Lake City Center For Nursing And Healing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake City, Georgia.
- Location
- 2055 Rex Road, Lake City, Georgia 30260
- CMS Provider Number
- 115535
- Inspections on file
- 26
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Lake City Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
Multiple residents who were dependent on staff for ADLs did not consistently receive scheduled showers, nail care, shaving, or skin moisturizing as outlined in their care plans and the facility’s ADL policy. One resident with muscle wasting and atrophy was repeatedly observed unkempt, unshaven, and with long, dirty fingernails despite being scheduled for regular showers and staff assistance with all ADLs, and reported not having had a bath in over two weeks. Another resident with hemiplegia, totally dependent for personal hygiene, was observed unshaven with long nails containing debris, even though the unit manager stated that shaving and nail care should occur on shower days. A third resident with gout and nutritional deficiency had documented frequent showers but was found with dry, flaky feet that had not been moisturized, contrary to expectations for skin care on bath days. A fourth resident with a collapsed vertebra, cognitively intact and requiring assistance with all ADLs, reported not having had a shower in weeks and was observed with matted, greasy hair, while a CNA attributed missed showers to short staffing and leadership confirmed expectations that scheduled showers and related grooming be provided and documented.
The facility failed to maintain adequate nursing staff to meet resident needs, as indicated by the Facility Assessment Tool and PBJ Staffing Data Report for Q2 2024. The facility, with a census of 212 residents, required 84 hours for licensed nurses and 233 hours for aides daily. However, it triggered low weekend staffing and received a one-star rating due to issues like missed PBJ data deadlines and RN staffing gaps. The Administrator and President of Operation acknowledged these deficiencies.
The facility failed to maintain food safety and sanitation standards, with issues such as improper hair restraint use, unlabeled food items, missing temperature logs, and unsanitary kitchen conditions. Structural problems, including a malfunctioning drainage system and gaps in the kitchen door, contributed to the deficiencies.
The facility failed to assess residents for self-administration of medications and did not ensure safe storage, leading to incidents where medications were found in residents' rooms without authorization. One resident with severe cognitive impairment experienced a medical emergency after accessing unknown medications, while others were found with expired or unauthorized medications. Staff interviews confirmed that no residents were assessed for self-administration, and medications should not have been left at the bedside.
The facility failed to properly store personal care items in five bathrooms, leading to potential cross-contamination. Observations showed that bedpans and urinals were not bagged or labeled and were improperly stored. The DON confirmed these findings and stated that CNAs were expected to rinse, bag, and label these items, which was not done.
A resident with intact cognition and multiple medical conditions was served a meal that did not align with her stated preferences, despite the facility's policy to support resident choice. The resident, who does not eat potatoes, was served sweet potatoes, which was incorrectly labeled on her meal card. The dietary manager acknowledged the error, and the resident expressed dissatisfaction with meal options, particularly on weekends.
The facility failed to maintain a safe, clean, and comfortable environment, with deficiencies noted in four rooms across two halls. Issues included missing paint, holes, crumbling walls, dirty floors, and broken air conditioning vents. The Administrator and Maintenance Director confirmed these concerns and were aware of the need for repairs.
The facility failed to complete PASRR Level II assessments for two residents with bipolar disorder, as required. Staff interviews revealed a lack of coordination and responsibility in verifying PASRR Level I accuracy, with the Admissions Director not checking for accuracy and the Social Service Department responsible for follow-up. The facility lacked a PASRR policy, contributing to the deficiency.
The facility failed to provide proper care for PICC lines for two residents. One resident's PICC line dressing was not changed according to physician's orders, and the IV tubing was not labeled. Another resident had no physician's orders for PICC line care, and the dressing was not changed weekly. Staff interviews revealed confusion about responsibilities and documentation for PICC line care.
The facility failed to adhere to physician orders for oxygen therapy for two residents, leading to incorrect oxygen delivery rates. One resident received less oxygen than prescribed, while another received more. These discrepancies were confirmed and corrected by an LPN, highlighting a lapse in following established protocols.
