Harborview Thomasville
Inspection history, citations, penalties and survey trends for this long-term care facility in Thomasville, Georgia.
- Location
- 930 South Broad St., Thomasville, Georgia 31792
- CMS Provider Number
- 115501
- Inspections on file
- 22
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Harborview Thomasville during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of dementia was identified as being at risk for elopement and required a functioning wander guard bracelet per their care plan. Staff discovered the bracelet was not working during an observation, and interviews confirmed that daily checks and timely replacement of malfunctioning devices were required by facility policy but were not followed.
Surveyors identified multiple deficiencies in food storage, labeling, and kitchen sanitation, including expired and unlabeled food items, unsanitary appliances and surfaces, and evidence of pests and dirt in food service areas. These failures were confirmed by the Dietary Manager and Administrator and had the potential to affect nearly all residents receiving an oral diet.
Surveyors identified improper storage of medications and biologicals, including medications left on the counter for return and expired supplies such as catheter trays, swab cap covers, and feeding tube bags in the medication storage room. Staff interviews revealed unclear processes for tracking discontinued medications and inconsistent checks for expired items, contrary to facility policy.
Several rooms were found to have privacy curtains that were either too short or not fully functional, resulting in residents being exposed during care. In one case, a resident with dementia and other medical conditions was observed sitting topless in her room, visible from the hallway due to the absence of a privacy curtain. Staff interviews confirmed they were unaware of these deficiencies until they were pointed out.
A resident with dementia was physically assaulted on two occasions by another cognitively impaired resident, first with a cane and later with a broom, resulting in a fall and ER evaluation. Despite facility policy and staff training on abuse prevention, law enforcement was not contacted after either incident, and staff efforts to keep the residents separated were not consistently effective.
Two residents with dementia were involved in separate incidents where one struck the other with a cane and later with a broom, causing a fall. Despite facility policy requiring reporting of such abuse to law enforcement, only internal notifications and assessments were completed, and law enforcement was not contacted. The DON confirmed the omission was due to the residents' dementia diagnoses, and the Administrator later acknowledged the reporting failure.
A resident with legal blindness and left side hemiparesis was not provided with the required assistance, adaptive utensils, or divided plate during meals, leading to the resident eating with his hands and experiencing difficulty. Staff failed to follow care plans and physician orders, and the resident's repeated requests for help were not addressed, as confirmed by observations, interviews, and review of facility policies.
Several residents with cognitive and physical impairments were left in beds at the highest position, contrary to their care plans, and unsupervised housekeeping carts containing hazardous items were accessible in multiple areas. Additionally, a resident-to-resident altercation occurred when one resident struck another with a broom obtained from an unattended cart. Staff confirmed lapses in following safety protocols and supervision requirements.
A resident with severe cognitive impairment and multiple diagnoses was found with bilateral bed rails that were loose and could easily bend outward, compromising safety. The DON and maintenance staff were unaware of the issue, and the facility's maintenance checks failed to identify the problem, despite policies assigning responsibility for regular inspection and reporting.
A medication error rate above five percent was identified when an LPN failed to prime insulin pen needles and did not hold the pen in place for the required ten seconds during insulin administration to a resident. Both the LPN and nursing leadership were unaware of these specific requirements, leading to errors in the medication administration process.
A resident with a diagnosis of an unspecified mental disorder and prescribed an antipsychotic was admitted without an accurate PASARR Level I assessment reflecting their mental health condition. The facility's policy requires all applicants to be screened for serious mental disorders, but the resident's Level I application did not list any mental health diagnoses, despite evidence of cognitive impairment and antipsychotic use. Staff confirmed the omission during interviews and record review.
Surveyors found that staff failed to follow care plan interventions for bed positioning and meal assistance for three residents. Two residents with cognitive and physical impairments were left in beds raised to the highest position, contrary to care plans requiring the lowest position for fall prevention. Another resident with hemiparesis and visual impairment did not receive the required assistance and cueing during meals, resulting in difficulty eating and food spillage. Staff and supervisory interviews confirmed these care plan failures.
