Jesup Ridge Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Jesup, Georgia.
- Location
- 3100 Savannah Highway, Jesup, Georgia 31545
- CMS Provider Number
- 115503
- Inspections on file
- 14
- Latest survey
- May 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Jesup Ridge Of Journey Llc during CMS and state inspections, most recent first.
Three residents who were discontinued from Medicare Part A therapy services were given the CMS-R-131 form, intended for Part B services, instead of the required NOMNC (CMS-10123) form. This failure to provide the correct notice meant that residents did not receive proper information about the termination of their skilled services or their appeal rights, as required by facility policy.
A resident with a history of bipolar disorder, manic episodes, and generalized anxiety disorder did not have a required PASARR Level II completed after experiencing behavioral changes and hospitalization. Facility staff were unaware of the need to conduct an updated PASARR following significant changes in the resident's condition, resulting in the absence of appropriate screening documentation.
A resident with a history of bipolar disorder and anxiety experienced multiple episodes of manic behavior, resulting in hospitalization. Despite these significant changes, facility staff did not complete a PASARR Level II or notify the appropriate state authorities, as required by policy. Staff interviews revealed they were unaware of the notification requirement following such changes.
Staff did not follow infection control protocols during peri care and suprapubic catheter care for a resident with a suprapubic catheter. CNAs wore the same soiled gloves while performing care and then touched the resident's clothing, equipment, and room surfaces without changing gloves or performing hand hygiene. Improper technique was also used during perineal care, and the CNA acknowledged the failure to change gloves between tasks.
A resident was prescribed an antibiotic based on an abnormal urinalysis dipstick result, without a confirmed infection or supporting urine culture. The antibiotic was ordered as prophylaxis rather than for a diagnosed UTI, and facility policy requiring evidence of infection prior to antibiotic use was not followed.
A resident with a history of sexually inappropriate behavior repeatedly exposed themselves, made sexual comments, and physically prevented other residents from moving freely, including an incident where a cognitively impaired, wandering resident was found in the bathroom with the offending resident exposing their genitals. Multiple incidents involving sexual remarks, gestures, and physical actions toward both staff and residents were documented, but facility administration failed to recognize or report several of these as abuse, resulting in ongoing risk and harm to vulnerable residents.
A resident with moderate cognitive impairment engaged in multiple incidents of sexually inappropriate behavior toward other residents, including making gestures, comments, and physical actions. Despite facility policy requiring prompt reporting, only one incident was reported to the state survey agency, as the interim Administrator did not initially recognize the other events as abuse. This failure to report affected several residents with significant cognitive and physical impairments and resulted in a deficiency under F609.
A resident with a history of sexually inappropriate and aggressive behaviors repeatedly engaged in sexual, verbal, and physical abuse toward other vulnerable residents, including indecent exposure and physical interference. Despite multiple incidents witnessed by staff, the facility failed to thoroughly investigate or report these allegations as required, and did not follow its own abuse prevention policies, resulting in Immediate Jeopardy.
A resident with a history of sexually inappropriate behavior repeatedly engaged in verbal, sexual, and physical abuse toward other cognitively impaired residents, including exposing themselves, making sexual comments, and physically interfering with others. The Administrator failed to report or investigate most of these incidents as abuse, only addressing one event, and did not recognize the need for intervention, resulting in Immediate Jeopardy due to non-compliance with abuse prevention and reporting requirements.
Failure to Provide Correct Medicare Part A Termination Notice
Penalty
Summary
The facility failed to provide the correct Medicare beneficiary notice to residents whose Medicare Part A therapy services were being discontinued. Specifically, three residents who had not exhausted their Medicare benefit days were issued the CMS-R-131 form, which is intended for Part B services, instead of the required Notice of Medicare Provider Non-Coverage (NOMNC), Form CMS-10123, which should be given at least three days prior to the end of Medicare Part A services. This omission was identified through record review and staff interviews, which confirmed that the incorrect form was used for a period of three months. The facility's policy requires that residents be given proper notice regarding the termination of Medicare Part A services, including information about the appeals process and the reason for discontinuation. However, the review found that the required NOMNC form was not provided to the affected residents, potentially impacting their ability to understand their rights and options regarding the discontinuation of skilled services. The error was attributed to a change in procedure during the administrator's absence, as reported by the staff responsible for issuing the notices.
