Legacy Transitional Care & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Georgia.
- Location
- 460 Auburn Avenue N.e., Atlanta, Georgia 30312
- CMS Provider Number
- 115585
- Inspections on file
- 31
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Legacy Transitional Care & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that food items in the freezer were not properly labeled or dated, and expired food was not discarded as required. The kitchen ice machine was also observed to have visible black residue, indicating unsanitary conditions, despite being in regular use for residents. Staff interviews confirmed knowledge of proper protocols, but these were not followed in practice.
A resident with limited English proficiency and dependent on staff for daily care was not provided with appropriate language assistance resources, despite facility policy requiring such support. The resident and family relied on gestures and limited English, with no communication aids or translation services available, and staff were unaware of or unable to access language line or translation devices. This resulted in the resident and family being unable to fully understand healthcare communications.
Multiple PTAC units in resident rooms were found with thick, gray, fuzzy debris and dusty filters during repeated observations. Facility policy required regular cleaning and disinfection, but unclear responsibility between housekeeping and maintenance staff led to the units remaining soiled.
The facility did not complete a significant change assessment for a resident upon re-admittance and transition to hospice care, and failed to accurately document the discharge status for another resident, resulting in inaccurate MDS records. Staff interviews confirmed that required assessments and verifications were not performed as per policy.
A resident with limited English proficiency did not have a fully comprehensive care plan addressing their communication needs, as required by facility policy. Although the care plan noted a risk for communication problems and listed some interventions, staff were unaware of the need for a communication device, and there was no documentation of the use of qualified interpretation services. This resulted in the resident's needs potentially going unmet.
A resident with a G-tube did not have tube placement or gastric residuals checked prior to medication administration, contrary to physician orders and facility policy. An LPN admitted to not performing these checks during the observed incident, and training records showed gaps in tube feeding education.
Surveyors identified multiple infection control failures, including the lack of a Water Management Program, improper storage of clean linen, unsanitary laundry conditions with leaks and debris, and failure to provide daily G-tube care for a resident with severe cognitive impairment. Staff interviews confirmed lapses in routine cleaning, maintenance, and adherence to infection control policies.
A facility failed to follow its food safety policy, leading to expired and moldy food items being found in the kitchen. A staff member was observed without a beard net, and interviews revealed a lack of awareness and oversight in food safety responsibilities, potentially risking residents' health.
A resident was not assessed for the ability to safely self-administer medications, as required by facility policy. The resident, with multiple health conditions, was found with a medication cup containing a tablet they forgot to take and could not identify. An LPN confirmed no assessments were conducted for self-medication administration, and the DON emphasized that medications should not be left at the bedside.
A facility failed to provide a resident with the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), impacting her ability to make informed decisions about her Medicare services. The resident was only verbally informed about the end of her Medicare Part A coverage and was not given the necessary forms or appeal instructions. The Social Services Director confirmed the absence of the resident's signature on the NOMNC and incorrect signatures on the SNF ABN, indicating a lapse in policy adherence.
The facility failed to maintain a safe and clean environment in two rooms, with issues such as a fan with gray substances and a privacy curtain caught in its blades, and a bathroom with a damaged ceiling and black stains. A resident reported inadequate cleaning and mold in the bathroom, which was confirmed by observations of a musty smell and black, brown substance on the ceiling.
The facility did not conduct required fingerprint and reference checks for several employees, including the Administrator, two CMAs, a CNA, and a Dietary Manager. The missing checks were discovered during a review of employee files, and the Administrator was unaware of these omissions due to the recent termination of the Human Resources Representative.
A facility failed to refer a Level II PASRR for a resident with PTSD, who was taking antidepressant medication. The Social Services Director was unsure if PTSD required a Level II PASRR, leading to a lack of appropriate evaluation and specialized services. The resident felt her mental health concerns were not addressed by the facility.
The facility failed to provide adequate nail care for two residents, resulting in one resident having long, jagged fingernails with a dark substance underneath, and another with extremely overgrown toenails. Despite care plans requiring staff assistance, there was no documentation of nail care being provided, and staff interviews confirmed the oversight. The facility also lacked records of podiatry consultations and foot assessments for the affected residents.
The facility did not maintain the dumpster area in sanitary conditions, with discarded items found around the dumpsters. The Dietary Manager confirmed the issue, stating the maintenance department was responsible, while the Maintenance Director indicated shared responsibility among all departments.
The facility failed to clean reusable medical equipment between uses, as observed with CMAs using blood pressure machines and cuffs on residents without cleaning them. Interviews confirmed awareness of infection prevention protocols, which were not followed, as stated by the DON.
The facility failed to ensure food items were properly labeled, discard expired foods, and maintain cleanliness of kitchen equipment, including the ice machine. Observations revealed unlabeled and undated food items, expired food, and dirty kitchen equipment. Interviews confirmed that dietary staff were expected to label and date food items and clean equipment after use, but follow-up observations showed some issues persisted.
The facility failed to provide a safe, clean, and comfortable environment for its residents, with multiple deficiencies observed in resident rooms and bathrooms, including loose handrails, food splattered on a feeding pump, peeling paint, damaged faucets, and broken lighting. These issues were confirmed by the Maintenance Manager and the Administrator, affecting the residents' quality of life.
The facility failed to maintain a medication error rate below five percent, resulting in a 7.14% error rate. Two residents received a multivitamin with minerals instead of the prescribed multivitamin oral tablet. The errors were confirmed by the LPN, LPN Unit Manager, and DON, indicating a lapse in following the facility's medication administration policy.
The facility failed to properly store medication for two residents, leading to unauthorized access. In one case, nasal saline was left in a discharged resident's room, and in another, an LPN left medication with a resident who was nauseated. Both instances were confirmed by staff and violated facility policy.
The facility failed to ensure proper hand hygiene during meal service and did not sanitize point-of-care equipment between uses, exposing residents to potential infection. Staff were inconsistent with hand hygiene, and equipment like blood pressure cuffs and glucose meters were not properly cleaned.