Failure to Provide Scheduled ADL Care Including Showers, Nail Care, and Shaving
Penalty
Summary
The deficiency involves the facility’s failure to provide activities of daily living (ADL) care, including scheduled showers, nail care, and shaving, to multiple residents who were dependent on staff assistance. The facility’s ADL policy required that, based on comprehensive assessment and resident needs and choices, residents’ abilities in ADLs should not deteriorate and that care and services would be provided for bathing, dressing, grooming, and oral care. A review of the grievance log over several months showed multiple complaints from residents and families about missed baths/showers, shaves, nail care, and lack of skin moisturizing. Despite this, several residents with documented self-care deficits and staff-dependent status for personal hygiene did not receive consistent ADL care as scheduled. One resident with muscle wasting and atrophy, cognitively intact and care planned to receive staff assistance with all ADLs, was scheduled for showers three times weekly on the day shift. Documentation showed only four showers in December, and repeated observations on different days showed the resident unkempt, with disheveled hair, unshaven face, and long fingernails with dirt and brown debris. The resident reported that his bath days were different from what was in the POC, stated he preferred bed baths, and reported not having had one in over two weeks, also expressing a desire for nail clipping and shaving. A nurse supervisor confirmed the resident’s long, dirty nails and unshaven condition. Another resident with hemiplegia and total dependence on staff for personal hygiene, care planned for staff assistance of two, had scheduled shower days twice weekly but was documented as receiving only a limited number of showers in December. Observations on consecutive days showed this resident unshaven with long fingernails containing brown debris, and the unit manager confirmed the lack of shaving and nail care despite the expectation that these tasks be completed on shower days. A third resident with gout and nutritional deficiency, assessed as needing staff assistance with personal hygiene and care planned for a self-care performance deficit, had scheduled showers three times weekly on the night shift. CNA documentation indicated frequent showers throughout December, yet observation of the resident’s feet revealed white, dry, flaky skin, and the unit manager acknowledged that the resident’s skin had not been moisturized and that it would not appear that way if scheduled showers and associated skin care were being provided. A fourth resident with a collapsed vertebra, cognitively intact and requiring staff assistance with personal hygiene, was care planned for staff assistance with all ADLs and scheduled for showers three times weekly on the day shift. Documentation showed only four showers in December, and observation revealed matted, greasy, disheveled hair. This resident reported that her shower days were different from those in the POC and stated she had not had a shower in three weeks, also noting she had not attended activities because of this. A CNA reported that this resident had not received showers due to CNA short staffing. The DON stated her expectation that residents receive scheduled showers three times weekly and as needed, with nails clipped and faces shaved on shower days and as needed, and that CNAs and unit managers were responsible for following POC shower schedules and documentation.
Inadequate Staffing Leads to Deficiency
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet the needs of its residents, as revealed by staff interviews and a review of the Facility Assessment Tool (FAT) and Payroll-Based Journal (PBJ) Staffing Data Report for Quarter 2, 2024. The facility, licensed for 242 beds, had a current census of 212 residents. The FAT indicated that the average daily staffing needs were 84 hours for licensed nurses providing direct care and 233 hours for nurses' aides. However, the PBJ Staffing Data Report showed that the facility triggered excessively low weekend staffing and received a one-star staffing rating due to several issues, including failure to submit PBJ data by the deadline, more than four days in the quarter without RN staffing hours, and failure to respond to or pass a CMS audit designed to discover discrepancies in PBJ data. Interviews with the Administrator and the President of Operation confirmed their awareness of these staffing deficiencies.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to several food safety and sanitation protocols, as observed during a kitchen tour. Dietary staff did not consistently wear hair restraints, leading to instances where hair was not fully covered while plating food. Additionally, the facility did not maintain proper labeling and storage of food items, with several unlabeled bags of fish, beef, chicken, biscuits, and turkey bacon found in the walk-in cooler and freezer. The temperature logs for refrigeration units were missing for several days, indicating a lack of monitoring to ensure food preservation. The kitchen environment was found to be unsanitary, with a buildup of grease and dirt on various surfaces, including the oven, hood vent, ceiling vents, and floor tiles. The reach-in refrigerator had a thick, dark liquid on its floor panel, and the kitchen floor was covered with water puddles and sticky substances. The facility also had structural issues, such as gaps in the kitchen door that allowed pests to enter, missing floor tiles, and a malfunctioning drainage system that caused water to seep onto the floor. The facility's maintenance and cleaning practices were inadequate, as evidenced by the presence of flies in the kitchen and personal items stored on kitchen counters. The Dietary Manager confirmed the lack of daily temperature logging and acknowledged the need for improved cleaning practices. The facility's leadership was aware of the plumbing issues and had begun seeking solutions, but the unsanitary conditions persisted, affecting the overall food safety and hygiene standards.