Failure to Complete PASARR for Resident with Mental Disorder
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident with a mental disorder. Record review showed that the resident was admitted with diagnoses including bipolar disorder, manic episode, and generalized anxiety disorder. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment. Although a PASARR Level I was completed at admission, there was no evidence of a PASARR Level II in the resident's electronic medical record, despite the presence of a qualifying mental health diagnosis. Interviews with facility staff, including the Social Service Director (SSD), Business Office Manager (BOM), and Administrator, revealed a lack of understanding and knowledge regarding the PASARR process, particularly in situations involving significant changes in a resident's mental or physical condition. The staff believed that PASARRs were only completed upon admission and that hospitals or behavioral health units were responsible for subsequent screenings. Documentation showed that the resident experienced multiple episodes of manic behavior, medication changes, and hospitalization, but no updated PASARR was completed by the facility.
Failure to Notify State Authorities After Significant Change in Resident with Mental Disorder
Penalty
Summary
The facility failed to identify and notify the appropriate state authorities for a Level II Preadmission Screening and Resident Review (PASARR) when a resident with a mental disorder experienced a significant change in condition. According to the facility's policy, residents with newly evident or possible serious mental disorders must be referred for appropriate services and the state mental health or intellectual disability authority must be notified promptly after a significant change in their mental or physical condition. In this case, a resident with a diagnosis of bipolar disorder and generalized anxiety disorder exhibited multiple episodes of manic behavior, which led to hospitalization in a Behavioral Health Unit. Despite these significant changes, there was no evidence in the resident's record that a PASARR Level II was completed or that the state authorities were notified. Interviews with facility staff, including the Social Service Director and the Administrator, revealed a lack of awareness regarding the requirement to notify state authorities following a significant change in condition for residents with mental disorders or intellectual disabilities. The staff confirmed that they do not conduct PASARRs in-house and were unaware of the notification requirement, even after the resident's behavioral issues and hospitalization. The deficiency was identified through record review, staff interviews, and policy review.
Failure to Follow Infection Control Practices During Perineal and Catheter Care
Penalty
Summary
Staff failed to adhere to infection control practices and facility policies during perineal care and suprapubic catheter care for one resident with a suprapubic catheter. Observations revealed that Certified Nurse Aides (CNAs) performed peri care and catheter care while wearing the same soiled gloves, then proceeded to touch the resident's clothing, mechanical lift, bed rails, linens, catheter bag, and tubing without changing gloves or performing hand hygiene. After completing these tasks, one CNA removed gloves and performed hand hygiene, while the other handled trash before performing hand hygiene. Both CNAs acknowledged during interviews that they should not have touched items with soiled gloves and recognized this as a breach of infection control protocol. Further observation showed that perineal care was performed using improper technique, including not washing the head of the penis or pulling back the foreskin, not using a clean area of the washcloth for each stroke, and failing to dry the area. The same soiled gloves were used to touch various surfaces and items in the resident's room, including the privacy curtain, nightstand, covers, and incontinent protectors. The CNA admitted after the procedure that gloves should have been changed between tasks and acknowledged touching items with soiled gloves without realizing it at the time.
Antibiotic Administered Without Confirmed Infection
Penalty
Summary
The facility failed to ensure that an antibiotic was not used without the presence of a diagnosed infection for one of four residents reviewed for antibiotic stewardship. According to the facility's policy, after an antibiotic order is received, the infection control coordinator or designee should complete a surveillance document using the McGeer criteria to confirm evidence of infection, and if the criteria are not met, the physician should be contacted. In this case, a resident was admitted and subsequently had a urinalysis (UA) performed, which showed abnormal results, but no culture and sensitivity (CNS) was ordered or documented. Despite the lack of a confirmed infection or supporting culture results, the resident was prescribed Macrodantin for seven days. Documentation in the resident's screening evaluation form indicated that the antibiotic was ordered as prophylaxis for an abnormal UA, not for a diagnosed urinary tract infection (UTI). The Infection Preventionist confirmed that the antibiotic was ordered based on a dipstick result performed by hospice, which appeared abnormal, but there was no evidence provided to the physician of a urine culture indicating bacterial growth. This sequence of actions did not align with the facility's antibiotic stewardship policy, as there was no documented infection or culture evidence to justify the antibiotic use.