The facility did not complete the required fingerprint screening for a CNA and a CMA, as mandated by their Abuse Prevention Policy. The HR Director acknowledged missing the Georgia Criminal History Check System (GCheck) for these employees, and the Administrator confirmed that background checks are usually done before hire, with fingerprints within thirty days after hire.
A facility failed to develop a baseline care plan for a resident with pressure ulcers upon admission. The resident, with moderate cognitive impairment, required limited assistance and had pressure ulcers on the left heel and sacral area. The baseline care plan did not address these ulcers, and the Licensed Weekly Skin Assessment lacked documentation of the existing wounds. Interviews revealed that care plans are typically completed within 48 to 72 hours, but the resident's plan was incomplete, and the comprehensive care plan was still in progress.
Two residents receiving oxygen therapy in a LTC facility were found to have deficiencies in their respiratory care. One resident was using oxygen without a physician's order, contrary to facility policy. Another resident's oxygen equipment was poorly maintained, with dusty and dirty components, and lacked proper documentation for cleaning and changing. The facility's failure to adhere to its own standards for oxygen therapy and equipment maintenance highlights significant lapses in care.
A resident with severe cognitive impairment and a history of wandering was involved in multiple aggressive altercations with other residents. Despite being aware of the resident's behavior, the facility did not provide adequate supervision, relying on redirection as the primary intervention. This failure to protect residents from abuse resulted in several incidents of resident-to-resident aggression.
The facility failed to provide adequate supervision for a resident with a history of wandering and aggression, leading to multiple altercations and an injury. Additionally, the call light system on one floor was non-functional, leaving residents without a means to alert staff for assistance. The administrator was aware of these issues but did not take effective action to address them.
A facility failed to accurately assess a resident's wandering behaviors, leading to multiple altercations with other residents. The resident, with severe cognitive impairment and a history of adjustment disorder and dementia, was involved in several incidents due to wandering into other residents' rooms. Despite these behaviors, the resident's care plan did not reflect the wandering, resulting in a determination of noncompliance and an Immediate Jeopardy situation.
The facility failed to maintain a safe, clean, and homelike environment on two floors, with institutional-like room setups, broken furniture, and missing privacy curtains. A resident reported a non-functional over-bed light, and interviews confirmed awareness of these issues.
The facility failed to provide adequate ADL care, particularly in toileting and nail care, for eight residents. A resident was left in a soiled bed for hours due to a malfunctioning call system, while others with cognitive impairments had long, dirty fingernails. Staff interviews revealed confusion about responsibilities for nail care, with the Social Services Director noting that charge nurses were responsible for ensuring nails were trimmed.
The call light system on the fourth floor of the facility was non-functional for three weeks, preventing residents from alerting staff for assistance. A resident was left in soiled conditions due to the malfunction. Staff, including LPNs and CNAs, reported the issue, but it remained unresolved. The Maintenance Director and administrator were aware of past issues, yet the system was not repaired, violating the facility's policy.
A facility failed to monitor and document behaviors for a resident with severe cognitive deficits and a history of physical altercations. Despite having a care plan addressing behavior problems, staff interviews and observations revealed a lack of awareness and implementation of behavior monitoring, leading to unsupervised wandering and aggression.
A resident with multiple health conditions, including bruxism, experienced a significant delay in receiving urgent dental care due to facility scheduling conflicts and oversight. Despite a physician's order and the resident's repeated requests, the resident waited nearly four months for dental services, highlighting a deficiency in the facility's social services support.
A resident with multiple health conditions, including bruxism, experienced a delay in receiving dental care despite repeated requests and complaints of mouth pain. The facility's contracted dental services faced issues such as water problems and scheduling conflicts, resulting in the resident not being seen for several months. The resident's care plan was not updated in a timely manner, and the registered dietitian was unaware of the dental issues despite a noted weight loss.
Failure to Maintain Food Safety and Sanitary Conditions in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and dating of food items in the freezer, as well as failed to discard expired food items. Specifically, a large box of beef stew was found in the reach-in freezer without any expiration or open date written on the box or a label. Staff interviews confirmed that the protocol required expired food to be discarded within three days of expiration, and that in-service education had been provided on proper labeling, storage, and discarding of food items. Additionally, the interior components of the kitchen ice machine, including the wall lining and dispenser area, were found to have visible black residue. The Dietary Manager acknowledged the unsanitary condition of the ice machine and confirmed it was in regular use for residents. The Maintenance Director confirmed that his staff was responsible for cleaning and sanitizing the ice machine on a regular basis, following manufacturer guidelines and facility rules, and that logs were maintained after each cleaning.
Failure to Provide Language Assistance for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide appropriate language assistance resources to a resident with limited English proficiency, as required by its own policy and federal regulations. The resident, whose primary language is Tigrinya, was admitted with a documented language barrier and was dependent on staff for activities of daily living. The care plan identified a risk for communication problems and included interventions such as gestures, family support, and pen and paper, but did not ensure access to qualified interpretation services. Multiple observations revealed that the resident relied on gestures and limited English words to communicate, with no communication aids or translated materials present in the room. The resident's family member also reported difficulty understanding medical care and facility documentation, and confirmed that translation services were not provided during interactions. Interviews with staff indicated a lack of awareness and access to the facility's language line or communication devices. Certified Nurse Assistants and an LPN were unaware of any non-English speaking residents on their units and reported not having access to language assistance tools. The Social Worker acknowledged the existence of an AI translation device and a language line, but confirmed that the resident's primary language was not supported by the device. The Director of Nursing stated that staff should have access to these resources, but evidence showed that they were not utilized for the resident in question. This series of inactions and lack of resource availability resulted in the resident and family not receiving healthcare communications in a language or format they could understand.
