Harborview Tifton
Inspection history, citations, penalties and survey trends for this long-term care facility in Tifton, Georgia.
- Location
- 1451 Newton Drive, Tifton, Georgia 31794
- CMS Provider Number
- 115412
- Inspections on file
- 24
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Harborview Tifton during CMS and state inspections, most recent first.
A facility applied to become the representative payee for a cognitively intact resident without obtaining the resident's consent, despite the resident being alert and oriented and having signed a payment agreement. Staff interviews and record review confirmed that consent was obtained for other residents in similar situations, but not for this resident.
A resident with significant medical needs reported being struck by another resident and subsequently experienced emotional distress and fear for personal safety. Although nursing staff assessed for physical injuries, the facility did not provide required emotional support, psychosocial assessment, or follow-up by the social worker, and key information about the resident's ongoing fear was not communicated among staff, resulting in a failure to fully implement the abuse prevention and response policy.
A resident with significant medical conditions reported being struck multiple times by another resident who entered his room at night. Although the incident was documented and reported internally, the facility did not notify law enforcement as required by policy. The resident experienced emotional distress and did not receive follow-up regarding the incident.
A resident who was cognitively intact reported being physically assaulted by another resident, resulting in emotional distress and fear for personal safety. Despite expressing ongoing psychological distress and keeping scissors for self-protection, the care plan was not updated to address these psychosocial needs, and no evidence was found that staff assessed or supported the resident's mental well-being after the incident.
A resident with multiple medical conditions reported being physically assaulted by another resident and subsequently expressed emotional distress and fear for his safety. Despite these concerns, there was no follow-up assessment or provision of medically related social services by the Social Worker, and the resident was not referred for psychological evaluation after the incident.
Two residents with stage IV wounds experienced unaddressed pain during wound care procedures. Despite care plans requiring pain assessment and management, LPNs continued wound treatments while the residents showed clear signs of pain, and pain medication was not administered as required by the care plans.
Two residents with complex medical histories experienced unaddressed pain during wound care procedures. Despite one having an active PRN Tylenol order and the other lacking any current pain medication order, neither received pain relief before or during treatment. Nursing staff did not assess for pain or follow pain management protocols, and both residents were observed expressing discomfort throughout the procedures.
Staff did not consistently wear required PPE, specifically gowns, during high-contact care activities such as wound and perineal care for residents on Enhanced Barrier Precautions. Despite clear signage and facility policy, CNAs and LPNs provided care without gowns, and glove supplies were handled improperly without hand hygiene. Interviews confirmed staff were either unaware of requirements or failed to follow them, even though PPE supplies were available.
A resident with severe cognitive impairment and multiple diagnoses, including morbid obesity, was injured during a transfer due to the facility's failure to specify the use of a mechanical swing lift in the care plan. The resident slid in the sling of a stand lift, resulting in a chest wall hematoma and anemia. Despite prior training, CNAs used the incorrect lift, leading to the incident.
A resident with severe cognitive impairment and morbid obesity was injured during a transfer when CNAs used a stand lift instead of a mechanical swing lift, despite the resident's inability to bear weight. The sling slipped, causing bruising and a chest wall hematoma. The CNAs continued the transfer improperly and failed to report the incident immediately, leading to the resident's hospitalization.
Failure to Obtain Consent for Representative Payee Application
Penalty
Summary
The facility failed to obtain consent before applying to become the representative payee for a resident who was cognitively intact, as evidenced by a BIMS score of 15 on multiple MDS assessments. The resident, who had diagnoses including paraplegia, chronic pain syndrome, opioid dependence, osteoarthritis, insomnia, and urine retention, was admitted to the facility and had an outstanding balance for care. Despite being alert and oriented, the facility applied to manage the resident's Social Security benefits without documented consent from the resident. The facility's policy defines misappropriation of resident property as the use of a resident's money without consent, and the application for representative payee was completed based on a physician's assessment that the resident could not manage finances, though the resident had previously signed a payment agreement. Interviews with facility staff confirmed that the resident was alert and oriented, and that consent was obtained for other residents in similar situations but not for this particular resident. The facility received one Social Security payment as representative payee before the resident was discharged, and the subsequent payment was rejected. The administrator and business office manager both acknowledged the lack of consent and the resident's cognitive intactness at the time the application was made.