Failure to Protect Residents from Sexual and Verbal Abuse by Resident with Known History
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident with a known history of sexually inappropriate behavior. The resident with a history of such behaviors was admitted with multiple medical conditions and moderate cognitive impairment, and their care plan documented prior incidents of sexually inappropriate language, gestures, and physical actions toward both staff and other residents. Despite these documented behaviors, the facility did not implement sufficient interventions to prevent further incidents, resulting in multiple episodes where the resident exposed themselves, made sexual comments, and physically prevented other residents from moving freely. Several incidents were documented involving the resident with inappropriate behaviors, including entering other residents' rooms, making sexual comments and gestures, grabbing staff and residents, and exposing themselves. In one significant event, a cognitively impaired and wandering resident was found in the bathroom of the resident with a history of sexual behaviors, where the latter was unclothed from the waist down and exposing their genitals. Other incidents included the resident standing over another cognitively impaired resident's bed with their genitals exposed, grabbing the wheelchair of another resident to prevent movement, and making repeated sexual remarks to both staff and residents. These actions were observed and reported by various staff members, including LPNs and CNAs, and were documented in nursing progress notes and interviews. The facility's administration failed to recognize or report several of these incidents as abuse, with the interim Administrator stating that only the most recent incident was reported because the others were not considered abuse due to factors such as the other residents being hard of hearing or showing no signs of injury. This lack of recognition and reporting, combined with insufficient interventions to prevent further abuse, resulted in multiple residents being subjected to sexual, verbal, and physical abuse. The facility's failure to protect residents from abuse and to respond appropriately to known risks led to a determination of Immediate Jeopardy, as the deficient practices were likely to cause serious harm to residents.
Removal Plan
- The facility will ensure residents are free from abuse, neglect, and exploitation. The facility will ensure interventions are implemented to prevent abuse involving resident-to-resident interactions and altercations for affected residents and any other allegations of abuse. Residents in the facility are at risk and have the potential to be affected.
- Resident #6 is currently on 1:1 supervision and remains on 1:1. Resident #6's care plan was updated to reflect the 1:1, and the facility is working on permanent housing out in the community with assistance from a local social services organization. A thirty-day discharge notice was issued to Resident #6. Behavioral health services are following resident #6. Resident #6 was moved to a private room. Residents #7 and Resident #8 are no longer in the facility. Residents #2, #3, #9, and #15 were seen by behavioral health services and visits have been completed, with no adverse outcome noted. Skin checks were performed on all female residents, along with all male residents who were non-interviewable with no negative outcomes. Social Services performed psychosocial checks on Residents #2, #3, #9, and #15 with no negative outcome.
- Current staff and contracted staff (all departments) were educated by Administrator, Director of Nursing (DON), and Unit Manager (UM). The members of the governing body (Corporate Regional Director of Clinical Services) educated the DON and the Administrator. The DON educated the UMs. The UMs educated current and contracted staff. Current staff and contracted staff who have not been educated will be educated prior to their next scheduled shift. Staff who have not been educated will be educated prior to returning to work (all departments). Education was provided on the following: Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect, which include identification of abuse, appropriate interventions in the event of alleged abuse and resident safety. One as needed (PRN) staff member has not been educated on the policies and cannot work until education is provided. New hires will receive the abuse and neglect education upon hire. Education will be provided to employees, contract staff, and any new hires prior to working (all departments).
- The governing body member Regional Director of Clinical Services and the Regional Directors of Operations completed the education of abuse and neglect with DON, Interim Administrator, Nurse Practitioner (NP), and Medical Director (MD).
- The Administrator, DON, and/or UM were educated on the 24-hr reports and risk management reports and the Administrator and/or DON to ensure immediate interventions. The Administrator and DON were trained on this process by the Regional Clinical Director and UM were trained by the DON.
- The Administrator and/or DON will ensure immediate interventions are implemented with every occurrence and/or allegation of abuse and neglect to ensure resident safety and protection. Allegations of abuse & neglect will be reported timely to the state agencies as applicable (police, Ombudsman, physician, family).
- An AD HOC QAPI meeting was conducted with Administrator, DON, Regional Director of Clinical Services, Medical Director, and Nurse Practitioner.
- The Medical Director and Nurse Practitioner were made aware and agree with the immediate jeopardy removal plan.
- Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect, which include identification of abuse, appropriate interventions in the event of alleged abuse and resident safety were reviewed and no changes were made.
- All corrections were completed.
