Legacy Transitional Care & Rehabilitation

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Improper infection control measures were observed during catheter care for a resident with a suprapubic catheter. The resident had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, major depressive disorder, benign prostatic hyperplasia with lower urinary tract symptoms, urine retention, benign neoplasm of the colon, and atrophy of kidney. The resident’s MDS indicated a BIMS score of 14, showing the resident was cognitively intact, and the care plan identified the resident as at risk for complications related to the indwelling catheter. During observation of catheter care, a restorative aide and a CNA assisted with the procedure. No hand hygiene was observed before the care began. Gown and gloves were applied, and double gloves were used. Wipes were removed from the package and placed on the bed pad. The groin was cleansed from inner to outer areas with separate wipes, and the catheter tubing was cleansed starting from the top of the catheter and moving away from it. Soap was added to water in a basin, the area was cleaned with soap and water, and then rinsed with a wet cloth. After removing gloves, clean gloves were applied without hand hygiene. In interview, the restorative aide and CNA stated they would know if a resident was on precautions by looking at the door signage and that the signage would indicate what PPE was needed. The restorative aide stated she used hand sanitizer when she went back into the hall, but the surveyor did not observe hand sanitizer use. She also confirmed that she placed opened wipes on the resident’s draw sheet and that she double gloved and did not sanitize her hands before putting on new gloves. The Administrator and DON stated staff were expected to explain care throughout the process, not double glove, and clean their hands with hand sanitizer or soap and water before and after each process of peri care and catheter care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

PASARR Level II was not submitted for one resident who had a diagnosis of schizophrenia and evidence of cognitive and behavioral concerns. Record review showed a quarterly MDS with a BIMS score of 8 indicating moderate cognitive impairment, delusions in Section E, schizophrenia in Section I, and an antipsychotic medication in Section N. The resident’s care plan identified impaired cognitive function and impaired thought processes related to schizophrenia, with interventions to administer medication as ordered, and also identified a risk for behaviors secondary to schizophrenia with interventions to monitor and document behaviors. The facility policy titled Preadmission Screening and Annual Resident Review stated that all potential admissions are to be screened on an individualized basis for PASARR and that recommendations from PASARR Level II determinations are to be incorporated into the resident’s assessment, care plan, and transition of care. Interviews with the Social Service Director, Social Worker, and MDS Director confirmed that the resident did not have a PASARR Level II submission and that PASARR status was not being checked by the MDS Director, even though the resident had been admitted with a diagnosis of schizophrenia.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that three of 14 shared bedrooms on the 400 hall were maintained in good repair. During observations, rooms [ROOM NUMBER] were found with chipped and peeling paint, scuffed sheetrock, holes in the wall, and a damaged or broken electrical outlet. One room also had an overbed light that was inoperable. These conditions were observed in multiple rooms during tour and screening of residents, including a damaged and broken outlet in one room, peeled and scraped wall paint with scuffed sheetrock in another, and similar wall damage with an inoperable overbed light in a third room. The facility’s Facility Maintenance Policy stated that resident rooms are to be inspected weekly for cleanliness, functionality of fixtures, and safety compliance, and that repairs and maintenance issues are to be addressed promptly. During walking rounds, the Maintenance Director confirmed the damaged walls with peeled paint and chipped, scuffed sheetrock, the damaged and broken outlet, and the inoperable overbed light. The Administrator later stated she was aware of the environmental concerns and said three Maintenance Personnel would be assigned to round the facility, each responsible for a designated floor, with additional tools to support daily checks.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance in two of seven restrooms on the 200 hall and two of 14 rooms on the 300 hall. Review of the facility’s Call System/Light Policy stated that the resident call system shall allow residents to call for staff assistance through a communication system that relays the call directly to a staff member or centralized staff work area, and that bedside and emergency call lights must be in functioning order. The Facility Maintenance Policy also stated that daily inspections of critical systems are required and that resident monitoring systems are a critical component for resident safety and communication. During observations on 9/30/2025, the call light system in one resident room was hanging off the wall with exposed wires and did not function when tested, and another room’s call light system was pulled out from the wall, hanging, and also did not function when tested. In the shared bathrooms for rooms 201 and 202 and for rooms 203 and 204, the emergency call devices were detached from the wall. Additional observations found the call light systems in the shared bathrooms on the 200 hall were hanging from the wall with exposed wires and were not functioning. Walking rounds with the Maintenance Director confirmed that rooms 301 and 305 and the bathrooms on the 200 hallway had non-functioning call lights. The Maintenance Director also stated that he conducts audits for the call devices to ensure they work.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $107,075

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $107,075

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $107,075

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $107,075

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $107,075

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $107,075

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $107,075

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $107,075

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $107,075

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.