Harborview Satilla
Inspection history, citations, penalties and survey trends for this long-term care facility in Waycross, Georgia.
- Location
- 1600 Riverside Ave, Waycross, Georgia 31501
- CMS Provider Number
- 115265
- Inspections on file
- 20
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Harborview Satilla during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including dementia, muscle weakness, CHF, osteoarthritis, and HTN, had a comprehensive care plan requiring two-person assistance and use of a mechanical lift for all transfers and care due to mobility and self-care impairments. Despite this, a CNA performed a transfer to a shower chair alone, without the required second staff member or adherence to the two-person mechanical lift intervention. The resident subsequently complained of left shoulder pain, was observed with bruising under the left axilla and arm, and an X-ray confirmed a left proximal humerus fracture. Facility leadership and the CNA acknowledged that the documented care plan required two-person mechanical lift transfers.
A resident with dementia, muscle weakness, CHF, osteoarthritis, and HTN, who was care-planned as a two-person assist for transfers using a mechanical lift, was transferred to a shower chair by a CNA without using the mechanical lift and without a second staff member physically assisting. Another CNA only held the shower chair while the first CNA lifted the resident under the arms, contrary to the facility’s Safe Resident Handling/Transfer policy and the resident’s documented transfer needs. Following this transfer, bruising and pain were noted in the resident’s left shoulder/axilla area, and imaging confirmed a proximal left humerus fracture.
Surveyors found that the facility did not follow its date-marking and food safety policy in the kitchen, where food is prepared for residents on oral diets. During a walkthrough with the DM, items in the walk-in freezer, including filet fish, sweet potato waffle fries, and chicken fingers, were observed to be opened, unsealed, undated, and/or unlabeled, with one bag of fish also noted to be freezer burned. These issues affected food stored for residents receiving facility-prepared meals.
Surveyors found that one of the facility’s dumpsters was left with its lid open and unattended, contrary to the facility’s written policy requiring garbage containers to be covered when not in use. During an observation with the Dietary Manager, the open dumpster was noted with no staff in the area, and both the Dietary Manager and the Administrator later confirmed that the lid should have been closed, resulting in a deficiency related to unsanitary handling of garbage and refuse for a census of 75 residents.
A resident with significant physical impairments and a care plan requiring two-person assistance for toileting and other activities was cared for by a single CNA, contrary to the documented interventions. This failure led to the resident falling out of bed and sustaining a femoral neck fracture and scalp hematoma.
A resident with severe contractures and total care needs was not provided with the required two-person assistance during perineal care in bed. While a CNA was providing care alone, the resident rolled off the bed and sustained a femoral neck fracture and scalp hematoma. Staff interviews indicated that two-person assistance was necessary for this resident, but only one CNA was present at the time of the incident, contrary to the facility's policy and the resident's assessed needs.
A resident at Facility B was found with cough drops at their bedside without a physician's order, contrary to the facility's policy on medication administration. The resident, who had severe cognitive impairment, had the cough drops brought in by a family member. Staff confirmed the policy violation and noted that medications should not be stored at the bedside without proper authorization.
Facility A failed to provide a written notice of transfer or discharge to a resident's representative, as required by their policy. The resident, with severe dementia and other medical conditions, was transferred to the hospital twice, but the representative was only notified by phone. Staff confirmed that no written notice was given, despite the facility's policy.
Facility A failed to provide a written notice of bed hold to a resident's representative during two hospital transfers, as required by policy. The resident, with severe dementia and other conditions, was transferred without the representative receiving the necessary written information. Staff confirmed that only verbal notifications were made, and the facility's Administrator acknowledged incomplete bed hold agreements.
Facility A failed to implement care plans for two residents. One resident, with a risk for falls, was not provided a scoop mattress as required by their care plan. Another resident, with severe cognitive impairment, did not receive necessary nail care, resulting in long, discolored nails and a foul odor. Staff interviews confirmed these deficiencies.