Failure to Report Alleged Abuse and Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to report multiple allegations of abuse involving a resident with moderate cognitive impairment who exhibited sexually inappropriate behaviors toward other residents. On several occasions, this resident was observed making inappropriate sexual gestures and comments, grabbing another resident's wheelchair to prevent movement, and masturbating in a public area. These incidents involved residents with varying degrees of cognitive impairment and physical disabilities, including severe cognitive impairment, hemiplegia, and functional quadriplegia. Despite clear facility policy requiring immediate reporting of all alleged violations related to mistreatment, exploitation, neglect, or abuse, the facility did not notify the state survey agency of these incidents in a timely manner. Interviews with staff and administration revealed that only one incident was reported, as the interim Administrator did not initially consider the other events to be abuse, particularly when the affected residents had hearing impairments or there were no visible signs of harm. The Director of Nursing also confirmed that only one incident was reported to the state survey agency. The failure to report these allegations was determined to have caused, or was likely to cause, serious injury, harm, or death to residents. The deficiency was cited under F609, related to the requirement for freedom from abuse, neglect, and exploitation. The Immediate Jeopardy began when the facility failed to report the first incident of inappropriate sexual behavior and continued as subsequent incidents were also not reported.
Removal Plan
- The facility will ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment are reported to the state survey agency and all other applicable state agencies within the required time frame. Full body skin assessments were completed for affected residents. Social worker visits for psychosocial wellbeing and behavioral health services were completed for affected residents with no negative outcomes noted. Incidents were reported to the state agency and investigated.
- Current facility staff and contracted staff (all departments) were educated by Unit Managers on Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect. Governing body educated DON and Administrator. DON educated Unit Managers. Unit Managers educated current and contracted staff. Remaining staff will be educated prior to their next scheduled shift. 99% of staff have been educated. DON, Administrator, and Unit Managers will educate remaining staff prior to returning to work.
- The Administrator, Interim Administrator, DON, Nurse Practitioner, and Medical Director completed education on abuse and neglect by the Regional Director of Clinical Services.
- The Administrator, DON, and/or Unit Manager will review 24-hour reports and risk management reports Mondays through Fridays. The RN supervisor will review 24-hour reports and incident reports on Saturdays and Sundays and report any unusual occurrences immediately to the Administrator. The Administrator and DON were trained on this process by the Regional Clinical Director and the UMs were trained by the DON.
- An AD HOC QAPI meeting was conducted with the Administrator, DON, Regional Director of Clinical Services, Medical Director, and NP. The meeting discussed Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, Proper Investigation of Occurrences and Allegations of Abuse and Neglect, potential IJ removal plan, residents affected, and interventions to prevent future occurrences.
- The Medical Director and Nurse Practitioner were made aware and agreed with the immediate jeopardy removal plan.
- Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect were reviewed and no changes were made.
- All corrections were completed.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report multiple allegations of sexual, verbal, and physical abuse perpetrated by a resident with a known history of sexually inappropriate and aggressive behaviors. Several incidents occurred involving this resident, including entering another resident's room and making sexual gestures and comments, grabbing the wheelchair of another resident to prevent movement, making inappropriate sexual comments to a resident, and being found masturbating in the doorway of a resident's room. In one significant event, a cognitively impaired resident was found in the bathroom of the resident with a history of inappropriate behavior, where the latter was unclothed from the waist down and exposing their genitals. Despite these repeated incidents, the facility did not conduct thorough investigations or report all allegations as required by policy. The residents involved in these incidents were particularly vulnerable, with many having severe cognitive impairments, communication deficits, or physical disabilities such as hemiplegia, quadriplegia, and dementia. The resident responsible for the inappropriate behaviors had moderate cognitive impairment and was ambulatory, allowing them to move freely within the facility. Documentation and interviews revealed that staff were aware of the resident's behaviors and had implemented some interventions, such as providing care in pairs and referring the resident for psychiatric services. However, these measures were insufficient, and the facility did not follow its own abuse prevention and investigation policies, failing to interview all relevant parties or document the events leading up to the incidents. The deficiency was further compounded by the interim Administrator's misunderstanding of what constituted abuse, as only one incident was reported to the state survey agency while others were dismissed due to the perceived inability of the victims to hear or recall the events. This lack of appropriate investigation and reporting persisted over several months, affecting at least five residents and resulting in a determination of Immediate Jeopardy due to the likelihood of serious harm or injury to residents.
Removal Plan
- The facility will ensure that all alleged violations of abuse, neglect, exploitation, and mistreatment are appropriately investigated and reported to state agencies. All residents have the potential to be affected. Incidents involving the residents have been reported to the state and investigations started, skin assessments, and incident reports made.
