a CNA, including being pushed and having her wheelchair moved out of reach. The resident had scratches and bruises, but the facility's investigation did not document inquiries into these injuries. The CNA was suspended and later quit, but the investigation concluded that abuse could not be substantiated. The administrator acknowledged that the resident should have been asked about the injuries.
A facility failed to provide a resident and their responsible party with a written notice of transfer to a hospital, as required by policy. The resident, who had moderately impaired cognition, was hospitalized for medical reasons but did not receive the necessary documentation. The Business Office Manager acknowledged the omission, although the ombudsman was informed.
A facility failed to monitor a resident for adverse effects and behaviors related to the use of an antidepressant medication, as required by their policy. The resident, who was cognitively intact and diagnosed with bipolar and generalized anxiety disorders, was prescribed sertraline for depression. Despite the care plan's requirement to monitor for adverse reactions, no documentation was found in the resident's records. The ADON confirmed the lack of monitoring documentation.
A medication cart on the B Hall was left unattended and unlocked, allowing potential unauthorized access to medications. The cart contained residents' liquid medications and insulin vials and was out of the nurse's sight for about 17 minutes. An LPN admitted to forgetting to lock the cart, and the DON confirmed that staff had been educated on the importance of securing medication carts.
The facility did not fill in the daily census on the Daily Nursing Staff Report(s) from late July to late August 2024. This omission was confirmed by the interim Administrator and could cause uncertainty for visitors about the staff-to-resident ratio. The facility census was 68 residents.
Failure to Timely Report Suspected Restraint Use as Possible Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of possible abuse involving the use of restraints on a resident to the State Survey Agency, as required by facility policy and regulation. The resident involved had multiple diagnoses, including Down syndrome, cerebral palsy, type 2 diabetes mellitus, congestive heart failure, chronic atrial fibrillation, epilepsy, chronic kidney disease stage 3, anxiety, restlessness and agitation, lumbar compression fractures, abdominal distension, obstructive uropathy, and urogenital implants. The resident’s MDS showed severely impaired memory and decision-making but no impairment in upper or lower extremity function, and indicated that no restraints or chairs that prevent rising were in use. The care plan documented limited mobility, use of a wheelchair, and need for staff supervision for short ambulation. On the early morning in question, two dietary staff members arriving for day shift observed the resident seated or reclined in a Broda (medical) chair near the nurses’ station. One dietary staff member reported that the resident asked for tea and appeared to have immobile arms, and believed the resident’s wrists were secured with Velcro, though she was uncertain due to dim lighting. She also observed the resident in disposable underwear with a sheet over his waist. The other dietary staff member observed the resident reclined, covered with a white blanket, appearing unable to move his arms or legs, with only his head moving forward, and heard the resident say, “I am done, I am done.” This staff member stated she reported her observations to nursing staff, who told her the resident had been awake all night and would remain in the chair for a while. Neither dietary staff member reported their observations to administration at that time. Later that morning, an Infection Control LPN observed the resident reclined in a Broda chair with feet elevated and recognized that the reclined Broda chair could be considered a restraint, instructing another LPN to transfer the resident to his regular wheelchair. She stated she did not see restraints or distress. The two dietary staff did not bring their concerns to their supervisor until two days later during a morning meeting, at which time they were asked for written statements and the concern was then reported to administration. The Administrator was not notified until that point, and the Facility-Reported Incident was submitted to the State Agency only after this delayed internal reporting. Facility policies required all allegations of abuse, neglect, or exploitation, including potential restraint use, to be reported immediately to the Administrator and appropriate agencies, and staff interviews confirmed that all staff, including non-nursing staff, were expected to immediately report suspected abuse or restraint use, even if uncertain. The delay from the initial observations to notification of administration and reporting to the State Agency constituted the failure to timely report the suspected abuse.
