Harborview Health Center Of Augusta
Inspection history, citations, penalties and survey trends for this long-term care facility in Augusta, Georgia.
- Location
- 3618 J Dewey Gray Circle, Augusta, Georgia 30909
- CMS Provider Number
- 115291
- Inspections on file
- 18
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Harborview Health Center Of Augusta during CMS and state inspections, most recent first.
A resident with advanced cancer and pressure ulcers did not receive consistent pain management due to unavailability of prescribed fentanyl patches on multiple occasions and infrequent administration of hydromorphone, despite orders for more frequent dosing. Staff did not consistently assess pain or notify the physician about missed medications, resulting in the resident experiencing pain during care.
During a kitchen inspection, multiple food items in both the refrigerator and freezer were found to be unsealed, unlabeled, or undated, including containers of dry goods, prepared foods, and refrigerated items. These deficiencies had the potential to affect nearly all residents receiving meals from the kitchen.
Two residents did not receive multiple ordered medications, including pain, antibiotic, cardiac, and seizure medications, due to unavailability. Staff and nursing leadership were unaware of the missed doses, and the facility lacked a procedure for handling unavailable medications, despite pharmacy contract provisions for emergency supply.
Insulin pens and vials on two medication carts were found without proper pharmacy labels, open dates, or expiration dates, and several were used past their expiration. An LPN confirmed that expired or unlabeled insulin should have been discarded, while the DON stated that nurses are expected to label and check insulin before use. These deficiencies were observed during inspection and confirmed through staff interviews.
A resident was not provided with written information about their right to accept or refuse medical or surgical treatment or to formulate an advance directive, as required by facility policy. The DON confirmed that no documentation existed to show this information was given at admission or re-admission.
A resident with multiple medical conditions became bedbound and cognitively impaired after hospital readmission, but the care plan was not updated to include interventions for pressure ulcer prevention. Despite developing three pressure ulcers and requiring substantial assistance, the care plan only listed general skin care measures, and no further Braden Scale assessments or documentation of repositioning were completed. Staff interviews and observations confirmed that necessary interventions, such as heel elevation, were not consistently implemented or documented.
A resident with multiple medical conditions and a decline in mobility and cognition after hospital readmission did not receive updated pressure ulcer prevention interventions. Despite being bedbound and requiring substantial assistance, the resident was observed repeatedly without heel elevation, and there was no documentation of repositioning or reassessment of pressure ulcer risk. The resident subsequently developed multiple pressure ulcers, and the facility lacked a policy on pressure ulcer prevention.
Two residents with significant risk factors, including diabetes and impaired mobility, did not receive ongoing podiatry services as recommended, despite documented needs for routine foot care and follow-up. Both residents experienced long, thickened, and sometimes painful toenails, and staff confirmed that podiatry visits had not occurred for some time, with neither resident listed for upcoming podiatry appointments.
A resident with a tracheostomy was found to have dirty and improperly maintained respiratory equipment, including an oxygen concentrator with dried particles and a dusty filter, as well as outdated suction tubing and an unbagged Yankauer suction tip. Staff confirmed that cleaning and supply changes were not performed as required by policy and physician orders.
Staff did not adhere to infection control protocols, including failure to wear gowns and perform hand hygiene during personal care and wound care for residents on Enhanced Barrier Precautions, and did not sanitize blood pressure cuffs between residents. These actions were not in accordance with facility policies, as confirmed by staff and leadership interviews.
The facility failed to ensure the confidentiality of personal and medical records for two residents. Medication cards containing sensitive information were left unattended on a medication cart, accessible to residents, staff, and visitors. An LPN confirmed the cards were improperly handled, and the Administrator acknowledged the expectation for proper disposal to maintain privacy.
The facility failed to follow its grievance procedures for a moderately cognitively impaired resident. The resident's representative filed a grievance about late medication administration, a dirty environment, a broken toilet seat, and the resident not being changed timely. The Concern Form lacked documentation of follow-up actions, dates, and whether the individual was satisfied with the resolution. Staff interviews revealed inconsistencies and a lack of clear communication regarding the grievance process.
