Jasper Point Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Jasper, Georgia.
- Location
- 618 Gennett Drive, Jasper, Georgia 30143
- CMS Provider Number
- 115502
- Inspections on file
- 19
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Jasper Point Of Journey Llc during CMS and state inspections, most recent first.
The facility failed to conduct Fall Risk Assessments during admission and after falls for two residents. One resident, admitted with a femur fracture and Alzheimer's, experienced multiple falls without timely assessments. Another resident, under hospice care, fell and sustained injuries before a high-risk assessment was completed. Interviews confirmed that assessments should occur at admission, but lapses in protocol were noted.
The facility failed to provide adequate nursing staff on weekends, potentially affecting the care of 51 residents. The Facility Assessment Tool indicated staffing needs of 36-48 hours for licensed nurses and 105-120 hours for nurse aides per day. However, the PBJ Staffing Data Report for FY Quarter 2 2024 showed excessively low weekend staffing, with only 77 hours per day for nurse aides. Interviews confirmed awareness of this issue.
The facility failed to maintain the walk-in freezer, leading to ice buildup that contaminated food and posed a risk to 51 residents. Despite awareness by the CDM, Maintenance Director, and Interim Administrator, there was no documentation of repairs or service visits.
The facility did not ensure the Medical Director or their appointee attended QAPI committee meetings as required by policy. The Medical Director or designee was absent from three of six reviewed meetings, violating the policy that mandates their participation. The Regional Director confirmed the absence and lack of documentation for these meetings.
The facility failed to submit a PASARR Level II for two residents after new mental illness diagnoses were added, potentially affecting their care. One resident was diagnosed with bipolar disorder but did not receive psychological services or a PASARR Level II. Another resident, also diagnosed with bipolar disorder, was on antipsychotic medication without a PASARR Level II reevaluation. The facility lacked a Social Services Director, and the Regional Nurse Consultant could not locate the necessary documentation.
A resident receiving continuous oxygen therapy did not have a comprehensive care plan addressing this treatment, as required by facility policy. Despite having a physician's order for oxygen via nasal cannula, the care plan lacked documented goals or interventions for oxygen administration. The oversight was confirmed by the Regional Director of Clinical Operations.
The facility failed to properly store respiratory supplies for two residents, increasing the risk of infection. A resident with COPD had a nebulizer mouthpiece and tubing uncovered, while another resident's BiPAP mask was left unbagged on a nightstand. These actions did not comply with the facility's policies, potentially compromising respiratory health.
A facility failed to comply with its policy on PRN psychotropic medications, allowing a resident to have an active PRN order for Ativan without an end date. The resident, diagnosed with panic disorder and conversion disorder with seizures, received Ativan multiple times over several months. The facility's policy requires PRN orders to be limited to 14 days unless extended with documented rationale, which was not done in this case.
A medication security breach occurred when an RN left five medication cards on top of a locked cart unattended while retrieving another medication. The facility's policy requires medications to be secured and supervised, which was not followed, posing a risk of unauthorized access.
A facility failed to ensure proper hand hygiene during wound care for a resident with a stage IV pressure ulcer. The LPN did not change gloves or perform hand hygiene between cleansing the wound and applying Dakin's solution-soaked gauze, contrary to the facility's policy. The resident, who was dependent on staff for daily activities, had a care plan emphasizing proper wound care. The LPN acknowledged the mistake, and the Regional Nurse Consultant confirmed the potential risk of infection.
Failure to Conduct Timely Fall Risk Assessments
Penalty
Summary
The facility failed to complete Fall Risk Assessments during the admission process and after falls for two residents, R3 and R4, who were reviewed for falls. R3 was admitted with diagnoses including a fracture of the left femur and Alzheimer's disease. Despite experiencing falls on three occasions, there was no evidence of a Fall Risk Assessment being completed at admission or after each fall. A fall risk evaluation was eventually completed, indicating a high risk. R4, admitted under hospice care, also did not have a Fall Risk Assessment completed at admission. After a fall resulting in a skin tear and pain, a Morse Falls Risk Evaluation was conducted, showing a high risk for falls. Interviews with the Director of Nursing (DON) and an LPN confirmed that fall risk assessments should be completed during admission, even for hospice residents. The DON, who started working at the facility after the admissions of R3 and R4, was unaware of who was responsible for the assessments prior to her tenure. The facility's Administrator expressed the expectation that all nurses complete required assessments, highlighting a lapse in protocol adherence regarding fall risk assessments for new admissions.