Failure to Maintain Clean PTAC Units in Resident Rooms
Penalty
Summary
Staff failed to maintain clean Packaged Terminal Air Conditioner (PTAC) units in seven resident rooms on the third and fourth floors, as evidenced by multiple observations of gray, thick, fuzzy debris on the front dividers of the units and dusty filters. These observations were made over several days in rooms 223, 227, 228, 302, 316, 317, and 323. The facility's policy required environmental surfaces to be cleaned and disinfected according to CDC and OSHA standards, but the PTAC units in these rooms remained visibly soiled during repeated checks. Interviews with the Housekeeping Director and Maintenance Director revealed confusion and lack of clarity regarding responsibility for cleaning the PTAC units. The Housekeeping Director stated that maintenance was responsible, but indicated a plan to coordinate with maintenance in the future. The Maintenance Director, however, stated that the responsibility was not assigned to one person, but expected the Housekeeping Director to ensure cleanliness. This lack of clear assignment contributed to the ongoing presence of debris and dust on the PTAC units.
Failure to Complete Accurate Resident Assessments and Discharge Documentation
Penalty
Summary
The facility failed to complete and document accurate resident assessments as required by its own policy and federal regulations. For one resident, who had diagnoses including adult failure to thrive and malignant neoplasms, the facility did not complete a significant change assessment upon the resident's re-admittance and transition to hospice care. Although the resident was admitted to hospice services and this was documented in physician orders and nursing notes, the quarterly Minimum Data Set (MDS) assessment did not reflect the initiation of hospice services in Section O, and no significant change assessment was completed following the resident's change in status. Additionally, for another resident with multiple diagnoses including dementia and mental health disorders, the facility failed to accurately document the discharge status. The discharge MDS indicated the resident was discharged to a hospital, while progress notes and discharge instructions showed the resident was actually discharged to a personal care home. The MDS Coordinator relied solely on census information without cross-referencing other documentation, resulting in inaccurate discharge records. Interviews with staff confirmed these documentation errors and highlighted lapses in verifying and communicating changes in resident status.
Failure to Implement Comprehensive Care Plan for Resident with Language Barrier
Penalty
Summary
The facility failed to follow a comprehensive, person-centered care plan for a resident with limited English proficiency (LEP). According to the facility's Care Plan Policy and Language Access Policy, each resident should have a care plan that addresses their individual needs, including communication barriers, and provides a written summary in a language the resident or their representative can understand. The care plan for the resident in question identified a risk for communication problems due to a language barrier and included interventions such as using gestures, family support, and pen and paper. However, staff interviews revealed that a communication device, which could have supported the resident's needs, was not included in the care plan, and the MDS staff member was unaware of its necessity. Additionally, the facility's policy required staff to identify language needs upon admission, document language preferences, and use qualified interpretation services when necessary. Despite these requirements, there was no documentation that the Language Line service was used or that the resident's language needs were fully addressed. The DON confirmed that if an intervention is indicated on the care plan, it is expected to be followed, but in this case, the care plan was not comprehensive enough to meet the resident's communication needs, potentially leaving those needs unmet.
Failure to Follow G-Tube Protocols and Physician Orders
Penalty
Summary
A deficiency was identified when staff failed to follow physician's orders regarding the care of a resident with a gastrostomy tube (G-tube). Specifically, during a medication administration observation, a charge nurse (LPN) did not check for gastric residuals or verify proper G-tube placement before administering scheduled medications and flushes, as required by both the physician's orders and the facility's policy. The resident involved had severe cognitive impairment and multiple diagnoses, including gastrostomy status, acute respiratory failure, seizures, and encephalopathy. The care plan and physician orders clearly specified the need to check tube placement and gastric residuals prior to feeding, flushing, or medication administration. Interviews with staff revealed inconsistent adherence to these protocols, with one LPN admitting to only sometimes checking for residuals and placement, and confirming that these checks were not performed during the observed incident. Review of training records showed that tube feeding was not directly addressed in the medication administration skills checklist, and computer-based education did not include tube feeding training. Although inservices and skill checkoffs were conducted, the observed failure to follow established procedures led to the deficiency.
Infection Control Failures in Water Management, Linen Handling, Laundry Sanitation, and G-Tube Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by several deficiencies in water management, linen handling, laundry sanitation, and resident care. The Maintenance Director confirmed that there was no Water Management Program in place, and the facility did not maintain documentation of water testing or perform routine water system flushing, aside from flushing water heaters. The Administrator acknowledged the absence of a Water Management Program and recognized the expectation for facilities to ensure water safety and maintain supporting documentation. Observations revealed that a clean linen rack was left uncovered and unsupervised in a hallway, contrary to facility policy and staff expectations that clean linen should always be covered to prevent infection. The Housekeeping Director and Administrator both confirmed that this practice was not acceptable and could lead to infection risks. Additionally, the laundry area was found to be in an unsanitary condition, with puddles of water, rust-like stains, excessive dust and debris, dirty resident clothing on the floor, and evidence that washing machine filters were not being cleaned daily as required. Staff interviews confirmed awareness of these issues, but cleaning and maintenance were not consistently performed. For one resident with a gastrostomy tube, the facility failed to provide proper care as ordered by the physician. The resident, who was severely cognitively impaired and dependent on enteral feeding, was observed to have a G-tube site with brown, crusty material and unsecured tape on multiple occasions. Nursing staff confirmed that the site had not been cleansed as required, and the responsible LPN admitted to only sometimes cleaning G-tube sites. The Unit Manager also acknowledged that the G-tube site had not been addressed between observations, despite daily care being ordered.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to its policy on dating, labeling, and discarding food, which was revised in January 2023. During a kitchen inspection, it was observed that a Kitchen Aid staff member was not wearing a beard net, which is a violation of food safety standards. Additionally, a pan of salad in the walk-in cooler was not discarded by its used-by date and showed signs of brown discoloration. Furthermore, packaged bread was found with a green fuzzy substance, indicating mold growth. These observations suggest a lack of compliance with food safety protocols, potentially putting residents at risk of foodborne illnesses. Interviews with the Dietary Manager and the Administrator revealed a lack of awareness and oversight regarding food safety responsibilities. The Dietary Manager was unaware of the absence of dates on food items, while the Administrator expressed concerns about improper food handling and emphasized the importance of a three-day lifespan for food items. The dietary staff was identified as responsible for ensuring proper storage and disposal of food in the kitchen storage areas, highlighting a gap in the implementation of the facility's food safety policies.