Surveyors found that personal care items, including urinals and bath basins, were not labeled or bagged in several bathrooms as required by facility policy. The DON confirmed these items should have been labeled and bagged, and a CNA stated that staff were expected to clean, bag, and label them after each use. This deficiency was observed in multiple rooms across two wings.
A resident with a history of major depressive disorder and suicide attempts was involved in multiple self-harm incidents using call light and bed remote cords. The facility failed to report these incidents to the state agency and did not provide necessary psychiatric services or remove potential hazards, leading to repeated self-harm attempts. Misunderstandings about reporting obligations contributed to the facility's noncompliance.
A facility failed to implement necessary safety interventions for a resident with a history of major depressive disorder and suicide attempts. Despite recommendations to monitor the resident's mood and behaviors, the care plan was not updated after the resident was found with cords wrapped around his neck on multiple occasions. This noncompliance led to repeated incidents of self-harm attempts, resulting in the resident's transfer to the hospital and discharge from the facility.
A resident with a history of major depressive disorder and suicide attempts was repeatedly found with cords wrapped around his neck in a facility. Despite the resident's known history and requests for psychiatric evaluation, the facility failed to remove potential choking hazards and did not provide adequate supervision or psychiatric services. The resident continued to exhibit suicidal behavior, highlighting the facility's inaction and failure to implement effective interventions.
A resident with a history of major depressive disorder and suicide attempts was not provided necessary behavioral health services in an LTC facility. Despite being seen by a geriatric psychologist, the resident was found multiple times with cords around his neck, indicating self-harm attempts. The facility failed to remove these hazards or provide timely psychiatric interventions, leading to an Immediate Jeopardy determination.
A facility failed to provide adequate supervision and oversight for a resident with suicidal ideations, leading to multiple self-harm attempts using cords. Despite a history of major depressive disorder and previous suicide attempts, the facility did not ensure a safe environment or implement effective interventions. The resident was found with cords wrapped around his neck on several occasions, and the facility failed to provide necessary psychiatric services or contact their behavioral consultant.
Two residents with mobility impairments and fall risks were found with their call lights out of reach, contrary to their care plans. Observations showed that the call lights were consistently on the floor, making them inaccessible. The DON acknowledged the issue and planned to reeducate staff on proper call light placement.
The facility failed to maintain a clean and homelike environment in seven rooms, with issues such as missing ceiling tiles, cracked moldings, and dirty linens. Observations confirmed no changes were made to address these deficiencies. Interviews revealed a breakdown in the process for reporting and addressing maintenance issues.
The facility failed to refund personal funds to two residents within the required 30 days after discharge. One resident, with Alzheimer's and COPD, received a refund six months late, while another, with diabetes and hypothyroidism, had funds withheld without authorization and was also refunded late.
A resident with Alzheimer's and other conditions was transferred to a behavioral facility without a 30-day discharge notice. Despite a care plan for long-term care and the previous administrator's willingness to readmit the resident, a corporate decision was made not to accept the resident back, citing safety concerns. The facility failed to issue the required notice, and the resident later expired at another facility.
Failure to Ensure Functioning Wander Guard Bracelet for Resident at Risk of Elopement
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident with severe cognitive impairment and a history of dementia, anxiety disorder, major depressive disorder, delusional disorder, and cognitive communication deficit. The resident was identified as being at risk for elopement, and the care plan specified that a wander guard bracelet should be worn and its proper functioning ensured. During an observation, it was found that the resident's wander guard bracelet was not functioning, as confirmed by the Unit Manager, who noted that the device did not respond and required replacement. Interviews with facility staff, including the Unit Manager, Administrator, COO, and Interim DON, revealed that the facility's policy required daily checks of wander guard bracelets to ensure they were working properly and that bracelets should be replaced if malfunctioning or if batteries were low. Despite these policies and care plan interventions, the non-functioning bracelet was not identified or replaced in a timely manner, resulting in a failure to provide adequate supervision and care as outlined in the resident's person-centered plan.
