Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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 moderate cognitive impairment, Alzheimer's disease, a stage 3 sacral pressure sore, and incontinence was exposed during wound care when a Wound Care Nurse and CNA left the blinds open in the resident's private room while changing a soiled brief. The Wound Care Nurse, CNA, Unit Supervisor, and DON all confirmed that privacy should have been provided by closing the blinds and pulling the curtains.
Resident-to-resident abuse occurred when a resident with dementia and severe cognitive impairment touched another resident’s breast over clothing in a common area. The affected resident, who had Down syndrome and severe cognitive impairment, was tearful afterward and later confirmed the bad touch. Staff and the administrator acknowledged the contact, and the other resident’s history included wandering, entering rooms, and other inappropriate behaviors.
A resident discharged home, but the MDS discharge assessment was not completed or transmitted to CMS. The resident had diagnoses including streptococcal sepsis, cellulitis of the right lower limb, and COPD, and the care plan noted the resident wanted to discharge after antibiotic therapy was completed. The MDS/Resident Assessment Director confirmed the discharge occurred without the required discharge assessment, and the Administrator was unsure why it was not completed.
Improper Medication Administration via Enteral Tube: An LPN crushed all of a resident’s medications together and administered them through a gastrostomy tube after flushing with water, despite the facility policy stating each medication must be given separately. The resident had cerebral palsy, asthma, protein-calorie malnutrition, dysphagia, and a G-tube, and was ordered NPO with water before and after each medication pass.
Expired and unlabeled medications were found on three med carts. An LPN observed expired eye drops and an unlabeled Lantus pen on one cart, expired Insulin Aspartate on another, and expired morphine liquid, tramadol, and lorazepam in a lock box on a third cart. The PC stated meds should have open and expiration dates, insulin from the emergency kit should be labeled with the resident's name and room, and narcotics for a deceased resident should not be left in the med cart.
Failure to follow EBP during wound care assistance. A resident with Alzheimer's disease, a stage 3 sacral pressure sore, and incontinence had an order for EBP for the wound. During an observation, a CNA assisted with changing the resident's soiled brief while wearing gloves but no gown, then continued helping the Wound Care Nurse without a gown. The CNA confirmed she should have worn a gown, and the DON stated staff were to wear gowns and gloves for residents under EBP.
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.
Resident Exposed During Wound Care
Penalty
Summary
Facility A failed to provide privacy to one resident during wound care. The resident had a significant change MDS assessment dated 12/23/2025 showing a BIMS score of 10, indicating moderate cognitive impairment, and diagnoses including Alzheimer's disease, a stage three sacral pressure sore, psychotic disturbances, and malignant neoplasm of the stomach. The care plan dated 12/9/2025 noted the resident had a pressure ulcer related to needing assistance with bed mobility and bowel and bladder incontinence. During observation on 2/11/2026 at 10:30 AM, the Wound Care Nurse knocked on the resident's door, introduced herself, and explained the procedure before returning to obtain supplies. The resident was in a private room with the blinds open, and CNA EE removed and changed the resident's soiled brief while the blinds remained open, exposing the resident during the wound care. The Wound Care Nurse confirmed the blind was open and should have been closed for privacy, CNA EE confirmed the resident was exposed during the entire care, and the Unit Supervisor and DON stated that blinds should be closed and curtains pulled when providing care.
Resident-to-Resident Inappropriate Touching
Penalty
Summary
Facility A failed to protect a resident with severe cognitive impairment from resident-to-resident abuse when another resident touched her breast over her clothing in a common area. The resident involved in the incident had diagnoses including Down syndrome and mild neurocognitive disorder, and her MDS showed a BIMS score of 3, indicating severe cognitive impairment. The other resident involved had diagnoses including Alzheimer’s disease and dementia with behavioral disturbances, and his care plan documented wandering, entering other residents’ rooms, walking in the hallway naked, and other inappropriate behaviors. According to the progress notes and staff interviews, the incident occurred while the resident was seated in a common area near the nurses’ station. Staff observed the other resident touch her left breast while he was rubbing her stomach, and staff intervened by separating the residents and redirecting him. The resident was tearful after the incident but denied pain or injury, and no redness, bruising, or marks were noted to her breast. The police report stated that the resident’s breast area was rubbed across the outer clothing as staff moved his hand away, and the LPN was unsure whether the contact was accidental. The resident later confirmed that she knew the other resident and did not like it when he came into her room. She stated that he touched her and pointed to her breast, describing it as a bad touch. The administrator also confirmed that the resident was crying and that the other resident patted her on the shoulder and then her breast while telling her she was going to be alright. The report documents that the resident-to-resident contact occurred in the facility and involved a vulnerable resident with significant cognitive impairment.