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to safely self-administer medications, as required by their policy. The policy mandates that a self-administration assessment be completed by the attending physician and the interdisciplinary care planning team to determine if a resident has the decision-making capacity to self-administer medications safely. However, for the resident in question, no such assessment was conducted. The resident, who was admitted with conditions including surgical amputation, gangrene, diabetes mellitus type two, and chronic kidney disease, was found with a medication cup containing a white tablet on their overbed table. The resident was unable to identify the medication or its purpose, indicating a lack of understanding or oversight in medication management. During an observation and interview, it was revealed that the resident had been left with the medication, which they forgot to take. A Licensed Practical Nurse (LPN) confirmed the presence of the medication cup and acknowledged that no residents had been assessed for self-medication administration. The LPN and a Certified Medication Aide (CMAT) both indicated that the medication was believed to have been taken by the resident, but it was not. The Director of Nursing (DON) confirmed that no self-medication administration assessment had been conducted and emphasized that medications should not be left at the bedside. This oversight in medication administration and assessment procedures led to the deficiency identified in the report.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to appropriately provide the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident, identified as R125, which could have impacted her ability to make informed decisions about her Medicare services and appeal rights. The facility's policy, revised in May 2018, mandates the issuance of Advance Beneficiary Notices per CMS guidelines to inform Medicare beneficiaries of items or services that Medicare may not cover. However, a review of R125's electronic medical record revealed that the NOMNC lacked her signature, and the SNF ABN contained signatures not belonging to her, indicating a failure to properly inform her of her Medicare coverage status. Interviews conducted with R125 and her family member revealed that R125 was only verbally informed about the ending of her Medicare Part A coverage and was not provided with the necessary forms or instructions for an appeal. The Social Services Director, responsible for providing these notices, confirmed the absence of R125's signature on the NOMNC and the incorrect signatures on the SNF ABN. The director acknowledged the need for more consistent documentation when residents cannot sign for themselves, highlighting a lapse in the facility's adherence to its policy and CMS guidelines.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two rooms across two of its four units. In one room, a personal circulating fan was observed with thick, gray substances on its blades, and a privacy curtain was caught in the fan blades. In another room, the shared bathroom had a dirty, damaged ceiling with black stains. These observations were confirmed during walking rounds with the Maintenance Director and Administrator, who acknowledged the issues. The facility census was 181 residents at the time of the survey. Additionally, a resident reported that the staff did not adequately clean their room or bathroom, only removing trash but rarely mopping. The resident also mentioned mold in the bathroom, which had been unsuccessfully treated with bleach a few months prior. An observation confirmed the presence of a urine-like smell and a black, brown substance on the bathroom ceiling, accompanied by a musty, mildew-like odor. The Administrator confirmed the absence of an Environmental Maintenance policy at the facility.
Failure to Conduct Background and Reference Checks
Penalty
Summary
The facility failed to conduct necessary background checks for several employees, as revealed during a record review and staff interview. Specifically, the facility did not attempt to obtain fingerprint checks through the Georgia Criminal History Check System (GCHEXS) for four out of ten employee files reviewed. Additionally, reference checks were not completed for two of the ten employee files. The employees affected included the Administrator, a Certified Medication Aide (CMA) hired in January 2024, another CMA hired in August 2024, a Certified Nursing Assistant (CNA) hired in July 2024, and a Dietary Manager hired in July 2024. Furthermore, the Director of Nursing (DON), hired in October 2022, also lacked evidence of reference checks. During an interview, the Administrator disclosed that the Human Resources Representative had been recently terminated, and she was unaware of the missing information in the employee files.
Failure to Refer Level II PASRR for Resident with PTSD
Penalty
Summary
The facility failed to refer a Level II Preadmission Screening and Resident Review (PASRR) to the appropriate state-designated authority for evaluation and determination of specialized services for a resident with a serious mental illness. The resident, identified as R171, had a diagnosis of post-traumatic stress disorder (PTSD) and was taking antidepressant medication. Despite these indicators, there was no documented Level II PASRR following the diagnosis, which is required for individuals with serious mental illnesses to ensure they receive the appropriate level of care and services. The Social Services Director, responsible for making PASRR referrals, stated that she reviewed PASRRs within the first 72 hours of admission and notified the state authority if a Level II PASRR was needed. However, she was uncertain if PTSD required a Level II PASRR. The resident expressed that the facility was not addressing her mental health concerns, although she found some comfort in interacting with other residents. The facility's policy required reporting any changes identified via the PASRR screen to the state mental health authority promptly, but this was not done for R171.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, R65 and R154, as part of their activities of daily living (ADLs). R65, who has moderate cognitive impairment and requires assistance with bathing, was observed with long, jagged fingernails with a dark substance underneath. Despite the care plan indicating the need for staff participation in bathing, there were no shower logs to confirm that nail care was provided. Interviews with staff confirmed the lack of nail care, as LPN CC acknowledged the condition of R65's fingernails. Similarly, R154, who has intact cognition and requires full staff assistance for ADLs, was found with extremely overgrown toenails, particularly the great toenails, which were thick and twisted. R154 reported not having seen a podiatrist since admission. The facility's records lacked documentation of a podiatry consultation, and nursing skin assessments did not include foot assessments. Interviews with staff, including CNA AA and LPN BB, revealed that nail care was not consistently provided or documented, and there was no indication of nail concerns on R154's shower sheet.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the dumpster area in sanitary conditions, as observed during an initial inspection. Discarded items such as gloves, plastic forks, cardboard, a chair, and combs were found on the ground surrounding the dumpsters. During an interview, the Dietary Manager confirmed the presence of these items and stated that while everyone used the dumpsters, the maintenance department was responsible for ensuring the area was kept sanitary. However, the Maintenance Director later stated that the responsibility for maintaining the cleanliness of the dumpster area was shared among all departments, with no single department or person designated to oversee the site.