A resident with a stage IV sacral pressure ulcer was found without a dressing, leaving the wound exposed to urine and feces. The facility's policy required dressings to be replaced if soiled or dislodged, but staff failed to adhere to this policy. Interviews revealed that staff were unaware of the missing dressing and did not notify a nurse, leading to a deficiency in care.
The facility failed to ensure that clinical records were complete and accurate for three residents. One resident had missing documentation for gabapentin administration, another had no documentation of intake on several dates, and a third had missing documentation for personal hygiene, bladder elimination, and the amount eaten on various dates. The Administrator confirmed the missing documentation and emphasized the need for accurate record-keeping.
Failure to Provide Consistent Pain Management and Medication Availability
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple serious medical conditions, including colon cancer, bone cancer, lung cancer, chronic pain syndrome, and pressure ulcers. The resident had an order for a fentanyl transdermal patch to be applied every three days, but the medication was not available on several scheduled dates. Additionally, the resident's pain was not consistently assessed, and staff did not use a pain assessment tool appropriate for his cognitive status as outlined in facility policy. The resident was observed to be in pain, exhibiting nonverbal indicators such as moaning and grimacing, and was unable to verbally express his pain level due to moderate cognitive impairment. Despite having an order for hydromorphone to be administered every six hours as needed for pain, the resident only received this medication once daily. Staff, including the DON and an RN, were unaware that the fentanyl patches were not available on multiple occasions and did not realize the hydromorphone was not being administered as frequently as ordered. The resident's physician was not notified about the missed fentanyl doses or the ongoing pain management issues. As a result, the resident experienced pain, particularly during repositioning for wound care.
Failure to Properly Label, Date, and Seal Food Items in Kitchen Storage
Penalty
Summary
The facility failed to ensure that all food items in the refrigerator and freezer were properly sealed, labeled, and dated, as observed during a kitchen inspection. Four large plastic containers holding breadcrumbs, thickener, flour, and sugar were found without labels or dates. In the walk-in refrigerator, metal containers of watermelon, ketchup, and cucumbers were found to be outdated, and several other items including a bowl of icing, two sandwiches, a bag of sliced cheese, a bag of ham, poured glasses of iced tea, and a cooked pan of broccoli lacked labeling or dating, with the broccoli also not sealed to prevent air exposure. In the walk-in freezer, a box of biscuits was found unsealed and exposed to air. These issues were identified during an observation with the kitchen cook and confirmed in an interview with the Administrator, who acknowledged the need for staff education on labeling and dating procedures. A total of 110 out of 112 residents who received meals from the kitchen were potentially affected by these failures.
Failure to Ensure Medication Availability and Administration
Penalty
Summary
The facility failed to ensure that medications were consistently available and administered as ordered for two residents. For one resident, multiple medications including a fentanyl transdermal patch for pain, Flomax for urinary retention, levofloxacin as an antibiotic, and zolpidem tartrate for sleep were not available on several occasions as documented in the Medication Administration Record. The absence of these medications was confirmed through observation of the medication cart, which lacked the required narcotic patches and documentation, and through interviews with nursing staff who were unaware of the missing medications. The Director of Nursing and a registered nurse also stated they were not aware of the unavailability of these medications and noted that the new automated medication dispensing system did not have narcotics available for supply. A second resident did not receive several critical medications, including amiodarone, amlodipine besylate, metoprolol succinate ER, Keppra, and Eliquis, as ordered during her stay. The resident’s family member reported that medications were not available upon admission, and the Director of Nursing confirmed she had not been informed of the missed doses. Review of facility policy revealed there was no procedure in place for when a medication was not available, and the pharmacy contract indicated that drugs and supplies should be provided as required, including after-hours emergency deliveries. Despite these provisions, the facility did not ensure medication availability, and staff did not report the missing medications to nursing leadership.