Failure to Assess and Safely Store Medications
Penalty
Summary
The facility failed to assess seven residents for their ability to self-administer medications and did not ensure safe storage of medications at the bedside. This oversight led to several incidents where medications were found in residents' rooms without proper authorization or assessment. For instance, one resident with severe cognitive impairment was found with a cup of unknown medications, leading to a medical emergency where the resident became lethargic and had unstable vital signs. Despite the severity of the incident, it was not reported to the State agency, and no preventative measures were implemented to prevent recurrence. Another resident, who was cognitively intact, was found with an expired inhaler at the bedside, which was not prescribed by the facility's physician. The medication was removed by a nurse, who confirmed it should not have been in the room. Similarly, a resident with a history of drug-induced disorders was observed with medications left at the bedside by a nurse who was called away to attend to another task. The nurse admitted to leaving the medications unattended, which was against the facility's policy. Additional observations revealed that residents with varying degrees of cognitive impairment had medications or medical supplies, such as isopropyl alcohol and hydrogen peroxide, left in their rooms without proper assessment or authorization for self-administration. Interviews with staff, including the DON and LPNs, confirmed that no residents had been assessed for self-administration, and medications should not have been left at the bedside. Despite these findings, the facility did not have a system in place to monitor or track such incidents, indicating a systemic failure in medication management and resident safety protocols.
Improper Storage of Personal Care Items
Penalty
Summary
The facility failed to ensure that resident personal care items were stored in a manner to prevent cross-contamination in five of 11 bathrooms on the 400 Hall. Observations revealed that items such as bedpans and urinals were not bagged or labeled, and were improperly stored on shelves above toilets, on the floor, or attached to rolling walkers. This practice was contrary to the facility's policy, which required personal items to be clean, stored appropriately, and not placed on floors. During observational rounds, the Director of Nursing confirmed the improper storage of these items and stated that the expectation was for Certified Nursing Assistants to rinse, bag, and label the urinals and bedpans with the room number. The lack of adherence to these procedures had the potential to expose residents to infections due to cross-contamination.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, as required by their policy on resident rights. The resident, who has intact cognition and multiple medical diagnoses including paranoid schizophrenia, type 2 diabetes, congestive heart failure, obesity, and renal failure, was served a meal that did not align with her stated preferences. Despite the facility's policy to support resident choice and provide food substitutes as needed, the resident was served sweet potatoes, which she does not eat, as indicated on her meal card. The dietary manager and registered dietitians acknowledged that the meal card should have specified the type of potatoes, and the dietary manager admitted that the resident should not have been served sweet potatoes. The resident expressed dissatisfaction with the meal options, particularly on weekends, and chose not to eat breakfast on the day of the observation. She also mentioned reluctance to request alternate meals, as they typically did not meet her preferences. The dietary staff had previously documented residents' food preferences, diets, restrictions, and allergies, and these were supposed to be reflected on the meal tray tickets. However, the oversight in accurately labeling the meal card led to the resident receiving food she did not want, highlighting a failure in the facility's process to ensure resident preferences are respected and accommodated.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by observations in two of the seven halls. Specific deficiencies were noted in four rooms across the 300 and 400 Halls. These rooms exhibited various issues, including missing paint on doors and walls, holes, punctures, and dents in the walls, crumbling walls with exposed rocks, dirty floors, and broken or soiled air conditioning vents. Additionally, one room's bathroom floor was found with dirt, debris, and a dead cockroach, while another room had food and debris in a broken air conditioning vent, loose light covers, and a missing floor tile at the entryway. During a follow-up round with the Maintenance Director, Administrator, and Housekeeping Supervisor, all the concerns in the identified rooms were confirmed. The Administrator, who had been at the facility for three weeks, acknowledged these issues during her initial walk-through and stated that facility improvements were actively being made. The Maintenance Director was aware of the structural damages and was working on repairs. The Administrator expressed her expectation for the facility to provide a clean, safe, and homelike environment for its residents.