A resident with a left-hand contracture and severe cognitive impairment did not receive proper nail care as per facility policy. Observations showed the resident's nails were long, discolored, and embedded into the palm, emitting a foul odor. The family and DON confirmed the neglect, highlighting a deficiency in care.
A resident with COPD and other conditions was observed receiving oxygen at 4 liters per minute, contrary to the physician's order of 2 liters per minute. Facility staff, including LPNs and the DON, confirmed the discrepancy, noting that nurses are responsible for ensuring correct oxygen rates. The facility lacks a dedicated respiratory department, placing the onus on nursing staff to monitor oxygen administration.
Facility B did not document the rationale for extending a PRN order for Alprazolam beyond 14 days for a resident with Alzheimer's/Dementia, contrary to its policy. The resident was prescribed the medication for anxiety, but the required documentation for extending the order was missing. Interviews revealed that the physician cited convenience for the prescription duration, indicating non-compliance with the facility's policy.
Facility A failed to properly label and discard expired food items in the walk-in cooler and dry storage, affecting 86 of 89 residents on an oral diet. During a kitchen tour, expired and unlabeled food items were found, including garlic, sweet potatoes, carrots, tomatoes, bananas, and pasta. The Dietary Manager and Administrator acknowledged the oversight, which was attributed to staff not following the facility's date marking policy.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Fracture
Penalty
Summary
Facility A failed to implement the comprehensive, person-centered care plan for one sampled resident, resulting in actual harm. The facility’s policy dated 1/1/2023 required development and implementation of comprehensive care plans with measurable objectives and timeframes to meet residents’ medical, nursing, mental, and psychosocial needs. The quarterly MDS for Resident 112 dated 11/29/2025 documented a BIMS score of 15, indicating little to no cognitive impairment, and noted that certain transfers were not attempted due to medical condition or safety concerns. Active diagnoses included dementia, muscle weakness, congestive heart failure, osteoarthritis, and hypertension. The resident’s care plan, initiated 6/8/2022 and revised 2/7/2024, specified that the resident needed assistance with grooming, bathing, and personal hygiene related to mobility and self-care impairment, and required two people at all times when giving care. Interventions included bathing assistance of two people, a requirement for two people for all care provided, and transfer assistance of two people with a mechanical lift. Despite these documented care plan interventions, on 12/5/2025 Certified Nurse Aide LL transferred the resident without assistance, contrary to the requirement for two-person mechanical lift transfers. Following a transfer to a shower chair, the resident complained of pain to the left shoulder and was noted to have bruising under the left axilla and left arm. An incident report dated 12/7/2025 recorded these findings, and an X-ray showed a fractured left proximal humerus. In interviews, CNA LL confirmed that the resident required a mechanical lift transfer with two people and acknowledged transferring the resident alone. The National Director of Risk Management and the Administrator both confirmed that the care plan documented the need for two-person assistance with a mechanical lift for transfers.
Unsafe Shower Transfer Without Required Two-Person Mechanical Lift Assist
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer practices and adequate supervision during a shower transfer for one resident, resulting in a left humerus fracture. The facility’s Safe Resident Handling/Transfer policy stated that residents were to be handled and transferred safely to prevent or minimize risk of injury and to provide a safe, secure, and comfortable experience. The quarterly MDS for the resident documented a BIMS score of 15, indicating little to no cognitive impairment, and noted that chair-to-bed-to-chair and tub/shower transfers were not attempted due to medical or safety concerns. The resident’s active diagnoses included dementia, muscle weakness, congestive heart failure, osteoarthritis, and hypertension. Progress notes dated two days after the incident documented bruising under the resident’s left axilla with reported tenderness, and an X-ray confirmed a fracture of the proximal left humerus. The facility incident report stated that the resident complained of left shoulder pain after a transfer to a shower chair, with bruising noted under the left axilla and left arm. CNA LL acknowledged that the resident required a mechanical lift with two staff for transfers but reported that, when all mechanical lift pads were in use and the resident insisted on a shower, she transferred the resident without assistance, while another CNA only held the shower chair and did not physically assist with the transfer. CNA MM confirmed that she held the shower chair while CNA LL physically lifted the resident under the arms without using the mechanical lift, despite the resident’s requirement for a two-person mechanical lift transfer. The Administrator and the National Director of Risk Management both confirmed that the resident was a two-person assist for transfers using a mechanical lift and that there should have been a second CNA assisting with the transfer.