Inadequate Weekend Staffing
Penalty
Summary
The facility failed to ensure adequate nursing staff on weekends, which had the potential to affect the care provided to the 51 residents residing in the facility. The Facility Assessment Tool dated 4/17/2024 indicated that the average daily census was 57 residents, with staffing needs of 36-48 hours for licensed nurses and 105-120 hours for nurse aides per day. However, the PBJ Staffing Data Report for FY Quarter 2 2024 revealed excessively low weekend staffing, with an average of only 77 hours per day for nurse aides on weekends. Interviews with the Regional Director of Clinical Operations and the Regional Nurse Consultant confirmed their awareness of the excessively low weekend staffing issue for the second quarter of 2024. This deficiency was identified through record reviews, staff interviews, and facility document reviews, highlighting the facility's failure to meet the required staffing levels on weekends.
Failure to Maintain Walk-In Freezer
Penalty
Summary
The facility failed to maintain the walk-in freezer properly, resulting in significant ice buildup on the freezer unit, shelving, and floor. This issue was observed during a survey, with ice formations ranging from 6 inches in diameter at the top to less than 1 inch at the floor. The Certified Dietary Manager (CDM) confirmed the ice buildup and noted that it had led to the discarding of numerous cases of food due to contamination concerns. The Maintenance Director was aware of the issue and manually removed ice periodically, but there was no documentation of a service visit or repair by an outside company, despite the freezer having been inspected previously. Interviews with facility staff, including the CDM, Maintenance Director, Regional Director of Environmental Services, and Interim Administrator, revealed a lack of communication and documentation regarding the freezer's condition and necessary repairs. The Interim Administrator and Maintenance Director were aware of the problem, but neither could provide documentation of any service visits or recommendations from the outside service provider. The Regional Director of Environmental Services was unaware of the issue until the survey. The ongoing ice formation posed a risk of food contamination for the 51 residents receiving meals from the kitchen.
Medical Director's Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director or an appointee of the Medical Director attended and participated in the Quality Assurance and Performance Improvement (QAPI) committee meetings at least quarterly, as required by their policy. The facility's policy, implemented on 8/1/2023, mandates that the QAPI committee be interdisciplinary and include the Director of Nursing, the Medical Director or their designee, and at least three other staff members, including the Administrator or another leader, and the Infection Preventionist. However, a review of the QAPI committee meeting sign-in sheets for six meetings revealed that neither the Medical Director nor their appointee attended three of these meetings, specifically on 11/2/2023, 1/26/2024, and 4/25/2024. During an interview, the Regional Director of Clinical Operations confirmed the absence of the Medical Director or their designee at these meetings and acknowledged the lack of documentation to indicate their participation. This absence indicates a failure to comply with the facility's policy regarding the composition and attendance requirements of the QAPI committee.
Failure to Submit PASARR Level II for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to submit a PASARR Level II for two residents after new mental illness diagnoses were added, which could affect the level of care and services provided. Resident 5 was admitted with diagnoses including generalized anxiety disorder, migraine, and major depressive disorder, and later diagnosed with bipolar disorder. Despite this new diagnosis, there was no documentation of psychological services in the past 12 months, and no PASARR Level II was submitted. The facility lacked a Social Services Director, and the Director of Nursing was unavailable for an interview. The Interim Administrator confirmed the absence of a PASARR Level II for Resident 5 and acknowledged the responsibility of the Social Services Director in submitting the necessary documentation. Resident 19 was admitted without a significant mental health diagnosis but later diagnosed with panic disorder and bipolar disorder. The PASARR Level I did not reflect these new diagnoses, and there was no evidence of reevaluation for a PASARR Level II. The resident was receiving olanzapine for bipolar disorder, but no psychological therapies or treatments were documented. The Regional Nurse Consultant was unable to locate a PASARR Level II for Resident 19 and could not contact the former Social Worker for clarification.