Failure to Properly Label, Date, and Remove Expired Insulin
Penalty
Summary
Surveyors observed that insulin pens and vials on two medication carts were not properly labeled or dated in accordance with manufacturer recommendations and professional standards. Specifically, several insulin pens and vials lacked pharmacy labels, were not dated when opened, and some were found to be used past their expiration dates. The manufacturer's guidelines for various types of insulin, including glargine, Humalog, Lispro, Novolog, Aspart, and Toujeo Solostar, require that these medications be used within 28 days of being removed from refrigeration. Despite these requirements, multiple insulin products on both the 100-hall and 200-hall carts were either missing open dates, missing expiration dates, or had expired but were still present on the carts. During interviews, an LPN acknowledged that the insulins should have been discarded when expired or labeled when opened, but was unsure who was responsible for ensuring compliance. The DON stated that her expectation was for the nurse who removed the insulin from refrigeration to label it with the opened and expiration dates, and that nurses should always check expiration dates before administration. The failure to properly label, date, and remove expired insulin was directly observed and confirmed by staff interviews.
Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide a resident and/or their representative with written information regarding the right to accept or refuse medical or surgical treatment and to formulate an advance directive. According to the facility's policy, staff are required to determine if a resident has an advance directive upon admission and, if not, to offer information about the right to create one. The policy also states that any decisions regarding the resident's choices should be documented in the medical record and communicated to the care team. However, the policy did not specify that this information must be provided in written form. Record review for one resident revealed no documentation that written information about advance directives or the right to accept or refuse treatment was provided at admission or re-admission. During an interview, the DON confirmed that there was no record of the resident receiving any information about advance directives, as the admission occurred under previous ownership and no documentation was available in the electronic medical record.
Failure to Update Care Plan and Implement Pressure Ulcer Prevention After Change in Condition
Penalty
Summary
The facility failed to update the care plan for a resident following a significant change in condition after hospital readmission, resulting in the development of three pressure ulcers. The resident, who had multiple medical diagnoses including rib and vertebral fractures, prostate cancer, and diabetes, was initially assessed as not at risk for pressure ulcers. However, after a hospitalization for deep vein thrombosis and pneumonia, the resident became bedbound, experienced cognitive decline, and required substantial assistance with mobility and activities of daily living. Despite these changes, the care plan was not revised to include specific interventions for pressure ulcer prevention after the resident's readmission. The only interventions listed were general measures such as gentle handling, observation of skin during ADLs, and weekly skin assessments. No new interventions were added after the resident developed a sacral pressure ulcer, a right heel pressure ulcer, and a left hip pressure ulcer. Additionally, no further Braden Scale assessments were completed after the change in condition, and there was no documentation system in place for staff to record repositioning. Observations confirmed that the resident was consistently found lying on his back in bed with heels not elevated, despite the use of a low air loss mattress. Interviews with nursing staff revealed that the resident required frequent repositioning and heel elevation, but these interventions were not reflected in the care plan or documented in the medical record. The lack of care plan updates and documentation contributed to the failure to implement appropriate pressure ulcer prevention measures.
Failure to Implement Pressure Ulcer Prevention Measures After Resident Readmission
Penalty
Summary
A deficiency occurred when a resident at risk for pressure ulcers did not have appropriate preventative measures in place following readmission from the hospital. The resident, who had multiple medical diagnoses including rib and vertebral fractures, prostate cancer, diabetes, DVT, and pneumonia, experienced a significant decline in mobility and cognition after hospitalization. Despite these changes, the care plan was not updated to reflect the increased risk, and no new interventions were added after the resident developed three pressure ulcers. Observations over several days showed the resident consistently lying in bed on his back without his heels elevated, despite staff interviews indicating that heel elevation was required. The resident had a low air loss mattress, but other preventative measures, such as regular repositioning and documentation of these interventions, were lacking. Staff interviews confirmed that the resident was largely bedbound and required substantial assistance, but there was no system in place for documenting repositioning, and the Braden Scale for pressure ulcer risk was not reassessed after the resident's condition changed. Medical record reviews revealed that the resident developed a sacral pressure ulcer, a right heel pressure ulcer, and a left hip pressure ulcer after readmission. Progress notes documented the emergence and progression of these wounds, as well as the treatments applied. The Director of Nursing confirmed that there was no facility policy on the prevention of pressure ulcers, further contributing to the lack of consistent preventative care for the resident.