Failure to Assess Resident Prior to Use of Broda Chair
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received an appropriate assessment before the use of a Broda chair, a specialized seating device. The facility could not provide a policy specific to assessment prior to use of mobility devices, and the existing Functional Impairment – Clinical Protocol only generally addressed assessment upon admission, with significant change, and periodically, including use of consultations and therapy evaluations to guide care planning. The resident involved had multiple diagnoses, including Down syndrome, unspecified cerebral palsy, type 2 diabetes mellitus, congestive heart failure, chronic atrial fibrillation, epilepsy, benign prostatic hyperplasia, chronic kidney disease stage 3, anxiety, restlessness and agitation, lumbar compression fractures, abdominal distension, obstructive uropathy, and urogenital implants. The most recent MDS showed severely impaired memory and cognitive skills for daily decision-making, but no impairment in upper or lower extremity function, use of a manual wheelchair for mobility, and no use of restraints, bed rails, bed alarms, or chairs that prevent rising. The care plan documented limited mobility with supervision for short ambulation distances and wheelchair use, and addressed fall risk and safety with interventions such as staff supervision and environmental safety measures. Staff interviews revealed that the Broda chair was used for the resident without a prior therapy assessment or documented PT referral. An LPN acknowledged that the resident had not been assessed for use of the Broda chair before it was used. A restorative CNA reported being unaware of the resident using a Broda chair and stated the resident used a regular wheelchair and was able and preferred to stand. A PTA explained that when a Broda chair is considered, nursing is expected to submit a PT referral for an assistive device evaluation, after which PT determines appropriateness and provides recommendations; she confirmed there was no PT referral for this resident and that she had never seen the resident in a Broda chair. During a joint interview with leadership staff, the LPN stated the Broda chair was used for comfort rather than mobility but acknowledged a PT referral should have been initiated, and the RN and Administrator agreed that an assessment should have been completed in accordance with policy. These findings show the resident used a Broda chair without the required assessment to determine appropriateness, need, and safe use.
Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to prevent resident-to-resident abuse when one resident with a history of inappropriate sexual behavior and severe cognitive impairment was able to have unsupervised access to another resident. The resident with high-risk heterosexual behavior and a BIMS score indicating severe cognitive impairment was care planned for behavioral problems, including inappropriate sexual behavior, with interventions to protect others. Despite these interventions, the resident was observed by an LPN holding another resident's hand, attempting to kiss his hands and arms, and pulling on his arm while the other resident tried unsuccessfully to pull away. No staff were present at the nurses' station at the time, as CNAs were making rounds, allowing the incident to occur without immediate intervention. The second resident involved had diagnoses including Alzheimer's disease, dementia, and impaired cognitive function, and was care planned for self-care deficits, aggression, wandering, and resistive behaviors. The incident was witnessed by an LPN, who intervened to separate the residents and was assisted by another staff member. The lack of supervision and failure to implement effective interventions allowed the opportunity for the inappropriate contact to occur, constituting a failure to protect residents from abuse as required by facility policy.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with specific interventions to ensure the psychosocial well-being and safety of a resident with multiple mental health diagnoses, including schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, and a history of suicidal ideation and attempts. Despite the resident being cognitively intact and having a care plan that included interventions such as 15-minute safety checks, use of only plastic silverware, placement in a room with a roommate, and removal of potentially harmful items, there were lapses in the execution and specificity of these interventions. Documentation revealed that the resident had recent incidents of self-harm, including drinking hand sanitizer and attempting to suffocate herself with a plastic bag. Observations showed that clear trash liners, which could pose a risk, were accessible in both the resident's and roommate's trash cans. Staff interviews indicated a lack of consistent understanding regarding the appropriateness of trash liners in the resident's environment. The facility's policy required comprehensive care plans with measurable objectives and timeframes, but the care plan for this resident did not adequately address all identified risks or ensure staff were fully informed and consistent in implementing interventions.
Failure to Assess and Document Alternatives Prior to Bed Rail Installation
Penalty
Summary
The facility failed to ensure that a resident was properly evaluated for bed rail use and that alternative measures were attempted prior to the installation of bed rails. According to the facility's policy, the use of bed rails is prohibited unless specific criteria are met, including the use of alternatives, an interdisciplinary evaluation, a resident assessment, and informed consent. For one resident with diagnoses including cerebral palsy, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, suicidal ideations, and paraplegia, there was no documentation of an initial bed rail assessment, alternatives tried, or consent for bed rail use. The resident was noted to be cognitively intact based on a Brief Interview for Mental Status (BIM) score of 15. Observations revealed a bed rail in the lowered position on the right side of the resident's bed, with the bed pushed against the wall on the left side. Staff interviews confirmed the presence of the bed rail and acknowledged that the required assessment, documentation of alternatives, and informed consent were not completed prior to installation. The Administrator and DON were unable to explain how the required documentation and interdisciplinary review were missed.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to maintain Registered Nurse (RN) coverage for eight consecutive hours seven days a week on specific dates, namely 8/10/2024, 8/11/2024, 8/24/2024, and 8/25/2024. This deficiency was identified through staff interviews and a review of the facility's Daily Nursing Staff Reports, which indicated the absence of RN coverage during each shift on the mentioned dates. The Administrator, who has been interim since July 2024, confirmed the requirement for RN coverage and acknowledged the potential for negative outcomes due to the lack of RN presence. This failure had the potential to leave all 68 residents without necessary medical assistance that only an RN could provide.
