Harmony Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Fitzgerald, Georgia.
- Location
- 176 Lincoln Ave, Fitzgerald, Georgia 31750
- CMS Provider Number
- 115654
- Inspections on file
- 24
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Harmony Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with hemiplegia, contractures, seizures, and dementia—requiring two-person assist for all ADLs—sustained fractures after falling from bed during incontinent care provided by only one CNA, contrary to the care plan. The care plan interventions for fall prevention were not followed, and staff interviews confirmed care plans were not consistently updated or adhered to.
A resident with significant physical and cognitive impairments, requiring two-person assist for all ADLs and transfers, was left unattended by a CNA during incontinent care. The resident rolled out of bed and sustained fractures to the left femur and right tibia. Staff interviews and documentation confirmed the resident's need for two-person assistance was clearly indicated in the care plan and electronic records, but this protocol was not followed, resulting in actual harm.
The facility did not ensure that wound care treatments were accurately documented for three residents with pressure ulcers, resulting in multiple missed entries on the Treatment Administration Record despite physician orders and facility policy requiring timely documentation. The DON confirmed that nurses performed the treatments but failed to record them, leading to incomplete medical records.
The facility failed to maintain the ice machine in a sanitary condition, as a black substance was found inside during an inspection. Additionally, two dietary staff members were observed without hairnets in the kitchen, despite being aware of the requirement. The facility's policy on cleaning and staff head covering was not adequately enforced.
The facility failed to implement a comprehensive infection prevention training program for staff, as outlined in their policy. The DON could not provide documentation of in-service training, and an LPN showed confusion about Enhanced Barrier Precautions, indicating a lack of understanding of infection control measures. This deficiency could increase the risk of healthcare-associated infections.
A resident with a long history of smoking was denied the right to smoke by the Interim DON due to health concerns, without a physician's order or updated care plan. Despite having little cognitive impairment, the resident was not allowed to attend smoke breaks, causing distress. The facility's policy emphasizes respecting residents' autonomy, including their choice to smoke.
The facility failed to follow care plans for three residents, leading to deficiencies in oxygen therapy and catheter management. One resident received oxygen at a higher flow rate than prescribed, while another's catheter drainage bag was placed on the floor without care plan documentation. A third resident adjusted their oxygen flow rate without this behavior being care planned. Staff confirmed these discrepancies, indicating lapses in adhering to and updating care plans.
A facility failed to ensure proper administration of inhaled medication for a resident with COPD and pneumonia. An RN administered a Trelegy inhaler without instructing the resident to rinse their mouth afterward, contrary to the DON's expectations. The facility lacked a policy for inhaled medication administration, contributing to this deficiency.
A resident with COPD and pneumonia was observed receiving oxygen at three liters per minute, contrary to the physician's order of two liters per minute. This discrepancy was confirmed by an LPN, who acknowledged the incorrect setting. The facility's policy requires verification of physician orders, which was not followed, potentially putting the resident at risk.
The facility failed to follow infection control practices during medication administration and catheter management for two residents. An LPN did not perform hand hygiene during medication administration, and another LPN handled medication with bare hands and did not sanitize between glove changes. A resident's catheter bag was found on the floor, contrary to infection control protocols. Additionally, the facility's infection control policies had not been reviewed annually as required.
A resident with a history of wandering and multiple behavioral health diagnoses eloped from a secure unit and was found outside the facility. Despite facility policy requiring notification, staff interviews and record review showed that neither the physician nor the responsible party were informed of the incident, and no documentation of such notification was found.
A resident with a history of wandering and multiple behavioral health diagnoses eloped from the facility, but the care plan was not updated to reflect this incident. Although several staff members were aware of the event and documentation confirmed the resident exited through a non-secure door, the MDS Coordinator did not revise the care plan due to being unaware of the elopement.
A resident with severe cognitive impairment and a history of wandering was able to exit the facility unsupervised through a side door, despite being assessed as at risk for elopement and assigned to a secure unit. Staff interviews and maintenance records revealed lapses in supervision and door security, as well as confusion among staff regarding the resident's location and the events leading up to the elopement.