Failure to Implement Abuse Policy Following Resident-on-Resident Incident
Penalty
Summary
A resident with multiple medical conditions, including morbid obesity, intracerebral hemorrhage, and an above-knee amputation, reported being struck multiple times by another resident while in bed. The incident was documented by nursing staff, who assessed the resident and found no visible injuries. Despite the resident expressing emotional distress, flashbacks, and a lack of safety following the event, there was no evidence that facility staff provided emotional support, counseling, or a psychosocial assessment as outlined in the facility's abuse policy. The resident also reported to a nurse practitioner that he was afraid to sleep and later was found to have kept scissors under his pillow for self-protection, but this information was not communicated to the social worker or acted upon for further psychological evaluation. The facility's policy required protection of the resident and specific reporting and response actions following allegations of abuse, including examination for injury, emotional support, care plan revision, and timely reporting to appropriate authorities. However, the social worker confirmed that she did not follow up with the resident after the allegation, and there was no documentation of a psychological evaluation or referral. Additionally, the nurse practitioner did not report the resident's ongoing fear or the presence of scissors to the rest of the care team. These failures indicate that the facility did not fully implement its abuse prevention and response procedures after the resident's allegation.
Failure to Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to law enforcement as required by its own policy and regulatory standards. A cognitively intact resident with multiple medical conditions, including morbid obesity, nontraumatic intracerebral hemorrhage, above-knee amputation, congestive heart failure, and gout, reported that another resident entered his room during the night, sat on his bed, and struck him multiple times in the chest. The resident expressed emotional distress, including feeling unsafe and experiencing flashbacks, and stated that no one followed up with him after the incident to discuss what happened or how he felt. Facility documentation, including nurses' notes and an incident report, confirmed that the event was reported internally to the Administrator and the responsible party, but there was no documentation that law enforcement was notified. The facility's policy requires reporting all alleged violations to law enforcement when applicable, but this step was omitted. The Administrator interviewed after the incident acknowledged that law enforcement should have been contacted in this case.
Failure to Revise Care Plan After Resident Abuse Allegation
Penalty
Summary
The facility failed to revise and update the care plan for a resident following an allegation of physical abuse by another resident. Despite the resident reporting emotional distress, fear, and flashbacks after being physically assaulted in his room, there was no evidence in the care plan that his psychosocial needs were assessed or addressed. The resident expressed feeling unsafe and reported keeping scissors under his pillow for self-protection, but the care plan only reflected previous behavioral concerns related to medication management and did not include interventions or measurable objectives to address his psychological well-being after the incident. Interviews with the resident and review of medical records confirmed that the resident was cognitively intact and able to communicate his experiences and feelings. Documentation from a nurse practitioner indicated that the resident was emotionally upset and fearful following the incident, yet no follow-up or support was provided by staff to address his mental and emotional health. The facility's policy required comprehensive, person-centered care plans that address all identified needs, including psychological needs, but this was not implemented for the resident after the reported abuse.
Failure to Provide Psychosocial Assessment and Social Services After Abuse Allegation
Penalty
Summary
A deficiency occurred when the facility failed to assess the psychosocial status and provide medically related social services to a resident following an allegation of physical abuse. The resident, who had diagnoses including morbid obesity, nontraumatic intracerebral hemorrhage, above-knee amputation, congestive heart failure, and gout, was cognitively intact according to a recent MDS assessment. The resident reported that another resident entered his room at night, sat on his bed, and punched him in the chest. He expressed feeling emotionally upset, experiencing flashbacks, and not feeling safe in the facility. Despite these reports, there was no documentation that the resident was assessed by the Social Worker or referred for psychological evaluation after the incident. The Nurse Practitioner documented the resident's fear and his actions to protect himself, such as keeping scissors under his pillow, but did not report these findings to other staff or request a social work evaluation. The Social Worker confirmed she did not follow up with the resident after the abuse allegation and was unaware of the resident's actions to protect himself. The Administrator acknowledged that the Social Worker should have followed up with the resident after the incident. The lack of follow-up and assessment by the Social Worker after the abuse allegation led to the deficiency.
Failure to Implement Pain Management During Wound Care
Penalty
Summary
The facility failed to implement care plans related to wound treatment and pain management for two residents with stage IV wounds. One resident, admitted with multiple diagnoses including type 2 diabetes, pressure ulcer, and chronic pain, had a care plan requiring weekly skin inspections, wound treatments, and pain management interventions such as monitoring pain episodes and administering medications as ordered. During wound care, the resident exhibited clear signs of pain, including moaning and moving away from the nurses, but the LPNs performing the dressing change did not acknowledge or address the pain, continuing the procedure without pausing or offering pain relief. Another resident with diagnoses including COPD, diabetes, cirrhosis, and fibromyalgia had a care plan specifying the administration of analgesia before treatments and immediate response to pain complaints. Despite this, the resident did not have an order for pain medication until after a wound treatment, during which she was observed moaning, grimacing, and attempting to move away from the dressing removal. Staff continued the procedure without providing pain relief, and the MDS RN later confirmed that the pain management care plan was not followed.