Failure to Maintain Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to maintain the chemical level of the low temperature dishwasher at a level that would sanitize soiled dishes, potentially affecting all 68 residents. During an observation, a dietary aide was seen running dishes through the dishwasher, which was not dispensing any sanitizer into the rinse cycle. The test strip used to check the sanitizer level did not change color, indicating a zero parts per million (PPM) concentration of chlorine. Despite this, the aide continued to wash dishes without notifying anyone about the issue. The facility's policy required the sanitizer level to be between 50 and 100 PPM, and the dishwasher log should have been completed three times daily to ensure proper maintenance. Further investigation revealed that the sanitizer level had not been checked since the morning, and the dishwasher log was incomplete for several days. The dietary aide admitted that she was supposed to inform the Dietary Manager if the sanitizer was not at the correct level but planned to do so only after the manager arrived the next morning. The Dietary Manager later confirmed that the sanitizer should have been at 50 PPM and acknowledged that the staff should not have used the dishwasher when the sanitizer level was zero.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from mental and verbal abuse, as evidenced by incidents involving several residents. Resident R19, who had no cognitive decline, was involved in multiple incidents of verbal harassment. R19 accused R53 of stealing, leading to a physical altercation where R53 struck R19 with magazines. Additionally, R19 made inappropriate remarks about R11's body, which were overheard by a staff member. Despite these incidents, R19's care plan was not updated with new interventions to address his behaviors. Resident R16, who was cognitively intact, also displayed verbally aggressive behaviors. R16 was reported to have asked R53 if she wanted to be raped, a statement that was overheard by a nurse. R16 admitted to making the inappropriate comment and apologized. Furthermore, R16 was accused of verbally abusing residents R122 and R71 by calling them derogatory names. Despite these incidents, R16's care plan did not include new interventions to manage her behaviors. The facility also failed to protect a resident from physical abuse. R53, who had severe cognitive impairment, struck R48 with a plastic plate during a disagreement over bingo prizes. R48, who had moderate cognitive decline, was not injured but the incident highlighted the facility's inability to prevent physical altercations. The facility's policies on abuse prevention were not effectively implemented, as evidenced by the lack of updated care plans and interventions for residents involved in these incidents.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents involving a resident with severe dementia, delusions, and paranoid schizophrenia, who exhibited aggressive behaviors towards other residents. The resident, identified as R6, had a history of negative behaviors and was involved in multiple altercations with other residents, including hitting another resident with a tray lid and striking another resident in the face. Despite these incidents, the facility did not implement new interventions in R6's care plan to address these behaviors. In one incident, R6 was involved in an altercation with another resident, R23, after being run into by R23's wheelchair. The facility's Activities Director witnessed the incident but was unable to prevent it. Another altercation occurred when R6 entered the wrong room and began touching another resident, R36, due to confusion after a room change. The facility did not provide adequate monitoring or redirection for R6, which contributed to these incidents. The facility's failure to provide continuous monitoring and appropriate interventions for R6's aggressive behaviors resulted in repeated altercations with other residents. Staff interviews confirmed that monitoring was insufficient, and the facility did not maintain the necessary supervision to prevent these incidents. The lack of timely psychiatric consultation and failure to update care plans further contributed to the deficiency.
Failure to Accurately Reflect DNR Status in Medical Records
Penalty
Summary
The facility failed to ensure that a resident's medical record accurately reflected her request to not have cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary failure. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had a documented Do Not Resuscitate (DNR) order in her paper chart. However, her electronic medical record (EMR) and admission record inaccurately indicated she was a full code, meaning CPR should be attempted. The resident's paper chart contained a sticker indicating DNR and a signed document titled "Do Not Resuscitate for Resident with Decision Making Capacity," which clearly stated that CPR was not to be initiated. Additionally, the Advanced Directive Checklist signed by the resident also had the DNR order check marked. Despite these clear indications in the paper record, the EMR and admission record failed to reflect the resident's wishes accurately. The Assistant Director of Nursing (ADON) confirmed the inaccuracies in the EMR and paper chart during an interview.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe for two residents, R6 and R36, as per their policy on Abuse, Neglect, and Exploitation. R6, who has severe cognitive impairments including Alzheimer's disease and schizophrenia, allegedly entered R36's room early in the morning, touched her inappropriately, and yelled at her. R36, also severely cognitively impaired, reported the incident to a CNA, who then informed an LPN. However, the incident was not reported to the abuse coordinator until five and a half hours later, which was confirmed by the facility's Administrator. The incident occurred when R6, in a wheelchair, entered R36's room and began touching her and pulling off her blankets. The CNA who witnessed the event removed R6 from the room and later reported the incident to the charge nurse. However, the report was not clearly communicated, leading to a delay in notifying the appropriate authorities. The facility's investigation included a handwritten statement from the CNA, who admitted to not ensuring the nurses heard the report. The Administrator acknowledged the delay in reporting the incident, which was not in compliance with the facility's policy.