Failure to Follow Care Plan for Fall Prevention Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan interventions related to fall prevention for a resident with significant medical and cognitive impairments. The resident had a history of hemiplegia, contractures in both knees, seizures, dementia with behavioral disturbances, and was dependent on staff for all activities of daily living (ADL), including transfers, which required assistance from two or more staff members. The care plan specifically identified the resident as being at risk for falls and required a two-person assist for ADL care due to extensive assistance needs and confusion, including delusions about being able to walk. Despite these documented needs and interventions, only one CNA provided incontinent care, during which the resident rolled out of bed and fell to the floor. As a result, the resident sustained a distal fracture of the left femur and a fracture of the lower end of the right tibia. Review of facility policy and interviews confirmed that care plans were not consistently updated or followed, and the required two-person assist was not provided at the time of the incident.
Failure to Provide Required Two-Person Assist Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when a resident who required a two-person assist for all activities of daily living (ADL) care and transfers was provided incontinent care by only one Certified Nursing Assistant (CNA). During this care, the resident rolled out of bed and fell to the floor, resulting in a distal fracture of the left femur and a fracture of the lower end of the right tibia. The resident's care plan and Minimum Data Set (MDS) assessment clearly indicated the need for two-person assistance due to significant physical and cognitive impairments, including hemiplegia, contractures, seizures, altered mental status, and a history of attempting to get out of bed unassisted. The facility's policy on incidents and accidents required staff to provide immediate assistance and follow established protocols to prevent accidents. However, interviews and record reviews revealed that the CNA entered the resident's room alone to provide care, contrary to the care plan and facility policy. The CNA left the resident on his side to retrieve an item from the hallway, during which time the resident continued to roll and fell from the bed. Documentation in the electronic medical record and staff interviews confirmed that the resident was dependent on staff for all ADLs and required two-person assistance for bed mobility and transfers. Further interviews with facility staff, including the Administrator, LPNs, and other CNAs, confirmed that the resident's need for two-person assistance was documented in the care plan, Kardex, and Point Click Care (PCC) system. Staff were expected to communicate changes in resident care needs during shift changes and to verify assistance requirements in the PCC system. Despite these protocols, the failure to provide adequate supervision and follow the resident's care plan directly led to the resident's fall and subsequent injuries.
Failure to Document Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure accurate and complete documentation of wound care treatments for three residents with pressure ulcers. For one resident with multiple chronic conditions, including congestive heart failure and peripheral vascular disease, there was no documentation on the Treatment Administration Record (TAR) for several dates when wound care was ordered. Another resident with diabetes and a chronic venous ulcer also had missing documentation on the TAR for multiple dates in both May and June, despite physician orders specifying wound care on certain days. A third resident with a history of diabetic foot ulcer and other chronic illnesses similarly had gaps in documentation for ordered wound treatments. The facility's policy required that wound treatments be documented at the time of each treatment, and if no treatment was due, the status of the dressing should be recorded each shift. However, review of the TARs showed that documentation was not consistently completed as required. The Director of Nursing confirmed that, although nurses were performing the treatments, they were not documenting them on the TARs, leading to incomplete medical records for these residents.
Deficiencies in Ice Machine Sanitation and Staff Head Covering
Penalty
Summary
The facility failed to maintain the ice machine in a clean and sanitary condition, as evidenced by the presence of a black substance on the upper inside of the machine. This was observed during an inspection in the main kitchen, where a white napkin used to wipe the area revealed the black substance. The facility's policy on cleaning the ice machine and equipment was reviewed, which outlined procedures for regular cleaning and sanitization. However, the observation indicated that these procedures were not adequately followed, as the ice machine was not maintained in a clean state. Additionally, the facility did not ensure that dietary staff wore appropriate head coverings in the food service area. During the inspection, two dietary staff members, identified as Dishwasher AA and Dishwasher BB, were observed without hairnets. Interviews with the staff confirmed that they were aware of the requirement to wear hairnets upon entering the kitchen but failed to do so. The Dietary Manager also confirmed that staff had been in-serviced about wearing hairnets and that hairnets were available outside the kitchen. This oversight in enforcing the use of hairnets further contributed to the facility's failure to adhere to professional standards in food service areas.