Failure to Provide Routine Podiatry Services for At-Risk Residents
Penalty
Summary
The facility failed to arrange and provide appropriate podiatry services for two residents identified as being at risk and in need of specialized foot care. One resident, with a history of anxiety, depression, and difficulty walking, had previously received podiatry care for long, thickened, and painful toenails, with recommendations for ongoing routine debridement and antifungal treatment. Despite a documented need for follow-up podiatry appointments, there was no evidence in the medical record that these follow-up visits occurred. The resident's care plan indicated a need for assistance with grooming and nail care, but there was no documentation of continued podiatry involvement as recommended. Another resident, diagnosed with Type 2 Diabetes Mellitus with diabetic polyneuropathy and nail dystrophy, reported that his toenails were extremely long and sometimes painful, and that it had been some time since anyone had addressed them. Although this resident had previously received podiatry care with recommendations for routine follow-up, there was no evidence of ongoing podiatry services. Facility staff interviews confirmed that diabetic residents should be seen by podiatry, but neither of the two residents were listed on the facility's podiatry roster, and the Social Services Director acknowledged that there had not been a podiatry provider in the facility for some time.
Failure to Maintain and Store Respiratory Equipment Appropriately
Penalty
Summary
The facility failed to maintain and store respiratory equipment appropriately for a resident with a tracheostomy. Observations revealed that the resident's oxygen concentrator was dirty, with dried particles and a sticky surface, and the air filter was covered in white dust. The suction tubing was outdated, and the Yankauer suction tip was not stored in a plastic bag as required. These findings were confirmed during multiple observations and interviews with staff, who acknowledged that the equipment should have been cleaned and supplies changed according to facility policy and physician orders. The resident involved had significant medical needs, including anoxic brain damage, chronic respiratory failure, a gastrostomy, and a tracheostomy. Physician orders specified that oxygen was to be administered via trach mask with humidified air, and that respiratory supplies and equipment were to be changed regularly, with the concentrator filter cleaned weekly. Despite these orders and facility policy, the required cleaning and maintenance were not performed, resulting in the presence of soiled and improperly stored respiratory equipment.
Failure to Follow Infection Control Protocols for PPE, Hand Hygiene, and Equipment Cleaning
Penalty
Summary
Staff failed to follow infection prevention and control protocols as outlined in the facility's policies on Personal Protective Equipment (PPE) and Hand Hygiene. Two CNAs did not wear gowns or perform hand hygiene before, between, or after glove changes while providing personal care to a resident on Enhanced Barrier Precautions (EBP) due to an indwelling urinary catheter and pressure ulcers. During the care, gloves were changed multiple times without hand hygiene, and clean gloves were donned without sanitizing hands. The CNAs also touched various surfaces in the resident's environment without changing gloves or performing hand hygiene, and left the room without sanitizing their hands. A wound care RN also failed to perform hand hygiene before, between, and after glove changes during a dressing change for another resident. Additionally, two Certified Medication Aides did not sanitize a wrist blood pressure cuff between uses on different residents. Interviews with staff and leadership confirmed that infection control procedures were not followed as per facility policy, despite recent training.