Improper Storage, Sealing, and Labeling of Frozen Food Items
Penalty
Summary
Facility A failed to ensure food was stored, sealed, and labeled correctly in the main kitchen, contrary to its policy titled "Date Marketing for Food Safety Policy" dated 1/1/2026, which requires adherence to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. During a kitchen walkthrough with the Dietary Manager, surveyors observed in the walk-in freezer a bag of filet fish that was freezer burned, undated, and unlabeled; sweet potato waffle fries that were unsealed and unlabeled; and two separate bags of chicken fingers that were opened, unsealed, and undated. These conditions were identified in the facility kitchen, which prepared oral diets for 75 sampled residents, and the Dietary Manager confirmed the observations during interview. The deficient practice had the potential to cause food contamination and foodborne illness among all residents consuming facility-prepared food, as stated in the report.
Improper Maintenance of Dumpster Lid for Garbage and Refuse
Penalty
Summary
Facility A failed to maintain one of two outdoor dumpsters in a sanitary manner as required by its policy titled "Disposal of Garbage and Refuse." The written procedure stated that containers must be durable, cleanable, free from cracks or leaks, and covered when not in use. During an observation conducted with the Dietary Manager, one dumpster was observed with its lid open and no staff present in the area. In a subsequent interview, the Dietary Manager confirmed the observation and acknowledged that the dumpster lid should be closed when not in use. Later, the Administrator also confirmed these findings and acknowledged that the dumpster lid should be closed when not in use, resulting in a deficiency related to improper disposal and containment of garbage and refuse for a facility census of 75 residents. No specific residents were individually identified or described in the report, and no resident medical histories or conditions at the time of the deficiency were provided.
Failure to Follow Two-Person Assistance Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to follow the comprehensive care plan for a resident who required two-person assistance for toileting and other activities of daily living. The care plan, based on the resident's medical history of hemiplegia, hemiparesis, muscle weakness, and other significant diagnoses, specified that two staff members were needed for toileting, transfers, bathing, bed mobility, and dressing due to the resident's inability to assist with their own care and severe physical limitations. Despite these documented needs and interventions, a Certified Nursing Assistant (CNA) provided care alone, without the required second staff member. As a result of this failure to follow the care plan, the resident fell out of bed while being cared for by a single CNA, sustaining a left femoral neck fracture and a left frontal scalp hematoma. Staff interviews confirmed that the care plan required two people for all care activities involving the resident, and that assistance could have been obtained from another CNA or nurse if needed. The incident was identified as actual harm to the resident due to noncompliance with the established care plan.
Failure to Provide Adequate Staff Assistance During In-Bed Care Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with significant medical conditions, including hemiplegia, hemiparesis, severe contractures, and total care needs, was not provided with adequate staff assistance during perineal care in bed. The facility's policy required that supervision and assistance be based on individual resident needs and identified hazards, but on the day of the incident, only one CNA was present to assist the resident, despite multiple staff interviews indicating that two-person assistance was necessary due to the resident's severe contractures and inability to help with care. During the incident, the CNA rolled the resident to one side to perform care and then moved to the other side of the bed. While the CNA was walking around the bed, the resident shifted and rolled off the bed, resulting in a fall. The resident sustained a left femoral neck fracture and a left frontal scalp hematoma, requiring emergency medical evaluation. The CNA reported that she was trained to provide one-person assistance for this resident, but other staff members stated that two-person assistance was typically required and that the CNA had been trained accordingly. Interviews with other CNAs and nursing staff confirmed that the resident's care needs required two people to safely provide assistance and maintain posture during bed mobility. The Director of Nursing and the Administrator were unable to explain why the CNA did not have a second person assisting and acknowledged that additional help could have been provided. The facility failed to ensure that adequate supervision and assistance were provided according to the resident's assessed needs, resulting in actual harm.