Deficient Food Storage, Labeling, and Sanitation in Dietary Services
Penalty
Summary
The facility failed to ensure that food was properly labeled, stored, and prepared in a sanitary manner, as well as to maintain cleanliness in food service areas, as required by facility policies. During a kitchen tour, surveyors observed multiple expired and unlabeled food items, including thickened juice concentrate, frozen chicken, bread, canned goods, snack cakes, and breadcrumbs. Some items lacked received or expiration dates, and expired products were found in both refrigerated and dry storage areas. The facility's policies required date marking and regular checks by dietary staff, but these procedures were not followed. In addition to food storage issues, the kitchen environment was found to be unsanitary. Surveyors observed dead insects, cobwebs, dirt, dust, and possible rodent feces in the dry pantry. A fan blowing toward the three-compartment sink was covered in dust and dirt, and a vent was also found to be dirty. The shelf above the sink was cluttered and dirty, and appliances such as the microwave, griddle, and ovens were visibly soiled with food residue and grime. The breaker box near the steamer was open and covered in a brown substance, and the kitchen floor and ceiling tiles were stained, dirty, and in disrepair. Additional surfaces, such as the stainless-steel dish crate storage and pipes beneath the dishwasher, were also found to be unclean. Interviews with the Dietary Manager and Administrator confirmed the surveyors' findings. The Dietary Manager acknowledged responsibility for ensuring proper labeling and disposal of expired food, as well as maintaining cleanliness, but admitted that these tasks had not been adequately performed. The Administrator stated that staff had not maintained a clean environment and that equipment was in poor condition despite being relatively new. The deficiencies had the potential to affect nearly all residents receiving an oral diet.
Improper Storage and Expired Medications and Supplies Found in Medication Room
Penalty
Summary
Surveyors found that the facility failed to ensure proper storage of medications, biologicals, and supplies in accordance with manufacturer recommendations and facility policy. During an observation of the medication storage room, medications were found stored on the counter awaiting return to the pharmacy after a resident's discharge. The RN present was unsure if there was a system or log for tracking discharged or discontinued medications, stating that the DON typically handled this process. For narcotics, the RN indicated they must be left in a locked box and given directly to the DON. The facility's policy requires routine inspection of medication rooms for outdated or discontinued medications, but this process was not clearly followed as described by staff. Additionally, expired biologicals and supplies were found in the medication storage room, including opened urethral catheter and foley trays, expired swab cap covers for IVs, and expired feeding tube bags. The RN confirmed that opened trays should have been discarded and acknowledged the presence of expired items. Interviews with the ADON and DON revealed that while purchasing staff help maintain the storage room, all staff are expected to check for expiration dates, but this responsibility was not consistently executed.
Failure to Provide Adequate Privacy Curtains for Residents
Penalty
Summary
Multiple observations revealed that several resident rooms were equipped with privacy curtains that were either too short or not fully functional, preventing residents from receiving full visual privacy during care. In one instance, a resident with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and vascular dementia was observed sitting in her wheelchair without a shirt, fully exposed to the hallway due to the absence of a privacy curtain. Maintenance staff and other residents were present in the hallway at the time, and the room door was open, allowing for direct visibility. The facility's policy required maintaining resident privacy, but this was not upheld in these cases. Additional observations found that privacy curtains in other rooms could not be fully drawn due to extra hooks in the curtain tracks, further compromising privacy for multiple residents. Interviews with staff, including the DON, RN Supervisor, and Maintenance Director, confirmed that they were unaware of the curtain deficiencies until brought to their attention. The lack of adequate privacy measures was noted in several rooms across two wings, affecting the dignity and privacy of the residents involved.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by two separate incidents in which one resident physically assaulted another. Both residents involved had diagnoses of dementia and were cognitively impaired, as indicated by low BIMS scores. In the first incident, one resident was observed hitting the other with a cane in the activities room, following a verbal exchange. Staff intervened, separated the residents, and conducted assessments, but no injuries were noted. In the second incident, after another verbal altercation, the same resident struck the other with a broom, causing the victim to fall and require evaluation at the emergency room. Again, both residents were assessed, and no injuries were noted for the aggressor. Despite the facility's policy prohibiting abuse and requiring protection of residents, law enforcement was not contacted after either incident. The DON stated that police were not called due to the residents' dementia diagnoses and prior experiences with law enforcement. The administrator later confirmed that police should have been notified and was unaware that this had not occurred. Staff had been trained on abuse prevention, and efforts were made to keep the residents separated, but these measures were not consistently effective, and the incidents recurred.