Failure to Clean Reusable Medical Equipment
Penalty
Summary
The facility failed to ensure that reusable medical equipment was cleaned between uses for different residents, which could potentially lead to the spread of infection and illness. During observations on November 6, 2024, Certified Medication Aids (CMAs) were seen using blood pressure machines and cuffs on residents without cleaning them between uses. Specifically, CMA DD used a blood pressure machine from the hallway to check a resident's blood pressure and returned it without cleaning. Similarly, CMA EE used a blood pressure cuff on a resident and returned it to the medication cart drawer without cleaning, then proceeded to use the same cuff on another resident without cleaning it. Interviews with the CMAs confirmed that they were aware of the infection prevention protocols, which included cleaning shared medical equipment between uses. The Director of Nursing (DON) also confirmed that all infection prevention policies, including the cleaning of reusable medical equipment, were to be followed during medication administration.
Failure to Properly Label, Date, and Maintain Cleanliness of Food Items and Kitchen Equipment
Penalty
Summary
The facility failed to ensure food items were properly labeled, discard expired foods, and maintain cleanliness of kitchen equipment, including the ice machine. During an inspection, it was observed that none of the items in the three large freezers were labeled or dated, and there was loose food at the bottom of two of the freezers. Unidentified food items were wrapped in plastic wrap, unlabeled and undated, and there were expired food items such as brownie mix. Additionally, dry items like flour and sugar were stored in large white containers without labels or dates. The ice machines were found to be dirty, with one machine having a pink, jelly-like substance under the dispenser. The Dietary Manager (DM) confirmed these findings and discarded the expired items, while the Maintenance Supervisor (MS) cleaned the ice machines and changed the filters and covers. However, follow-up observations revealed that some issues persisted, such as undated and unlabeled dry food containers and dirty kitchen equipment like the toaster, blender, and large can opener. Interviews with the DM and MS revealed that the dietary staff were expected to label and date all food items and clean kitchen equipment after use. The DM stated that she interacts with staff daily about these expectations. The MS confirmed that he was responsible for cleaning and maintaining the ice machines and that the facility had regular pest control and trash removal services. The Administrator also confirmed that the kitchen staff were expected to maintain a clean and orderly kitchen, properly label and date food items, discard expired items, report any concerns with food and equipment, and adhere to specific dietary needs of the residents.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. Observations revealed multiple deficiencies in 11 of 84 resident rooms and 10 of 48 bathrooms, including loose handrails, food splattered on a tube feeding pump, gaps behind toilets, stopped-up sinks, peeling paint, damaged faucets, and broken lighting. Additionally, there were issues with ceiling damage, holes in the floor, leaks around the base of toilets, broken paper dispensers with sharp edges, and missing or damaged baseboards and PTAC units. These deficiencies were confirmed by the Maintenance Manager and the Administrator during walking rounds, who acknowledged the need for immediate repairs but did not provide a policy regarding the environment. One resident with mobility issues, identified as R128, reported difficulty maneuvering a wheelchair in the bathroom due to the size of the room and the placement of handrails. Observations in this resident's room revealed peeling paint, a loose PTAC casing, and a dusty hall vent with black flying bugs. Another resident, R428, had food splattered on their feeding pump, and their room had a loose handrail, a missing dresser drawer, and a broken bedside table. These conditions were observed over multiple days, indicating ongoing neglect in maintaining a safe and clean environment. Additional observations included windows that would not close, beeping smoke detectors, and out-of-order shower rooms. Several rooms had damaged ceiling tiles, large holes in walls, and exposed plumbing. The facility's failure to address these issues compromised the residents' ability to reach their highest practicable level of functioning and negatively impacted their quality of life. The facility census at the time was 179 residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than five percent, resulting in a medication error rate of 7.14%. This was identified through observations, record reviews, and staff interviews. Specifically, two medication errors were observed out of 28 opportunities for two residents. The errors involved the administration of a multivitamin tablet with minerals instead of the prescribed multivitamin oral tablet (multiple vitamin) for both residents. The residents involved had diagnoses including spinal stenosis, alcohol abuse, esophagitis, muscle weakness, alcohol abuse withdrawal, cerebral infarction, and anemia. Their care plans indicated risks related to nutrition and hydration due to their conditions and therapeutic diets. The errors were confirmed by the LPN who administered the medications and further validated by the LPN Unit Manager and the Director of Nursing, who emphasized that medications should be given as ordered and according to the six rights of medication administration. During the medication administration observation, the LPN administered the incorrect form of multivitamin to both residents. The LPN confirmed the error during an interview, acknowledging that the multivitamin with minerals was given instead of the prescribed multivitamin oral tablet. The LPN Unit Manager and the Director of Nursing also confirmed that medications should be administered exactly as ordered, highlighting a failure in adhering to the facility's medication administration policy. This deficiency indicates a lapse in the facility's medication administration process, leading to a medication error rate exceeding the acceptable threshold.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to properly store medication for two residents, leading to unauthorized access to medications. In the first instance, a container of nasal saline was found on a bedside table in a room where the resident had been discharged three weeks prior. The LPN present confirmed that the medication should have been placed in the medication room for destruction by the Nurse Manager or DON. The CNA and LPN Unit Manager also confirmed that the medication should not have been left at the bedside and should have been checked and removed after the resident's discharge. In the second instance, a resident who was not feeling well had medication from the 9:00 am medication pass left on their bedside table. The LPN Unit Manager confirmed that the medication pass was at 9:00 am and that the medication should not have been left with the resident. The resident stated they were nauseated and afraid to take the medication, so the LPN gave them the pills to take later. The DON confirmed that the LPN who left the medication was an agency nurse and that the facility's policy requires nurses to ensure residents take their medication or document refusal and notify the Nurse Practitioner or Physician.