Unauthorized Bedside Storage of Medication
Penalty
Summary
Facility B failed to ensure that over-the-counter medications were not stored at the bedside for one resident, identified as R151. The facility's policy on medication administration requires that residents can only self-administer medications if they are authorized by their attending physician and the interdisciplinary team, and the medications must be kept in a locked safe box in the resident's room. However, it was observed that R151 had a plastic zip closure storage bag of cough drops on his bedside table without a physician's order or a care plan for self-administration of medication. R151 was admitted with multiple diagnoses, including severe cognitive impairment, and there was no documentation in the electronic medical records (EMR) for a physician's order for the cough drops. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that the cough drops were brought into the facility by a family member, and it was against the facility's policy to have medications at the bedside without proper authorization. The LPN advised R151 that he could not have the cough drops at his bedside, and the DON stated that it was discussed upon admission that no medication could be brought into the facility. The Administrator also expected staff to follow policies and procedures, and staff were to be reeducated about self-administration of medication.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
Facility A failed to provide the required written notice of transfer or discharge to a resident's representative, as mandated by their policy. The deficiency was identified during a review of the facility's policy titled 'Transfer and Discharge,' which was revised on 7/1/2024. The policy requires that a notice of transfer and the facility's bed hold policy be provided to the resident and their representative. However, for one resident, who was transferred to the hospital on two separate occasions, there was no evidence that such notice was provided to the resident's representative. The resident, who had diagnoses including sepsis, severe dementia with psychotic disturbance, and epilepsy, was transferred to the hospital on 10/22/2024 and 1/4/2025, but the representative was not informed in writing. Interviews with facility staff, including LPNs and the Business Office Manager, revealed that while the resident's representative was notified via telephone, no written notice was provided. The staff confirmed that the facility's practice was to notify representatives by phone and complete a transfer document in the electronic health record, but they did not provide written documentation regarding the reason for transfer or discharge. The Business Office Manager and the Administrator both acknowledged that no written notice was given, despite the facility's policy requirements.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
Facility A failed to provide a written notice of bed hold to a resident's representative during two separate hospital transfers. The facility's policy requires that written information regarding bed hold policies be provided to residents and/or their representatives prior to and upon transfer for absences such as hospitalization or therapeutic leave. However, in the case of one resident, identified as R2, there was no evidence of such notice being provided during transfers on two occasions. The resident, who had diagnoses including sepsis, severe dementia with psychotic disturbance, and epilepsy, was transferred to the hospital on two separate dates and readmitted to the facility without the representative receiving the required written notice. Interviews with facility staff, including LPNs and the Business Office Manager, confirmed that while verbal notifications were made via telephone, no written documentation was provided to the resident's representative regarding the bed hold policy. The representative, from the Office of the State Guardian, also confirmed not receiving any written notice and was unaware of one of the hospital stays until visiting the resident. Additionally, the facility's Administrator acknowledged that bed hold agreements were incomplete, lacking necessary signatures and contact information, and were not sent in writing to the representative.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
Facility A failed to implement the care plan for two residents, R22 and R12, as observed during a survey. For R22, who was admitted with diagnoses including depression and anxiety, the care plan dated 11/27/2024 indicated a risk for falls and included the use of a scoop mattress as an intervention. However, observations on 1/9/2024 revealed that R22 was using a standard facility mattress instead of the prescribed scoop mattress. Interviews with the LPN and the Director of Nursing confirmed the discrepancy, acknowledging that the care plan was not followed as written. For R12, who had diagnoses including dementia and required total assistance with all Activities of Daily Living, the care plan included nail care as needed. During an observation on 1/7/2025, R12's left hand was found with long, discolored fingernails embedded into the palm, emitting a foul odor. Interviews with R12's family member and the DON confirmed the lack of proper nail care, as the staff failed to trim the nails and clean the hand, contrary to the care plan's requirements. The MDS Coordinator also confirmed that the care plan's intervention for nail care included trimming and cleaning, which was not executed by the staff.