Failure to Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to report two separate incidents of resident-to-resident physical abuse to law enforcement, as required by its own policy and federal regulations. In both incidents, one resident with dementia struck another resident, also with dementia, first with a cane and later with a broom, resulting in the second resident falling to the ground. Both residents were cognitively impaired, as indicated by their low BIMS scores. After each incident, assessments were completed and responsible parties, physicians, and families were notified, but there was no documentation that law enforcement was contacted. Facility policy mandates reporting any reasonable suspicion of a crime, including assault and battery, to law enforcement, regardless of the residents' cognitive status. Interviews with the DON and Administrator confirmed that law enforcement was not notified after either incident. The DON stated that police were not contacted due to the residents' dementia diagnoses and past experiences where law enforcement did not take action. The Administrator acknowledged that law enforcement should have been notified in both cases and was unaware that this had not occurred.
Failure to Assist Resident with ADLs During Meals
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically eating, to a resident with significant impairments. The resident in question was legally blind, had left side hemiparesis, contractures in the left elbow and hand, and required substantial to maximal assistance to use utensils and consume meals. Despite care plans and physician orders specifying the need for a divided plate, set-up, cueing, and assistance during meals, the resident was repeatedly observed eating with his hands due to lack of staff support. Staff did not provide the required divided plate or adaptive utensils, and the resident reported being left to feed himself despite his inability to hold utensils or see his food. Multiple observations confirmed that staff failed to assist or cue the resident during meals, resulting in the resident using his hands and experiencing difficulty and mess while eating. Interviews with the resident, staff, and therapy personnel confirmed the lack of consistent assistance and the absence of required adaptive equipment. The resident had filed grievances about not receiving help, and staff acknowledged that assistance was inconsistent, sometimes due to turnover in dietary management. The occupational therapist confirmed the resident required 1:1 assistance and verbal cues during meals, and that the divided tray was not consistently provided as ordered. These failures directly contradicted the facility's own ADL policy and the resident's care plan, resulting in the resident not receiving necessary services to maintain good nutrition and dignity during meals.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. Two residents with significant cognitive and physical impairments were observed lying in beds that were left in the highest position, contrary to their care plans which required beds to be in the lowest position when unattended. Both residents had diagnoses including dementia and other conditions affecting mobility and cognition, and their care plans specifically identified the need for bed safety interventions due to their risk of falls. Staff confirmed that the beds were left elevated after providing care and acknowledged forgetting to return them to the lowest position, despite being in-serviced on this safety protocol. Additionally, the facility failed to prevent resident-to-resident altercations and to secure potentially hazardous equipment. Two cognitively impaired residents, both with dementia and a history of wandering, were involved in a physical altercation in a common area, where one resident struck the other with a broom, resulting in a fall. The incident occurred in an area where residents had unsupervised access to housekeeping carts containing brooms and other cleaning equipment. Multiple observations revealed that housekeeping carts containing cleaning chemicals and equipment were left unattended and accessible to residents in various wings of the facility. Supervisory staff confirmed that these carts should not have been left unlocked or unattended, especially given the presence of residents with dementia who could access hazardous items. The facility's own policy required the environment to be as free of accident hazards as possible and for residents to receive adequate supervision, but these requirements were not met in the instances described.