Inadequate Hand Hygiene and Equipment Sanitization
Penalty
Summary
The facility failed to ensure staff implemented appropriate hand hygiene during meal service and the sanitization of point-of-care equipment, exposing residents to potential infection. Observations revealed that staff were inconsistent with hand hygiene between passing trays in the dining room, and a resident was not offered hand hygiene before or after meal consumption. Interviews with staff confirmed that hand hygiene was expected but not consistently practiced. Additionally, the facility did not have a specific hand hygiene policy, relying instead on CDC guidelines and staff education. Further observations showed that a Licensed Practical Nurse (LPN) did not sanitize a blood pressure cuff between uses on different residents, and a Medication Technician did not use a barrier during a fingerstick blood sugar procedure, nor did she consistently clean the glucose meter properly. Interviews with the Infection Control Nurse and the Director of Nursing (DON) confirmed these practices were not in line with the facility's infection prevention policies. The DON acknowledged the lack of a formal hand hygiene policy and emphasized the importance of staff education and adherence to CDC guidelines.
Failure to Complete Pre-Employment Fingerprint Screening
Penalty
Summary
The facility failed to ensure proper pre-employment screening, specifically fingerprinting, for two staff members, a Certified Nursing Assistant (CNA) and a Certified Medical Assistant (CMA). The facility's Abuse Prevention Policy, last reviewed in May 2024, mandates that background, reference, and credential checks, including fingerprinting, should be conducted on employees prior to or at the time of employment. However, the review of employee files revealed that the CNA hired on February 1, 2024, and the CMA hired on January 16, 2024, did not have the fingerprint process completed. Both employees had active, unencumbered certifications. Interviews with the Human Resource Director and the Administrator confirmed the oversight, with the HR Director acknowledging the missed Georgia Criminal History Check System (GCheck) and the Administrator stating that background checks are typically performed before hire, with fingerprints completed within thirty days after hire.
Failure to Develop Baseline Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a baseline care plan for a resident, identified as R172, that included goals and interventions to meet immediate care needs upon admission. R172 was admitted with diagnoses including pressure ulcers on the left heel and sacral area. The admission Minimum Data Set (MDS) indicated moderate cognitive impairment and required limited assistance with all care. However, the baseline care plan did not address the resident's pressure ulcers, focusing only on personal preferences, code status, and risk of infections. Additionally, the Licensed Weekly Skin Assessment did not document the existing pressure ulcers, indicating a lack of proper assessment and documentation. Interviews with the MDS Director and the Director of Nursing (DON) revealed that baseline care plans are typically completed within 48 to 72 hours of admission, but R172's care plan was incomplete and did not address the pressure ulcers. The MDS Director acknowledged the oversight and stated that the comprehensive care plan was still in progress. The DON confirmed that residents with pressure ulcers should have an actual care plan addressing their needs. Despite the facility's practice of completing care plans within 21 days, the lack of a timely and comprehensive care plan for R172's pressure ulcers was evident.
Deficient Respiratory Care Practices in LTC Facility
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents receiving oxygen (O2) therapy. Resident R281 was observed using O2 without a physician's order, which is against the facility's policy that requires a written order specifying the liter flow per minute. The Director of Nursing (DON) confirmed that R281 had been receiving O2 since admission without an order, and the nursing staff was responsible for managing O2 therapy. Despite the resident's reliance on O2, there was no documentation of a physician's order, highlighting a lapse in following the facility's protocol. Resident R1, who was dependent on supplemental O2, was found with O2 equipment that was not maintained according to the facility's standards. The O2 tubing and nasal cannula (NC) were observed lying on the floor, and the O2 concentrator was covered in dust with a dirty filter that had not been changed since February 2023. The resident reported that the O2 machine had not been cleaned in a long time, and the filter appeared to have spore-like substances. The Unit Manager (UM) and DON confirmed the lack of a current order for cleaning the O2 concentrator and the failure to change the filter and tubing as required. The facility's policy mandates weekly changes and cleaning of O2 equipment, but observations revealed that these practices were not followed for R1. The DON stated that maintenance was responsible for checking the concentrators, but the dirty filter and casing were not addressed. The failure to maintain the O2 equipment and obtain necessary physician orders for O2 therapy represents a significant deficiency in the facility's respiratory care practices.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect eight residents from abuse, resulting in multiple incidents of resident-to-resident altercations. One resident, identified as R1, was involved in several aggressive encounters with other residents, including slapping and hitting them. R1, who had severe cognitive impairment and a history of wandering, was not adequately supervised, leading to these altercations. Despite being aware of R1's aggressive behavior, the facility did not assign a staff member for one-to-one supervision, relying instead on redirection as the primary intervention. The incidents involved residents with varying levels of cognitive impairment, some of whom were unable to recall the events or express their concerns. R1's behavior was documented in several progress notes, indicating a pattern of aggression towards other residents, including R17, R18, R19, R12, and R22. Staff members, including CNAs and LPNs, reported difficulties in managing R1's behavior and expressed concerns about the safety of other residents. The facility's Director of Nursing acknowledged R1's involvement in multiple altercations and the need for closer surveillance. Interviews with staff and residents revealed a lack of effective interventions to prevent R1 from wandering into other residents' rooms and causing disturbances. The facility's administrator and medical staff were aware of the ongoing issues but did not implement sufficient measures to address the risk posed by R1's behavior. The facility's failure to provide adequate supervision and intervention for R1 resulted in a situation that had the likelihood to cause serious harm to residents.
Removal Plan
- R1 was assessed by the Psych Physician Assistant per physician order. A skin assessment was conducted on R1 with no skin alterations noted. The Corporate Operations Consultant, the Administrator and the Social Services Director met to discuss placement options for R1. R1 was transferred to a Psychiatric Facility per the physician order. The facility Social Worker will assist the Psychiatric facility with finding placement for R1. An immediate discharge notice was issued to R1 and R1's legal representative.