Failure to Complete MDS Discharge Assessment
Penalty
Summary
Facility B failed to complete and transmit a Minimum Data Set (MDS) discharge assessment to CMS for one resident, R137, who was reviewed for discharge. R137 was admitted with diagnoses including streptococcal sepsis, cellulitis of the right lower limb, and chronic obstructive pulmonary disease. The EMR progress notes showed that R137 discharged home, but the MDS section did not contain a completed discharge assessment. The care plan noted that R137 wished to discharge once antibiotic therapy was completed and included interventions such as contacting the MD for discharge orders, arranging community resources to support independence after discharge, and reviewing medications and MD orders with the resident and family. During interview, the MDS/Resident Assessment Director confirmed that R137 was discharged but the discharge assessment was not completed, and the Administrator stated she was unsure why the discharge had not been completed.
Improper Medication Administration via Enteral Tube
Penalty
Summary
Facility A failed to ensure services provided met professional standards of quality care for one resident with a gastrostomy tube. The facility policy titled Medication Administration via Enteral Tube stated that each medication was to be administered separately and not combined or added to an enteral feeding formula. The resident had diagnoses including cerebral palsy, asthma, protein-calorie malnutrition, gastrostomy tube, and dysphagia, and required maximal assistance with ADLs. The resident also had a diet order for nothing by mouth and an order to receive 60 ml of water before and after each medication pass. During observation, an LPN crushed all of the resident’s medications together in a medication pouch. After flushing the tube with 100 ml of water, the LPN administered the crushed medications through the tube. The LPN confirmed that all medications were crushed and administered together and acknowledged that they should have been crushed and administered separately. The DON later stated that nurses were to crush each medication separately and administer them separately through a feeding tube.
Expired and Unlabeled Medications Found on Medication Carts
Penalty
Summary
Facility A failed to ensure that medications and biologicals stored on three medication carts were labeled and stored in accordance with accepted professional principles. On the [NAME] Hall medication cart, an LPN observed a bottle of eye drops that had expired on 1/18/2026 and a Lantus pen that was not labeled with a resident's name. The LPN confirmed that the eye drops were expired and that the Lantus pen was unlabeled and came from the emergency box. On the Sunflower Hall medication cart, an LPN observed Insulin Aspartate that had been opened on 1/10/2026 and expired on 2/7/2026, and the LPN confirmed it was expired. On the Dogwood Trail medication cart, an LPN observed morphine liquid, tramadol, and lorazepam in the third drawer lock box for a resident that had expired on 1/26/2026. The pharmacist consultant stated that medications should be labeled with open and expiration dates, that insulin from the emergency kit should include an open date, expiration date, patient's name, and room, that eye drops were good for 30 days after opening, and that narcotics for a deceased resident were to be turned in immediately to the DON and should not be left in the medication cart.
Failure to Follow Enhanced Barrier Precautions During Wound Care Assistance
Penalty
Summary
Facility A failed to ensure infection control practices were followed for one of two sampled residents reviewed for pressure ulcers. R22 had diagnoses that included Alzheimer's disease, a stage three sacral pressure sore, psychotic disturbances, and malignant neoplasm of the stomach. The resident's care plan noted that R22 had a pressure ulcer related to assistance needed with bed mobility and bowel and bladder incontinence. A physician order dated 1/26/2026 directed enhanced barrier precautions for the wound every shift. During an observation on 2/11/2026 at 10:30 AM, the Wound Care Nurse knocked on R22's door, introduced herself, and explained the procedure. She cleaned the bedside table, returned to her treatment cart to obtain supplies, and then received assistance from CNA EE. CNA EE was wearing gloves but no gown, removed and changed R22's soiled brief, washed her hands, changed gloves, and continued assisting the Wound Care Nurse without a gown. CNA EE confirmed she was not wearing a gown and acknowledged that she should have worn one. The DON stated that staff were to check the sign on the door, read what it says before entering, and wear gowns and gloves for residents under enhanced barrier precautions.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waycross
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waycross Health And Rehabilitation | 0.3 mi | ★★★★★ | 3 | 0 |
| Baptist Village, Inc. | 3.3 mi | ★★★★★ | 7 | 0 |
| Bayview Nursing Home | 21.3 mi | ★★★★★ | 10 | 0 |
| Twin Oaks Convalescent Center | 22.2 mi | ★★★★★ | 0 | 0 |
| River Brook Healthcare Center | 26.7 mi | ★★★★★ | 15 | 0 |
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