Failure to Maintain Bed Rails in Safe and Operable Condition
Penalty
Summary
The facility failed to ensure that bed rails for one resident were maintained in a safe and operable manner, resulting in the rails being loose and not securely fitted. Observations revealed that the resident was lying in bed with bilateral bed rails that could easily bend outward due to an unsecured, loose fit. The Director of Nursing confirmed the rails were very loose and not providing a secure, tight fit. The Maintenance Director and Administrator were unaware of the issue, and the last documented maintenance check did not identify any problems. The resident's electronic health record indicated severe cognitive impairment and diagnoses including anxiety disorder, vascular dementia with behavioral disturbances, and unspecified glaucoma, but no impairment in upper or lower extremities. The facility's Preventative Maintenance Program assigned responsibility for bed rail checks to the Maintenance Director, with monthly inspections reported. However, the loose rails were not identified or addressed until observed during the survey. The DON stated that CNAs were responsible for reporting such issues, but the problem persisted until the survey. The Maintenance Director confirmed that the knobs on the rails were loose and required tightening due to a loose screw.
Medication Error Rate Exceeds Five Percent Due to Improper Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and regulation. During observation of 38 medication administration opportunities for five residents, two errors were identified, resulting in a medication error rate of 5.26 percent. Specifically, an LPN administered insulin to a resident using two different insulin pens but did not prime the needles prior to administration and did not hold the pen against the abdomen for ten seconds after injection, as required to ensure full delivery of the medication. The LPN was observed cleaning the injection sites and administering the correct dosages but omitted these critical steps in the insulin pen protocol. Interviews with the LPN, DON, and ADON revealed a lack of awareness regarding the need to prime insulin pen needles and to hold the pen in place for ten seconds post-injection. The facility's policy on medication administration, including insulin pump management, was reviewed, but both the LPN and nursing leadership confirmed they were unaware of these specific requirements for insulin pen use. This lack of knowledge and adherence to proper insulin administration technique directly contributed to the medication errors observed.
Failure to Accurately Complete PASARR Level I Assessment for Resident with Mental Disorder
Penalty
Summary
The facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR) Level I assessment for one resident who had a diagnosis of an unspecified mental disorder and was prescribed an antipsychotic medication. According to the facility's policy, all applicants must be screened for serious mental disorders or intellectual disabilities in accordance with state Medicaid rules, with a Level I screen required prior to admission. If the Level I screen is positive, a Level II evaluation must be completed before admission. In this case, the resident's PASARR Level I application did not list any mental health diagnoses, despite the resident having a diagnosis of an unspecified mental disorder and being prescribed Seroquel for this condition. Further review of the resident's medical record showed a moderate cognitive impairment and ongoing antipsychotic use, both of which could indicate the need for a PASARR Level II evaluation. Staff interviews confirmed that the resident's mental health diagnosis and medication use were not reflected in the PASARR Level I assessment, and the Director of Admissions acknowledged that the resident could potentially qualify for a Level II review. The deficiency was identified through staff interviews, record review, and examination of facility policy.