- The Behavioral Health Physician's Assistant, the facility's Psychiatric provider, the Administrator, the Director of Nursing Services, and Corporate Operations Consultant had a telephone conference to discuss alternate placement for current or future residents that may present to be a danger to self or others.
- An Ad Hoc QAPI meeting was held with the Medical Director, Corporate Operations Consultant, Administrator, Director of Nursing, Social Services Director, MDS staff, and Nurse Managers to review the IJ Removal Plan, altercations involving R1 and alternate placement of R1. The Abuse Policy and the Behavior Management Policy were reviewed, and no changes were made.
- The Staff Development Coordinator educated the following facility staff on the Abuse Policy, the Behavior Management Policy, and Resident to Resident Altercation Policy: three of four Registered Nurses; 21 of 22 Licensed Practical Nurses; 17 of 17 Medication Technician; the Activity Director, three of three Activity Assistants; 33 of 33 Certified Nursing Assistants; the Administrator; the Human Resources Director; the Admissions Director; the Marketing Director; four of four receptionists; the Business Office Manager; the Business Office Assistant, two of two Medical Records Coordinators; the Dietary Manager; 13 of 13 Dietary Assistants; the Housekeeping/ Laundry Director; the Maintenance Director; the Maintenance Assistant; the Laundry Supervisor; 11 of 11 Environmental Employees; the Therapy Director; three of three therapy assistants; the Social Services Director; two of two Social Services Assistants; the MDS Director; and two of two MDS Coordinators. In-services will be conducted on an ongoing basis by the Staff Development Coordinator and nurse managers. Agency staff will be educated on the facility policies prior to working in the facility. Those employees identified to be on LOA or FMLA will be in-serviced upon return, prior to their shift. All new employees will be in-serviced during the facility orientation.
- A Skin Assessment Audit was conducted by the nurse management team for 63 of 63 residents on the secured memory unit. There were no new areas of concern identified.
- The corrective actions were completed and facility alleges that immediate jeopardy is removed.
Deficiencies in Resident Supervision and Call Light System
Penalty
Summary
The facility failed to provide adequate protective oversight for residents in the secured memory unit, particularly for a resident with a history of wandering and aggressive behavior. This resident was involved in multiple physical altercations with other residents over a period of several months, starting in September 2023. Despite being aware of the resident's aggressive tendencies, the facility did not assign one-to-one supervision, which led to an incident where the resident was pushed by another resident, resulting in a fracture of the left elbow. Additionally, the facility did not ensure that the call light communication system was functioning on the fourth floor. Observations revealed that the system was not operational, with no sound or visual alerts to indicate when residents required assistance. Staff interviews confirmed that the system had been non-functional for several weeks, and the maintenance director was aware of the issue but had not resolved it. The administrator was aware of both the resident's behavior issues and the malfunctioning call light system upon being hired but did not take effective action to address these problems. The lack of supervision for the wandering resident and the non-functional call light system posed significant risks to resident safety and well-being.
Removal Plan
- An Ad Hoc Abuse Performance Improvement Meeting was held with the Administrator, Director of Social Services, the DON, Corporate Operations Consultant, and the Corporate Nurse Consultant to identify the root cause of resident-to-resident altercations with a subsequent plan of action. The Abuse Prevention Policy, Resident to Resident Policy, and the Behavioral Management Policy were reviewed no changes made.
- The Administrator's job description was reviewed with the Administrator by the Corporate Operations Consultant. No revisions were made.
- The Corporate Operations Consultant in-serviced the Administrator, DON, and Social Services Director (SSD) on how to properly conduct an abuse investigation, how to track and to determine trends, root cause analysis and communication among departments on abuse reporting. The facility QAPI policy was reviewed specifically regarding how to determine root cause analysis.
- The Corporate Operations Consultant audited, completed, and signed the facility Abuse Log from September 2023 through current for any further areas of concern. Name of Audit- Abuse Log Audit. Trends noted to be primarily on third floor and in the evenings involving R1. Residents and the time of altercations were discussed with the Administrator and Director of Social Services. Interventions were put into place on the Abuse Performance Improvement Plan.
- The Corporate Nurse Consultant and DON audited the resident-to-resident altercations from September 2023 through current. The audit is named Resident to Resident Documentation Audit. It was identified that care plans were not initiated on all resident-to-resident altercations. Care plans were implemented. The DON and Administrator will discuss all abuse allegations in the morning meeting to ensure all departments respond appropriately. Documentation will be monitored through the Abuse Performance Improvement Plan and reported during QAPI by the Director of Nursing and Administrator.
- The Administrator was educated through the company online training modules on Implementation of QAPI Programs in Nursing Facilities through a one hour approved course. The Administrator successfully completed a post class test and received a certification. The Corporate Operations Consultant conducted educated the Administrator on how to conduct a QAPI meeting and how to identify and complete a Root Cause Analysis.
Inaccurate Assessment of Wandering Behaviors Leads to Resident Altercations
Penalty
Summary
The facility failed to ensure the accuracy of the comprehensive assessment for a resident, identified as R1, who exhibited wandering behaviors. R1, who was admitted with diagnoses including adjustment disorder, psychotic disorder, and dementia with agitation, was involved in multiple resident-to-resident altercations due to wandering. Despite having a severe cognitive impairment, R1 was noted to be independent in mobility, and the quarterly MDS assessment inaccurately documented that R1 did not exhibit wandering behaviors. R1's wandering led to several incidents, including physical altercations with other residents. On one occasion, R1 wandered into another resident's room, resulting in a physical altercation that caused R1 to sustain a fracture of the left elbow. Multiple staff members, including LPNs and CNAs, documented R1's aggressive behavior and involvement in altercations, indicating a pattern of wandering and aggression that was not accurately reflected in R1's care plan. The facility's failure to accurately assess and document R1's wandering behavior and the associated risks led to a determination of noncompliance with participation requirements. This noncompliance was identified as having the likelihood to cause serious injury, harm, impairment, or death to residents, resulting in an Immediate Jeopardy situation being declared.