Failure to Include Oxygen Therapy in Resident's Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident, identified as R15, who was receiving oxygen therapy. The facility's policy on Comprehensive Care Plans requires that the care plan describe the services necessary to maintain the resident's highest practicable well-being. Additionally, the policy on Oxygen Administration mandates that the care plan identify interventions for oxygen therapy based on the resident's assessment and orders. However, a review of R15's care plan revealed no documented care area, goals, or interventions for the administration of oxygen, despite the resident having a physician's order for continuous oxygen via a nasal cannula at 2 liters per minute. Observations and interviews confirmed that R15 was receiving oxygen as ordered, and the resident reported wearing the oxygen most of the time, except during meals and showers. The Regional Director of Clinical Operations verified the absence of a care plan area for oxygen administration and acknowledged that it should have been included. The omission was attributed to an oversight by the MDS Coordinator, who is responsible for ensuring the care plan reflects the current services and care provided to the resident.
Improper Storage of Respiratory Supplies
Penalty
Summary
The facility failed to properly store respiratory supplies for two residents, R14 and R27, increasing the risk of spreading microorganisms and potentially leading to respiratory infections. For R14, who has a history of acute chronic diastolic congestive heart failure, pleural effusion, acute respiratory failure with hypoxia, viral pneumonia, and COPD, observations revealed that her nebulizer mouthpiece and tubing were not stored in protective bags as required by the facility's policy. The nebulizer mouthpiece was found lying on top of the oxygen concentrator and the tubing was in a drawer, both uncovered. The Regional Nurse Consultant confirmed these observations and acknowledged that the charge nurse was responsible for ensuring the equipment was clean and stored properly. Similarly, for R27, who has chronic respiratory failure with hypoxia and hypercapnia, morbid obesity with alveolar hypoventilation, and COPD, the BiPAP machine's mask was observed lying directly on the nightstand without a protective covering. R27 confirmed that the staff assisted her with the BiPAP machine at night but did not place the mask in a bag or protective covering, and she was unsure if it was cleaned. These observations indicate a failure to adhere to the facility's policies on respiratory equipment cleaning and storage, potentially compromising the residents' respiratory health.
Failure to Adhere to PRN Psychotropic Medication Policy
Penalty
Summary
The facility failed to ensure compliance with its policy on the use of psychotropic medications, specifically regarding the administration of PRN orders for antianxiety medication. The policy mandates that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed condition and for a limited duration of 14 days unless extended by a physician with documented rationale. However, a resident with diagnoses of panic disorder and conversion disorder with seizures had an active PRN order for Ativan injection without an end date, which was not reviewed or updated by the Director of Nursing as required. The resident received Ativan on multiple occasions over several months, indicating a lack of adherence to the policy's stipulation for limited duration. The medication was administered for seizures and panic attacks, with one instance noted in the nurse's notes where the resident was agitated and unable to be redirected, leading to the administration of Ativan with good results. Despite the facility's policy and the presence of a duplicate order identified by the pharmacist, the PRN order continued without proper documentation or an end date, as confirmed by the Regional Nurse Consultant.
Medication Security Breach on 300 Hall Cart
Penalty
Summary
The facility failed to maintain medications in a locked and secure environment when not under direct supervision of the nurse, specifically involving the 300 Hall medication cart. During an observation, it was noted that a Registered Nurse (RN) left the medication cart locked but with five medication cards containing medications on top of the cart unattended while she went to the medication room to retrieve another medication. This incident occurred over a span of four minutes, during which the medications were not secured as per the facility's policy. The facility's policy on Medication Storage, implemented on 2/12/2022, mandates that all medications must be stored securely and under direct supervision during medication pass. The RN acknowledged the lapse in protocol, admitting that she should have locked the medications in the cart before leaving it unattended. The Regional Nurse Consultant confirmed that the expectation is for medications to be locked in the cart unless attended by a nurse, highlighting the risk of unauthorized access to medications by residents, staff, or visitors.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident with a stage IV pressure ulcer in the sacral region. The facility's policy on clean dressing change, implemented on 2/12/2022, requires hand washing and the use of clean gloves to prevent infection and cross-contamination. However, during an observation, an LPN did not change gloves or perform hand hygiene between cleansing the wound and applying Dakin's solution-soaked gauze, which is a deviation from the facility's policy. The resident involved had a history of pressure ulcers and was dependent on staff for daily activities, including dressing, bathing, and toileting. The resident's care plan emphasized the need for frequent checks for wetness and soiling, and proper wound care as per physician's orders. Despite these guidelines, the LPN admitted to not following the correct procedure during wound care, which was confirmed by the Regional Nurse Consultant, who stated that this practice could potentially lead to a wound infection.
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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