Failure to Follow Care Plans for Bed Positioning and Meal Assistance
Penalty
Summary
Surveyors identified deficiencies in the facility's implementation of comprehensive care plans for multiple residents. One resident with dementia, right leg amputation, and right hand contracture was observed lying in bed with the bed in the highest position, contrary to the care plan directive for the bed to be in the lowest position to prevent falls. Staff confirmed the bed was not positioned as required, and the resident was left unsupervised despite being at risk for falls. Another resident with severe cognitive impairment and multiple diagnoses was also found in bed with the bed in the highest position and loose bed rails, again in violation of the care plan which specified the bed should be in the lowest position for safety. Staff interviews confirmed that the care plan was not followed, and the CNA admitted to forgetting to lower the beds after providing care. A third resident with moderate cognitive impairment, left-sided hemiparesis, and visual impairment was not provided with the required assistance and cueing during meals as outlined in the care plan. Observations showed the resident attempting to eat independently despite being unable to use one hand and having difficulty seeing, resulting in food spillage and the use of hands to eat. The resident reported not receiving help despite requesting it, and staff confirmed that the resident should have been provided with a divided plate and a weighted spoon, as well as one-on-one assistance and verbal cues during meals. The care plan interventions were not consistently implemented, and the resident's needs for setup and assistance were not met. The facility's policy requires that comprehensive, person-centered care plans be developed and implemented for each resident, with staff responsible for carrying out specified interventions. However, observations, interviews, and record reviews revealed that staff failed to follow care plan interventions for bed positioning and meal assistance for three residents. These failures were confirmed by supervisory staff and were not in accordance with the facility's own policies and procedures.
Failure to Properly Store and Label Personal Care Items
Penalty
Summary
Surveyors identified a deficiency in the facility's infection prevention and control program related to the storage of personal care items. Observations on multiple occasions revealed that urinals and bath basins in several resident bathrooms were not labeled or bagged as required by facility policy. Specifically, these items were found unlabeled and unbagged in bathrooms on Wing S and Wing W, despite the policy stating that bedpans and urinals are for single resident use, must be labeled with the resident's name, and stored in the resident's bedside cabinet. The facility's Director of Nursing confirmed during rounding that these items should have been bagged and labeled with the resident's room number. Interviews with staff, including a CNA, indicated that the expectation was for urinals and bath basins to be cleaned after each use, then bagged and labeled. However, the observed practice did not align with these expectations or the written policy. The failure to properly label and store these personal care items was noted in four of 31 bathrooms, indicating a lapse in adherence to infection control protocols as outlined by the facility.
Failure to Report and Address Suicidal Ideations
Penalty
Summary
The facility failed to report incidents involving a resident with suicidal ideations who attempted self-harm using call light and bed remote cords. The resident, diagnosed with major depressive disorder and a history of suicide attempts, was admitted to the facility and later requested transfer to a psychiatric facility. Despite this, the facility did not ensure the removal of potential choking hazards from the resident's reach, leading to multiple self-harm attempts. On three separate occasions, the resident was found with cords wrapped around his neck, indicating attempts to harm himself. The first incident occurred when the resident was found with a call light cord around his neck and was subsequently sent to the emergency room. Despite the severity of the situation, there was no evidence that the resident received psychiatric services or that the facility contacted their behavioral consultant. The facility's failure to provide appropriate psychiatric care and remove hazardous items contributed to the resident's repeated self-harm attempts. The facility's noncompliance with reporting requirements was evident as these incidents were not reported to the state agency. Interviews with the Director of Nursing and the Administrator revealed a misunderstanding of reporting obligations, as they believed the incidents were not reportable due to the absence of physical injuries. This oversight highlights a significant gap in the facility's adherence to regulatory requirements, particularly concerning the safety and well-being of residents with behavioral health needs.
Failure to Implement Safety Interventions for Resident with Suicidal Ideations
Penalty
Summary
The facility failed to implement care plan interventions to monitor the safety of a resident who had a history of major depressive disorder and suicide attempts. The resident was admitted with a diagnosis of major depressive disorder and had previously requested to be sent to an inpatient psychiatric facility. Despite recommendations to monitor the resident's mood and behaviors, the facility did not update the care plan to reflect necessary safety interventions after the resident was found with a call light cord wrapped around his neck. On multiple occasions, the resident was found with cords wrapped around his neck, indicating attempts to harm himself. The first incident occurred when the resident was found with a call light cord around his neck, leading to his transfer to the emergency room for suicidal ideations. Despite this, there was no evidence that the resident received psychiatric services or that the care plan was updated to address these safety concerns. The resident continued to have access to potentially harmful items, such as the call light and bed remote cords, which he used in subsequent attempts to harm himself. The facility's noncompliance with program requirements was identified as causing or likely to cause serious injury, harm, impairment, or death to residents. The facility failed to develop a comprehensive person-centered care plan that addressed the resident's suicidal ideations and safety measures. This lack of appropriate interventions and monitoring led to repeated incidents where the resident attempted to harm himself using available cords, ultimately resulting in his transfer to the hospital and discharge from the facility.