Failure to Complete PASRR Level II Assessments
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level II was completed for two residents, R73 and R47, who were reviewed for PASRR Level II. Both residents were admitted with diagnoses that included bipolar disorder, which should have triggered a PASRR Level II assessment. However, the PASRR Level I assessments for both residents did not include the diagnosis of bipolar disorder, and there was no evidence that a PASRR Level II assessment was completed. This oversight was identified through staff interviews and record reviews, revealing a lack of coordination and verification of the PASRR process. Interviews with facility staff, including the Admissions Director, Licensed Practical Nurse/MDS Coordinator, Social Service Assistant, and Social Service Director, highlighted a breakdown in communication and responsibility regarding the PASRR process. The Admissions Director admitted to not checking the PASRR Level I for accuracy, while the Social Service Department was identified as responsible for following up on PASRR submissions. The Social Service Director confirmed that the residents did not have PASRR Level II assessments and acknowledged the need for a review of the process to ensure accuracy. The facility did not have a policy in place for PASRR, contributing to the deficiency.
Deficient PICC Line Care in LTC Facility
Penalty
Summary
The facility failed to provide care according to professional standards for two residents, R11 and R261, who were reviewed for intravenous catheter care. For R11, the facility did not follow the physician's orders for dressing changes for a PICC line and failed to ensure the IV infusion tubing was labeled and dated. R11 was readmitted to the facility with diagnoses including sepsis and chronic osteomyelitis and was on IV antibiotics. Observations revealed that the PICC line dressing was soiled and had not been changed since 6/27/2024, despite an order to change it every Monday. Additionally, the IV tubing was not labeled with a date or infusion time. Interviews with staff, including LPN FF and the Director of Nursing Services (DNS), revealed a lack of clarity and responsibility regarding the monitoring and documentation of the PICC line care. LPN FF was unsure who was responsible for changing the dressing and admitted that the order for dressing changes had not appeared on her eMAR. The DNS confirmed that there was no documentation of the PICC line dressing being changed or the site being monitored for infection, and acknowledged that the nurse administering medications was responsible for these tasks. For R261, the facility failed to obtain physician orders and provide care for a PICC line. R261 was admitted with diagnoses including major respiratory failure and COPD, but there were no physician's orders for the care of the PICC line. Observations confirmed that the PICC line dressing was dated 7/3/2024, and interviews with LPN II and the Assistant Director of Nursing (ADON) confirmed the absence of physician orders for the PICC line care. The ADON stated that physician's orders should have been obtained and the dressing should be changed weekly.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders for oxygen therapy for two residents, R65 and R187, which could potentially place them at risk for medical complications. For R65, the electronic medical record indicated a physician's order for oxygen at three liters per minute (LPM) via nasal cannula, starting from December 22, 2023. However, observations on July 14 and 15, 2024, revealed that R65 was receiving oxygen at two LPM instead of the prescribed three LPM. This discrepancy was confirmed by LPN HH, who adjusted the oxygen rate to the correct level. Similarly, for R187, the physician's order specified oxygen at two LPM via nasal cannula, starting from June 3, 2024. Observations on July 14 and 15, 2024, showed that R187 was receiving oxygen at three LPM instead of the ordered two LPM. LPN HH confirmed the error and adjusted the oxygen rate accordingly. The Assistant Director of Nursing expressed that it was expected for nursing staff to check oxygen concentrators every shift to ensure they are set at the prescribed rate.
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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