Failure to Provide Adequate Nail Care for a Dependent Resident
Penalty
Summary
Facility A failed to perform adequate nail care for a resident who was totally dependent on staff for activities of daily living. The resident, identified as R12, had a left-hand contracture and severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of three. The facility's policy required routine cleaning and inspection of nails during ADL care, and R12 had a physician's order for weekly nail care every Tuesday. However, observations revealed that R12's fingernails on the left hand were long, discolored, and embedded into the palm, emitting a foul odor. This condition had the potential to cause skin injury or discomfort. Interviews with the resident's family member and the Director of Nursing (DON) confirmed the neglect in nail care. The family member reported that the staff were not trimming the resident's fingernails, and the hand had a sour odor due to lack of washing. The DON acknowledged the long nails and mild odor, stating that all staff, including certified nursing assistants and licensed nursing staff, were expected to monitor and provide nail care. The failure to adhere to the facility's nail care policy resulted in a deficiency in the care provided to R12.
Oxygen Administration Deficiency
Penalty
Summary
Facility B failed to ensure that oxygen was administered at the prescribed rate for a resident receiving oxygen therapy. The facility's policy on oxygen administration requires that oxygen be administered under a physician's order, except in emergencies. The resident, who has diagnoses including dementia, COPD, anxiety disorder, and allergic rhinitis, was observed to have oxygen administered at 4 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This discrepancy was noted during observations on two consecutive days, with no respiratory distress observed in the resident. Interviews with facility staff, including LPNs and the DON, revealed that the nurses are responsible for ensuring the correct oxygen rate is administered. However, the resident's oxygen was consistently set at 4 liters per minute, as confirmed by multiple staff members. The facility does not have a dedicated respiratory department, and the responsibility for monitoring oxygen rates falls on the nursing staff. The deficiency was identified through staff interviews and observations, highlighting a failure to adhere to the physician's order for oxygen administration.
Failure to Document Rationale for Extended PRN Psychotropic Medication
Penalty
Summary
Facility B failed to comply with its policy on the use of psychotropic medications by not documenting the rationale for extending a PRN order for an antianxiety medication beyond 14 days for a resident. The facility's policy requires that PRN orders for psychotropic drugs be used only when necessary to treat a diagnosed specific condition and for a limited duration of 14 days unless a rationale for extension is documented. In this case, the resident, who was admitted with Alzheimer's/Dementia and associated symptoms, was prescribed Alprazolam 0.5 mg PRN for anxiety, with a start date of 11/4/2024 and an end date of 11/4/2025, without the required documentation for extending the order beyond 14 days. Interviews with the Director of Nursing and the primary physician revealed awareness of the 14-day limit for PRN psychotropic medications. However, the physician cited convenience as the reason for the prescription duration, indicating a lack of adherence to the facility's policy. The resident's clinical record did not contain the necessary documentation to justify the continued use of Alprazolam beyond the 14-day period, leading to the identified deficiency.
Improper Food Labeling and Expiration Management
Penalty
Summary
Facility A failed to adhere to its policy on date marking for food safety, which led to the presence of expired and improperly labeled food items in the walk-in cooler and dry storage area. During a tour of the kitchen, several food items were found to be either expired or lacking proper labeling, including large containers of peeled garlic, a box of sweet potatoes, carrots, tomatoes, and bananas, as well as an opened bag of pasta without a use-by date. These deficiencies were identified during a kitchen tour conducted with the Dietary Manager. Interviews with the Dietary Manager and the Administrator revealed that the responsibility for labeling and discarding expired food items was assigned to dietary staff, but these tasks were not completed as expected. The Dietary Manager acknowledged that the items identified during the survey were either expired or not labeled correctly, and the Administrator confirmed that the failure to follow the policy could potentially affect all residents receiving an oral diet.
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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