Failure to Investigate Resident Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident who reported being treated roughly by a CNA. The resident, who was cognitively intact, reported that the CNA was rude, pushed her wheelchair out of reach, and made her lie in her own urine. The resident also reported being shoved, which was immediately reported to the abuse coordinator, and a police report was made. The resident was assessed for injuries, with scratches on her wrists and bruising on her shins noted. However, the investigation did not document any inquiry into these injuries. The facility's investigation concluded that abuse could not be substantiated, and the CNA involved was suspended but quit shortly after. Despite a follow-up interview with the resident, there was still no documentation that the resident was asked about the scratches and bruises. The administrator, who was not employed during the investigation, acknowledged that the resident should have been asked about these injuries. The lack of thorough investigation into the resident's reported injuries represents a deficiency in the facility's handling of the abuse allegation.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a resident and their responsible party with a written notice of transfer and the reasons for the transfer, as required by their policy. This deficiency was identified during a review of the facility's policy titled 'Transfer and Discharge,' which mandates that a transfer notice be provided to the resident and representative when a discharge is initiated by the facility for medical reasons to an acute care setting such as a hospital. The review of the electronic medical record (EMR) and hard chart for one resident revealed no transfer/discharge notices were provided, despite the resident being hospitalized. The resident in question, who had moderately impaired cognition, was readmitted to the facility with multiple diagnoses, including acute respiratory failure and chronic kidney failure. During an interview, the resident confirmed hospitalization but could not recall receiving any written notices. The Business Office Manager admitted that no written transfer/discharge notice was sent to the resident or their responsible party, although the ombudsman was notified. This oversight had the potential to leave the resident and their responsible party unaware of the transfer and its reasons.
Failure to Monitor Adverse Effects of Antidepressant Medication
Penalty
Summary
The facility failed to monitor for adverse consequences and behaviors related to the use of antidepressant medication for one resident, identified as R24, who was part of a sample of 43 residents reviewed for unnecessary medications. The facility's policy on antipsychotic medication use, dated July 2022, requires staff to observe, document, and report any side effects or adverse consequences of such medications to the attending physician. However, a review of R24's records, including the Medication Administration Record (MAR), Treatment Administration Record (TAR), and the TASKS tab, revealed no documentation of monitoring for adverse consequences or behaviors. R24 was admitted with diagnoses including bipolar disorder and generalized anxiety disorder and was prescribed sertraline HCl (Zoloft), an antidepressant, for depression. Despite the care plan's directive to monitor and document any adverse reactions to psychotropic medications, there was no evidence of such monitoring in the resident's records. During an interview, the Assistant Director of Nursing (ADON) confirmed the absence of documentation for monitoring behaviors or adverse consequences, acknowledging that such monitoring should have been documented.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure the security of a medication cart on the B Hall, which was left unattended and unlocked, allowing potential unauthorized access to medications. During an observation, the cart was found between rooms B5 and B78, out of the nurse's sight, and unlocked. Inside the cart were residents' liquid medications and insulin vials, easily accessible to anyone passing by. Two residents were noted to be within close proximity to the unlocked cart, which remained unsecured for approximately 17 minutes until the Assistant Director of Nursing locked it. Interviews with staff revealed that an LPN admitted to forgetting to lock the cart due to moving too quickly to another hall. The LPN acknowledged the importance of keeping the cart locked to ensure resident safety. The Director of Nursing confirmed that medication carts are expected to be locked when not in use or out of sight and mentioned that nursing staff had been educated on this requirement, although she was unsure of the last training session.
Failure to Indicate Daily Census on Nursing Staff Reports
Penalty
Summary
The facility failed to indicate the daily census on the Daily Nursing Staff Report(s) from 7/29/2024 through 8/26/2024. This omission was identified during a review of the reports provided by the Administrator. The reports, which are required to be posted daily for nursing homes participating in Medicare and Medicaid programs, contained a space for the facility census, but this information was not filled in. The absence of this information could lead to uncertainty for resident family, friends, or other visitors regarding the ratio of nursing staff to residents. The facility census at the time was 68 residents. During an interview, the interim Administrator, who had been in the role since July 2024, confirmed that the census should have been indicated on the posted reports.
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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