- Current facility staff and contracted staff (all departments) were educated by the nursing administration staff on the Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, education on behaviors and on documentation of behaviors and interventions in the electronic medical records, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect, which include identification of abuse, appropriate interventions in the event of alleged abuse and resident protection from abuse. New hires will receive the abuse and neglect education, and procedure and protocol upon hire. Education will be provided to employees, contract staff, and any new hires prior to working. A member of the governing body (Regional Director of Clinical Services) educated the Director of Nursing (DON), and Interim Administrator. A member of the governing body (Regional Director of Clinical Services) educated the DON, Interim Administrator, Medical Director, Nurse Practitioner (NP) and Administrator for Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, education on behaviors and on documentation of behaviors and interventions in the electronic medical records, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect, which include identification of abuse, appropriate interventions in the event of alleged abuse and resident protection from abuse. The DON educated the Unit Managers, and the Unit Managers educated current and contracted staff. Current staff and contracted staff who have not been educated will be educated prior to their next scheduled shift. The DON, Administrator, and Unit Manager will educate remaining staff who have not been educated prior to returning to work (all departments).
- The Interim Administrator, Administrator, DON, NP, and the Medical Director completed the education on abuse and neglect and reporting of abuse and resident protection by the Regional Director of Clinical Services.
- An AD HOC QAPI meeting was conducted with the Administrator, DON, Regional Director of Clinical Services, Medical Director, and Nurse Practitioner to discuss the IJ and Removal Plan.
- The Medical Director and Nurse Practitioner were made aware and agree with the immediate jeopardy removal plan.
- All corrections were completed.
- The immediacy of the IJ was removed.
Failure to Implement Abuse Policy and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility Administrator failed to provide adequate oversight to ensure the abuse policy was implemented when a resident with a known history of sexually inappropriate behaviors repeatedly engaged in verbal, sexual, and physical abuse toward other residents. Multiple incidents involving this resident included being found unclothed and exposing themselves in the presence of other cognitively impaired residents, making inappropriate sexual gestures and comments, physically preventing another resident from moving their wheelchair, and masturbating in the doorway of another resident's room. These incidents affected several residents, all of whom were vulnerable due to cognitive impairment or other conditions. Despite these repeated occurrences, the Administrator did not report or investigate the majority of the incidents as abuse, only reporting one incident where a resident was found in another resident's bathroom with the perpetrator unclothed. The Administrator stated that the other incidents were not considered abuse because the involved residents were hard of hearing or showed no signs of distress, and believed such behaviors were part of living in the facility. This lack of recognition and response to abuse allegations resulted in a failure to protect residents from further harm and to comply with established abuse prevention and reporting policies. The deficiency was determined to have caused, or was likely to cause, serious injury, harm, or death to residents, and was cited at a scope and severity level of Immediate Jeopardy. The Administrator's failure to report and investigate abuse allegations, particularly beginning with an incident where a resident expressed inappropriate sexual gestures and comments while standing over another resident's bed, constituted non-compliance with federal requirements for administration and resident protection.
Removal Plan
- The Governing Body will ensure facility administrative staff and facility staff receive education and can demonstrate knowledge of facility systems and competency of procedures for the prevention of abuse and neglect, abuse investigations and resident protection and safety of all residents.
- The Regional Director of Clinical Services provided education for Director of Administrator and Interim Administrator on the Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect.
- The Regional Director of Clinical Services provided education for Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect to the Administrator, Interim Administrator, Director of Nursing (DON), Nurse Practitioner (NP), and Medical Director (MD).
- A member of the governing body (Regional Director of Clinical Services) educated the DON and the Administrator.
- The governing body member, Administrator, DON, Regional Director of Operations, Regional Director of Clinical Services reviewed the following policies: Behavior Assessment and Monitoring, Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect.
- The Administrator's and DON's job descriptions and education was reviewed by the Regional Directions of Operations.
- The DON educated the Unit Managers (UM), and the Unit Managers educated current and contracted staff.
- Current staff and contracted staff who have not been educated will be educated prior to their next scheduled shift.
- The DON, the Administrator, and UM will educate remaining staff who have not been educated prior to returning to work (all departments).
- The DON, UM, and the Administrator will review the 24-hr report and risk management report found in the electronic medical records.
- The Registered Nurse (RN) supervisor will review the 24-hr report and risk management report found in the electronic medical records and will report any unusual occurrence immediately to the Administrator.
- The Administrator and DON were trained on this process by the Regional Clinical Director and the UMs were trained by the DON.
- An AD HOC QAPI meeting was conducted with the Administrator, DON, Regional Director of Clinical Services, Medical Director, and Nurse Practitioner.
- The Medical Director was made aware and agrees with the immediate jeopardy removal plan.
- The governing body member arrived and currently remains in facility.
- Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect were reviewed and no changes were made.
- All corrections were completed.
- The immediacy of the IJ was removed.
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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