Deficiencies in Resident Environment and Privacy
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on the Third and Fourth Floors, as observed during a survey. On the Fourth Floor, rooms were set up in an institutional-like manner with four beds lined up in a row and curtain dividers, which were broken in some rooms. The furniture was in disrepair, with broken and peeling bed stands, stained chairs, and missing wall moldings. Some rooms lacked nightstands and privacy curtains, compromising the residents' privacy and comfort. Additionally, a resident reported that their over-bed light was not functioning, and the string to operate it was out of reach, which had been reported several times without resolution. On the Third Floor, similar issues were observed, including a quad room with a busted hole in the wall near the door entrance. Interviews with the Administrator and Maintenance Director confirmed awareness of the broken furniture and the institutional-like setup of the quad rooms. They acknowledged that privacy curtains had only been replaced on the Second Floor, and broken furniture was due for replacement. The Resident Counsel President also confirmed that some rooms lacked privacy curtains, which should have been present.
Deficiency in ADL Care: Toileting and Nail Care Neglect
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care, specifically in toileting and nail care, for eight residents. One resident, who was cognitively intact and required substantial assistance, was found sitting in a soiled bed for several hours after a bowel movement. The resident had used the call light for assistance, but due to a malfunctioning call monitoring system, no staff responded. This issue had persisted for three weeks, with the resident repeatedly informing staff without resolution. Several residents with severe cognitive impairments and ADL self-care performance deficits were observed with long, dirty fingernails, indicating a lack of personal hygiene assistance. Despite care plans directing staff to assist with personal hygiene, residents reported that staff had not offered to trim their nails, even when requested. Interviews with staff, including CNAs and LPNs, revealed a lack of awareness and action regarding the residents' nail care needs. The facility's policy on ADLs did not address nail care, contributing to the oversight. Staff interviews indicated confusion about responsibilities for nail trimming, with some believing it was the duty of CNAs and activities staff, while others thought it was the responsibility of nurses. The Social Services Director confirmed that charge nurses were responsible for ensuring residents' nails were trimmed, highlighting a disconnect between policy and practice.
Call Light System Failure on Fourth Floor
Penalty
Summary
The facility failed to ensure that the call light communication system was functioning on the fourth floor, which resulted in residents being unable to alert staff for assistance. Observations and interviews revealed that the call light system was not operational, with no sound or visual alerts at the nurse's station. A resident reported pressing the call light multiple times without response, leading to a situation where the resident was left in soiled conditions for several hours. Staff confirmed that the system had been non-functional for approximately three weeks, and maintenance requests had been documented but not addressed. The Maintenance Director and facility administrator were aware of previous issues with the call light system, but the problem persisted without resolution. Staff members, including LPNs and CNAs, acknowledged the malfunction and had reported it through the appropriate channels. Despite these reports, the system remained inoperative, and the facility's policy requiring a functioning call system was not upheld. The deficiency was noted during a survey, highlighting a significant lapse in the facility's ability to provide timely assistance to residents.
Failure to Monitor and Document Resident Behaviors
Penalty
Summary
The facility failed to monitor and document behaviors for a resident involved in multiple resident-to-resident physical altercations due to wandering on the unit. The resident, who was admitted with diagnoses including adjustment disorder with depressed mood, psychotic disorder with delusions, and dementia with agitation, had a severe cognitive deficit as indicated by a BIMS score of three. Despite being independently mobile, the resident's comprehensive care plan, which included interventions for behavior problems related to auditory hallucinations, was not followed as there was no documentation of behavior monitoring. Interviews with facility staff, including the MDS Director, Physician Assistant, and Nurse Practitioner, revealed a lack of awareness and implementation of a behavior monitoring plan for the resident. Observations noted the resident ambulating unsupervised in the hallway of a secured memory unit. The staff acknowledged the resident's behaviors and the need for closer surveillance, yet failed to document or monitor these behaviors as required by the facility's Behavioral Management Program policy.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide adequate assistance and support from social services for a resident, identified as R8, to receive urgent dental services. R8, who was admitted with diagnoses including congestive heart failure, diabetes type 2, paranoid schizophrenia, bipolar disorder, and bruxism, requested dental services for a toothache. A physician ordered a dental consult on 11/29/2023, and social services sent a referral on 11/30/2023. However, the care plan for dental services was not updated until 2/28/2024, after surveyor interviews. Despite being cognitively intact and able to express his needs, R8 reported ongoing pain and dissatisfaction with the delay in receiving dental care. Interviews and records revealed that although R8 was on the list for dental services since November 2023, he was not seen by the dentist due to various issues, including water problems in the building and scheduling conflicts. The dentist visited the facility in November and December 2023 but did not see any residents, and R8 was missed again during a visit on 2/14/2024. No additional referrals were made for R8 to be seen outside the facility, resulting in a delay of almost four months before he received the necessary dental care.
Delayed Dental Care for Resident with Mouth Pain
Penalty
Summary
The facility failed to provide timely dental services to a resident who repeatedly requested care due to mouth pain. The resident, who has a history of congestive heart failure, diabetes type 2, paranoid schizophrenia, bipolar disorder, and bruxism, was admitted with a physician's order for a dental consult. Despite multiple requests and complaints of toothache, the resident did not receive dental care for several months. The facility's dental service policy mandates routine and emergency dental services, but the resident's care plan for dental services was not updated until after surveyor interviews. Interviews with the facility's administrator and social service director revealed that dental services are contracted monthly, but the resident was not seen due to various issues, including water problems and scheduling conflicts. The resident was placed on a list for dental services in November, but was not seen until March. During this period, the resident experienced significant discomfort, as evidenced by his difficulty speaking and grinding teeth. The registered dietitian was unaware of the resident's dental issues, despite a noted weight loss in January, which may have been related to the resident's dental condition.
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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