Failure to Provide Pain Management During Wound Care
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents during wound care treatment, as observed and documented by surveyors. One resident, with multiple diagnoses including diabetes, pressure ulcer, and dementia, was observed experiencing significant pain during wound care. Despite vocalizing discomfort and attempting to move away from the nurse's hands, the resident did not receive any pain medication prior to or during the procedure. The medical record showed an active order for Tylenol as needed for pain, but there was no evidence that it had been administered during the relevant period. Another resident, with a history of chronic illnesses such as COPD, diabetes, cirrhosis, and fibromyalgia, also experienced pain during wound care. The resident was observed moaning, grimacing, and squirming in response to the removal of dressings and wound cleaning. At the time of the observation, there was no active order for pain medication, as previous prescriptions had been discontinued and a new order was not in place until after the resident was admitted to hospice care later that day. The resident confirmed experiencing discomfort and pain during the treatment. Interviews with nursing staff revealed that pain assessments were not conducted prior to wound care, and pain management protocols were not followed. Staff acknowledged that they should have stopped the procedure to assess and address pain, but instead focused on completing the wound care. The Director of Nursing confirmed that staff should have assessed the residents for pain and determined the cause, but this was not done during the observed incidents.
Failure to Use Required PPE During High-Contact Care Activities
Penalty
Summary
Staff failed to adhere to the facility's Infection Prevention and Control Program by not wearing appropriate personal protective equipment (PPE), specifically protective gowns, during high-contact resident care activities. Multiple observations revealed that certified nurse aides (CNAs) and licensed practical nurses (LPNs) did not wear gowns while providing perineal care and wound care to residents who were on Enhanced Barrier Precautions (EBP). The facility's policy and posted signage required the use of gloves and gowns for such activities, but staff either did not read the signage, did not see PPE available, or simply forgot to don the required gowns. Three residents with significant medical conditions, including stage IV pressure ulcers, diabetes, and other chronic illnesses, were involved in these incidents. In each case, staff provided care such as perineal cleaning and wound dressing changes without the mandated protective gowns, despite clear EBP signage on the residents' doors and documented orders for EBP in the electronic medical records. Staff interviews confirmed a lack of compliance, with some staff unaware of the requirements or unable to explain their failure to use PPE. Additionally, improper handling of glove supplies was observed. A staff member responsible for distributing gloves was seen transferring gloves between boxes with bare hands and without using hand sanitizer, moving partially filled boxes from room to room. This practice was confirmed during interviews and was not in accordance with infection control protocols. The facility had supplies of gowns available in storage areas, but these were not consistently accessed or used by staff during resident care.
Failure to Implement Proper Transfer Care Plan
Penalty
Summary
The facility failed to develop a care plan intervention to address the transfer needs of a resident who required the use of a mechanical swing lift during transfers. This oversight resulted in actual harm when the resident, who was severely cognitively impaired and unable to bear weight, slid down in the sling of a stand lift, causing a chest wall hematoma and subsequent anemia that required a blood transfusion. The resident had multiple diagnoses, including intracranial injury, schizophrenia bipolar type, mood disorder, anxiety disorder, and morbid obesity, and was dependent on staff for transfers. The care plan in place did not specify the need for a mechanical swing lift, leading to the use of an inappropriate stand lift by three CNAs during a transfer. The CNAs, despite having received training, failed to act appropriately when the resident slipped in the sling, continuing the transfer and causing injury. The facility's investigation revealed that the CNAs used the stand lift instead of the mechanical swing lift, which was necessary due to the resident's inability to bear weight, contributing to the incident.
Improper Use of Stand Lift Leads to Resident Injury
Penalty
Summary
The facility failed to transfer a resident using the correct transfer lift, resulting in actual harm. The resident, who was admitted with diagnoses including intracranial injury, schizophrenia bipolar type, mood disorder, anxiety disorder, and morbid obesity, was severely cognitively impaired and dependent on staff for transfers. The resident's care plan did not specify the need for a mechanical swing lift, and during a transfer, the resident was incorrectly moved using a stand lift, which was inappropriate given the resident's inability to bear weight. The incident occurred when three CNAs attempted to transfer the resident using a stand lift, despite the resident's inability to bear 50% of her weight. During the transfer, the sling slipped, causing the resident to be in a hang glider position, which resulted in bruising and a chest wall hematoma. The CNAs continued with the transfer despite the resident slipping, which was against the proper procedure. The CNAs had received training on the stand lift but failed to act appropriately during the incident. The facility's investigation revealed that the CNAs did not report the incident immediately, and the bruising was only identified days later. The DON confirmed that the staff should have used a mechanical swing lift instead of a stand lift, as the resident could not bear the required weight. The failure to use the correct equipment and the lack of immediate reporting contributed to the resident's injury and subsequent hospitalization.
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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