Deficiency in Infection Prevention Training Program
Penalty
Summary
The facility failed to establish, implement, and sustain a comprehensive training program for all staff, which included education on standards, policies, and procedures for infection prevention. The facility's policy titled 'Annual Inservice Education for Long Term Care 2024' outlined an annual education calendar that was supposed to be implemented each year, covering various topics including infection control and prevention. However, the facility was unable to provide documentation of in-service training provided to staff, indicating a lapse in the execution of the training program. During the survey, the Director of Nursing (DON) admitted to being unable to locate any records of in-service education provided by the previous DON. Additionally, an LPN expressed confusion about Enhanced Barrier Precautions (EBP) during an interview, revealing a lack of understanding of the difference between EBP and Transmission-Based Precautions (TBP). The LPN was also unsure about the documentation process for this information in the resident's chart. This lack of training and understanding among staff had the potential to increase the risk of healthcare-associated infections and compromise the quality of care provided to the residents.
Resident's Right to Smoke Denied Without Proper Assessment
Penalty
Summary
The facility failed to honor a resident's right to self-determination and dignity by not allowing them to exercise their right to smoke. The resident, who had a history of smoking a pack a day for over 50 years, was restricted from smoking by the Interim Director of Nursing (DON) due to health concerns such as pneumonia, coughing, and lips turning blue. However, this decision was made without a physician's order, an updated care plan, or a completed smoking assessment indicating that the resident was ineligible to smoke. The facility's policy on Resident Rights and Dignity Management emphasizes the importance of respecting residents' autonomy, including their choice to smoke. The resident, identified as having schizoaffective disorder bipolar, chronic obstructive pulmonary disease, and emphysema, had a Brief Interview for Mental Status (BIMS) score indicating little to no cognitive impairment. Despite this, the resident was not allowed to attend the designated smoke break, which was confirmed through observation and interviews. The Nurse Practitioner noted that the resident should have been informed about the potential health risks of smoking but still allowed to make their own decision. The resident expressed that the restriction on smoking was causing more harm than good, as it significantly reduced their smoking from three to four cigarettes per day to none.
Failure to Follow Care Plans for Oxygen Therapy and Catheter Management
Penalty
Summary
The facility failed to ensure that the care plan was followed for three residents, leading to deficiencies in their care. For one resident with chronic obstructive pulmonary disease (COPD) and pneumonia, the care plan required oxygen therapy at 2 liters per minute via nasal cannula. However, observations revealed that the oxygen was being delivered at 3 liters per minute, contrary to the physician's order. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) and the Unit Manager, who acknowledged that the care plan was not being adhered to. Another resident with neuromuscular dysfunction of the bladder and other conditions had an indwelling catheter. The care plan did not address the placement of the catheter drainage bag, which was observed lying on the floor during multiple visits. An LPN confirmed that the bag was placed on the floor to facilitate drainage, but this practice was not included in the care plan. The Director of Nursing (DON) acknowledged that this situation needed to be care planned, indicating a lapse in updating the care plan to reflect the resident's needs. The third resident, diagnosed with COPD and chronic respiratory failure, was observed receiving oxygen at a higher flow rate than prescribed. The resident adjusted the oxygen flow rate himself, setting it at 4 liters per minute instead of the ordered 2 liters. An LPN confirmed that the resident had been educated about the risks of adjusting the oxygen flow, but the behavior was not care planned. The MDS Coordinator and DON both acknowledged that the resident's behavior should have been included in the care plan, highlighting a failure to document and address the resident's actions in the care plan.
Failure to Ensure Proper Administration of Inhaled Medication
Penalty
Summary
The facility failed to ensure proper administration of inhaled respiratory medication for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and pneumonia. During an observation, a Registered Nurse (RN) prepared and administered a Trelegy inhaler to the resident without instructing them to rinse their mouth afterward, which is a standard practice to prevent potential side effects. The RN confirmed in an interview that she does not typically instruct residents to rinse their mouths after using inhalers, although some staff do. The facility did not provide a policy for administering inhaled medications when requested. The Director of Nurses (DON) stated that it is her expectation for residents to rinse their mouths after receiving inhaled medications. The resident's care plan included administering aerosol or bronchodilators as ordered and monitoring for side effects, but the lack of mouth rinsing was not addressed. This oversight in following proper medication administration procedures was identified as a deficiency during the survey.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy to a resident, identified as R24, in accordance with the physician's orders. R24, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and pneumonia, was observed receiving oxygen at a rate of three liters per minute via nasal cannula, despite the physician's order specifying two liters per minute as needed for shortness of breath. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) during an observation and interview, who acknowledged that the oxygen concentrator was set incorrectly. The facility's policy on Respiratory System Management requires verification of the physician's order in the resident's clinical record, which was not adhered to in this case. The resident's care plan, which included monitoring for signs of acute respiratory insufficiency and ensuring oxygen settings as ordered, was not followed. Interviews with the LPN and the Unit Manager confirmed that it is the responsibility of the nursing staff to ensure compliance with physician orders and care plans, which was not done in this instance, potentially putting the resident at risk for medical complications.