Failure to Ensure Safe Environment for Resident with Suicidal Ideations
Penalty
Summary
The facility failed to ensure a safe environment for a resident with a history of major depressive disorder and suicide attempts. The resident, who was admitted with diagnoses including major depressive disorder with severe psychotic symptoms and suicidal ideations, was found on multiple occasions with cords wrapped around his neck. Despite the resident's known history and requests for psychiatric evaluation, the facility did not remove potential choking hazards such as call light cords and bed remote cords from the resident's room. On several occasions, the resident was found attempting to harm himself using these cords. On one occasion, the resident was found with a call light cord wrapped around his neck and was subsequently sent to the emergency room for suicidal ideations. Despite this incident, the facility failed to provide adequate psychiatric services or contact their behavioral consultant. The resident continued to exhibit suicidal behavior, including calling 911 and attempting to hang himself with a bed remote cord. The facility's inaction and failure to implement effective interventions to prevent these incidents were evident. The resident was not adequately supervised, and the facility did not ensure that the environment was free of hazards that could facilitate self-harm. The lack of consistent monitoring and follow-up with psychiatric services contributed to the ongoing risk to the resident's safety.
Failure to Provide Behavioral Health Services and Remove Hazards
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident, identified as R2, who had a history of major depressive disorder and previous suicide attempts. R2 was admitted to the facility and later requested to be sent to an inpatient psychiatric facility, which he attended briefly before returning to the nursing facility. Despite being seen by the facility's geriatric psychologist consultant, who recommended monitoring R2's mood and behaviors, the facility did not ensure adequate psychiatric services were provided following significant incidents. On multiple occasions, R2 was found with cords wrapped around his neck, indicating attempts at self-harm. On 9/27/2024, R2 was discovered with a call light cord around his neck and was sent to the emergency room for suicidal ideations. Despite this, there was no evidence of psychiatric services being provided upon his return to the facility. Similar incidents occurred on 10/2/2024 and 10/26/2024, where R2 was found with cords around his neck, yet the facility failed to remove these hazards or provide necessary psychiatric interventions. The facility's noncompliance with behavioral health services and failure to address R2's worsening behaviors and safety concerns led to an Immediate Jeopardy determination. The facility did not ensure that choking hazards were removed from R2's reach, nor did they provide timely psychiatric services following his episodes of suicidal ideation. This lack of action and oversight contributed to the serious risk of harm to R2.