Failure to Maintain Confidentiality of Resident Information
Penalty
Summary
The facility failed to ensure the confidentiality of personal and medical records for two residents. During an observation, it was noted that medication cards containing resident information were left unattended on top of the medication cart in the 400-hall. These cards were exposed and accessible to residents, staff, and visitors walking in the hall. The medication cards included sensitive information such as the resident's name, room number, physician name, and prescribed medication. This was in direct violation of the facility's policies on Resident Rights and Confidentiality of Personal and Medical Records, which mandate that personal and medical information should not be left unattended or viewable by unauthorized persons. During interviews, an LPN confirmed that the medication cards were inappropriately left unattended and demonstrated the correct procedure for disposing of them, which involves tearing off the top of the card containing resident information and placing it in the cart for proper disposal. The Administrator also confirmed that the expectation was for the nurse to tear off the top of the medication card and dispose of it appropriately to maintain the residents' privacy. This incident highlights a failure in adhering to the facility's policies and procedures regarding the confidentiality of resident information.
Failure to Follow Grievance Procedures
Penalty
Summary
The facility failed to follow its grievance procedures for a resident who was moderately cognitively impaired, as evidenced by a BIMS score of 10 out of 15. The resident's representative filed a grievance citing concerns about late medication administration, a dirty environment, a broken toilet seat, and the resident not being changed timely. The facility's policy required prompt efforts to resolve grievances and to provide a written decision to the resident or representative, but these steps were not completed. The Concern Form lacked documentation of follow-up actions, dates, and whether the individual was satisfied with the resolution. Interviews with staff revealed inconsistencies and a lack of clear communication regarding the grievance process, with the Social Services Director and Regional Nurse unable to recall specific details or confirm resolution steps taken. The Administrator acknowledged meeting with the family and addressing the medication issue but did not provide an explanation for the incomplete Concern Form. The Social Services Director mentioned logging the grievance for tracking but could not confirm if a resolution was reached. The Regional Nurse, who was previously the interim DON, stated she would typically write a response and pass it to the Social Services Director but did not remember the details of her involvement in this case. This lack of documentation and follow-up indicates a failure to adhere to the facility's grievance policy, resulting in the resident's concerns not being adequately addressed or resolved in a timely manner.
Failure to Maintain Dressing for Stage IV Sacral Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a stage IV sacral pressure ulcer had a dressing maintained, leaving the wound exposed to urine and feces. The resident, who had diagnoses including type two diabetes with hyperglycemia and morbid obesity, was observed without a dressing on the sacral ulcer during a wound care observation. The facility's policy required that dressings be replaced if they became soiled or dislodged, but this was not adhered to in this case. The Wound Care Nurse confirmed that the dressing was missing and stated that nursing staff should have either replaced it or notified her if it had fallen off during care. Interviews with the Assistant Director of Nursing, Certified Nurse Aides, and the Administrator revealed that the staff were expected to notify a nurse if a dressing became soiled or dislodged. However, the Certified Nurse Aides were unaware that the dressing was missing and had not informed the nurse. The failure to maintain the dressing as per the facility's policy and the lack of communication among staff led to the deficiency in care for the resident's pressure ulcer.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate documentation for three residents. For Resident 3, the electronic medical records indicated that gabapentin was not documented as administered on multiple occasions in March and April 2024, with no corresponding nursing notes to explain the omissions. The Regional Nurse confirmed that the missing documentation should have been recorded accurately. Resident 3 was admitted with diagnoses including chronic pain, left hand contracture, and gastrostomy status, and had a BIMS score indicating moderate cognitive impairment. For Resident 1, there was no documentation of the resident's intake on several dates in March 2024. Resident 1 was admitted with diagnoses including necrotizing fasciitis, cystitis, and acute respiratory failure with hypoxia. For Resident 4, there was missing documentation for personal hygiene, bladder elimination, and the amount eaten on various dates in January and March 2024. The Administrator confirmed the missing documentation and stated that the expectation was for care provided to be documented appropriately. Resident 4 was admitted with diagnoses including chronic kidney disease, type two diabetes, and congestive heart failure.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