Infection Control Deficiencies in Medication Administration and Catheter Management
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration for two residents. During an observation, an LPN did not perform hand hygiene before or after preparing and administering medications to a resident with acute and chronic respiratory failure and neuromuscular dysfunction of the bladder. The LPN admitted to not following the hand hygiene protocol. In another instance, a different LPN handled a medication capsule with bare hands and failed to perform hand hygiene between glove changes during medication administration. The facility also failed to ensure proper management of an indwelling catheter for a resident with neuromuscular dysfunction of the bladder, colostomy malfunction, and chronic viral hepatitis C. Observations revealed that the resident's catheter bag was repeatedly found lying on the floor, which was confirmed by an LPN who stated that it was necessary for drainage. The Director of Nurses acknowledged that a catheter bag should never be on the floor and should be placed on a barrier if necessary. Additionally, the facility did not review its infection control policies and procedures annually as required. The Infection Control Manual had not been updated for over a year, with the last revision dated September 2023. The Director of Nurses confirmed the oversight and indicated that the facility would begin updating the policies and procedures.
Failure to Notify Physician and Responsible Party After Resident Elopement
Penalty
Summary
The facility failed to notify the physician and responsible party following an elopement incident involving a resident with a history of wandering and elopement risk. The facility's own Elopement Management policy required that, after an elopement, a progress note be completed in the clinical record with an accurate timeline of events and that both the medical doctor and responsible party be notified and documentation of this notification be made. Review of the clinical record for the resident, who had diagnoses including schizoaffective disorder, traumatic brain injury, post-traumatic stress disorder, and unsteadiness on feet, revealed no evidence that such notifications were made after the resident left the secure unit and exited the facility. Staff interviews confirmed that the resident was found outside the facility and returned to the secure unit, but staff could not recall the exact date of the incident. One LPN stated she found the resident outside and returned him to the secure unit, while another LPN, who was working on the secure unit at the time, was unaware of the incident and did not notify the physician or responsible party. A CNA also recalled the resident leaving the facility but did not provide further details regarding notification. Documentation, including a maintenance request, confirmed the resident exited through a side door, but there was no record of required notifications being made.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to revise and update the care plan for one resident following an elopement event. The resident, who had diagnoses including schizoaffective disorder, traumatic brain injury, post-traumatic stress disorder, and unsteadiness on feet, was assessed as exhibiting wandering behavior and was independent in mobility and ambulation. The resident's care plan, initiated previously, identified a risk for elopement and included placement on a secure unit. However, after the resident eloped from the facility, there was no evidence that the care plan was updated to reflect this incident, as required by the facility's Elopement Standard and Task List. Staff interviews revealed that multiple staff members were aware of the resident's elopement, with one LPN finding the resident outside and a CNA recalling the incident. Despite this, the MDS Coordinator confirmed she was unaware of the elopement at the time, which resulted in the care plan not being revised. Documentation, including a maintenance request, confirmed the resident exited through a side door not associated with the secure unit. The lack of care plan revision following the elopement constituted the identified deficiency.
Failure to Prevent Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and secure the environment to prevent elopement for a resident with severe cognitive impairment and a history of wandering. The resident, who had diagnoses including schizoaffective disorder, traumatic brain injury, post-traumatic stress disorder, and unsteadiness on feet, was assessed as being at risk for elopement and was supposed to reside on a secure unit. Despite these precautions, the resident was able to exit the facility through a side door on the North Hall, which was not the secure unit assigned at the time. Staff interviews and maintenance records confirmed that the resident was found outside the facility and brought back inside, with uncertainty about how the resident exited and which unit the resident was residing on at the time. The facility's Elopement Standard required accurate documentation and supervision for residents at risk of elopement, but the incident revealed lapses in both supervision and door security. Maintenance logs showed the door had been checked and passed prior to the incident, but the resident was still able to exit. Staff accounts indicated confusion regarding the resident's whereabouts and the timeline of events, and there was a lack of clarity about which staff were responsible for the resident's supervision at the time of the elopement. The failure to secure the door and provide adequate supervision directly led to the resident's unsupervised exit from the 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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