Failure to Ensure Resident Safety and Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide adequate supervision and oversight for a resident with suicidal ideations, leading to multiple incidents where the resident attempted self-harm using cords from the call light and bed remote. The resident, who had a history of major depressive disorder and previous suicide attempts, was admitted to the facility and later requested transfer to a psychiatric facility. Despite this, the facility did not ensure the resident's environment was free of choking hazards, nor did they implement effective interventions to maintain the resident's safety. On several occasions, the resident was found with cords wrapped around his neck, indicating attempts to self-harm. These incidents occurred despite recommendations from a geriatric psychologist to monitor the resident's mood and behaviors. The facility failed to provide psychiatric services or contact their behavioral consultant following these incidents, and the resident continued to have access to potentially harmful items like the call light cord. The facility's noncompliance with program requirements was identified as causing or likely to cause serious harm to residents. The deficiencies were related to the failure to report alleged violations, develop and implement a comprehensive care plan, ensure a safe environment free of accident hazards, and provide necessary behavioral health services. The facility's administration and nursing leadership did not adequately address the resident's needs or ensure appropriate interventions were in place, resulting in a determination of Immediate Jeopardy.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, R4 and R5, which is a critical component of their care plans. R4, who has a history of falls and mobility impairments due to conditions such as hemiplegia and hemiparesis, was observed on multiple occasions with his call light lying on the floor, out of reach. This was despite his care plan specifically stating that the call light should be within reach to mitigate his fall risk. Observations on different dates showed that R4's call light was consistently not accessible, compromising his ability to call for assistance when needed. Similarly, R5, who suffers from conditions including type 2 diabetes, hypertension, and Alzheimer's disease, was also found with his call light out of reach on several occasions. R5's care plan highlights the importance of having the call light within reach due to his generalized weakness and unsteady gait. However, observations revealed that his call light was repeatedly found on the floor, making it inaccessible. The Director of Nursing acknowledged the issue and indicated a need for staff reeducation on proper call light placement.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in seven of 33 rooms, as observed by surveyors. Specific deficiencies included missing or damaged ceiling tiles, cracked wall moldings, missing floor tiles, broken or missing toilet paper holders, and holes in walls. Additionally, there were black scuff marks on walls, a dirty pillowcase, and various maintenance issues such as clogged commodes and missing towel racks. These observations were confirmed during a follow-up visit, indicating no changes had been made to address the issues. Interviews with facility staff revealed a lack of effective communication and follow-up on maintenance issues. The Maintenance Director stated that department managers are responsible for checking rooms and reporting issues to the Administrator, who is then supposed to enter work orders into the TELs system. However, the persistent deficiencies suggest a breakdown in this process. The Director of Nursing also confirmed that bed linens, including pillowcases, should be clean, yet a resident was observed with a dirty pillowcase, further highlighting the facility's failure to uphold basic cleanliness standards.
Delayed Refunds of Personal Funds After Resident Discharge
Penalty
Summary
The facility failed to ensure timely refunds of personal funds to two residents, R4 and R8, after their discharge, as required by their policy. The policy mandates that personal funds be conveyed within 30 days of discharge, eviction, or death. However, R4, who was a hospice resident with diagnoses including Alzheimer's disease and chronic obstructive pulmonary disease, was discharged and only received a refund six months later. The Receivable Account manager confirmed that R4's responsible party was making monthly payments, and hospice was covering the remaining care costs, resulting in a refund due to the responsible party. Similarly, R8, who had diagnoses including type 2 diabetes mellitus and hypothyroidism, was also discharged and did not receive her monthly personal funds for three months prior to discharge. The facility withheld $70.00 monthly for an outstanding balance without authorization from the responsible party. A refund was issued six months after discharge. The Receivable and Accountant manager acknowledged the unauthorized withholding and confirmed the refund was due.
Failure to Provide 30-Day Discharge Notice
Penalty
Summary
The facility failed to provide a 30-day notice of discharge to a resident, identified as R4, who was transferred to a behavioral facility for evaluation. R4 had a history of Alzheimer's disease, chronic obstructive pulmonary disease, unsteadiness on feet, epilepsy, seizures, hypertension, and dementia. The care plan indicated R4's desire to receive long-term care services, with interventions involving active participation of the responsible party in discharge planning. Despite this, R4 was transferred to the emergency room and subsequently to a behavioral facility without a 30-day notice, and the facility decided not to accept R4 back after his evaluation. The decision not to readmit R4 was made by a corporate person, despite the previous administrator's willingness to take him back if stable. The Corporate Regional Director of Operations acknowledged R4's past behaviors but could not explain why the 30-day notice was not issued. The report notes that R4 had exhibited behaviors and safety concerns prior to an incident involving another resident, but there was no evidence of the facility's intention to allow R4's return or provide the required notice. R4 eventually expired at another skilled nursing facility.
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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