Macon Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Macon, Georgia.
- Location
- 505 Coliseum Drive, Macon, Georgia 31217
- CMS Provider Number
- 115362
- Inspections on file
- 22
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Macon Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident was transported to a dialysis center with no apparent injuries but later developed a serious head injury and was sent to the emergency room, where they were pronounced deceased. The facility did not report the injury of unknown origin to the SSA within the required timeframe, as the Administrator delayed notification until after receiving information from the Coroner.
A resident was transported to dialysis without apparent injury but later developed a bleeding scalp laceration and was diagnosed with a subarachnoid hemorrhage, leading to death. The facility did not obtain key records or statements from the ER, law enforcement, or dialysis clinic, and relied on outside investigators without persistent follow-up, resulting in an incomplete investigation of the injury.
A CNA provided incontinent care to a resident with a stage 3 pressure ulcer and on Enhanced Barrier Precautions without wearing a protective gown, as required by facility policy. The CNA acknowledged the omission, and the DON confirmed that staff are expected to use gowns and gloves for residents on EBP.
The facility failed to ensure care plans were developed or implemented for six residents, leading to deficiencies such as untrimmed beards, unclean fingernails, uncovered catheter bags, incorrect oxygen therapy, improper tube feeding, and lack of care plan updates for medications.
The facility failed to provide necessary care and services to five residents, leading to unmet personal needs and diminished quality of life. Specifically, the facility did not ensure that two residents had clean and trimmed nails, one resident had a trimmed and clean beard without food particles, and two residents received baths and removal of facial hair. These deficiencies were observed through resident and staff interviews, record reviews, and direct observations by surveyors.
The facility failed to ensure a urinary catheter privacy bag was provided for a resident, resulting in the resident's urine being visible from the hallway. Observations and staff interviews confirmed the deficiency, and the DON noted that the resident often removes the privacy bag, but staff should ensure it is covered.
The facility failed to update the care plan for a resident whose indwelling urinary catheter had been removed five months prior. Despite the removal, the care plan still included goals and interventions for the catheter, leading to a risk of unmet needs and diminished quality of life. Staff interviews and direct observation confirmed the oversight.
The facility failed to obtain a podiatry appointment for a resident who required toenail care, despite multiple requests and notifications to staff. The resident, who is dependent on staff for all activities of daily living, showed a thick, long toenail with jagged edges and experienced discomfort due to the lack of timely care.
A resident with a history of cerebrovascular accident, dysphagia, type 2 diabetes, and mild protein-calorie malnutrition was administered Glucerna instead of the physician-ordered Nepro formula. This discrepancy was confirmed by the DON, who acknowledged the error in tube feeding administration.
The facility failed to ensure proper documentation and availability of tracheostomy supplies for two residents and did not follow physician orders for oxygen therapy for two other residents. Observations revealed missing physician orders, unstocked supplies, and dirty oxygen concentrators, indicating lapses in communication and responsibility among staff.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident to the State Survey Agency (SSA) within the required timeframe. According to the facility's Abuse Prevention Policy, all alleged violations involving abuse, neglect, exploitation, mistreatment, or injuries of unknown source must be reported immediately, but no later than two hours after the allegation is made, especially if the event involves abuse or results in serious bodily injury. In this case, a resident was transported from the facility to a dialysis center without any apparent injury. While at the dialysis center, the resident developed a hematoma to the head that was bleeding profusely and was subsequently sent to the emergency room, where a CT scan revealed a subarachnoid hemorrhage. The resident received care in the emergency room and was later pronounced deceased. The facility received notification of the incident after the resident was sent to the emergency room. The Administrator was informed by the Coroner of the resident's death and the nature of the injuries later that evening. The initial report to the SSA was not submitted until after the Administrator received this information, which was outside the required reporting timeframe. The facility's final investigative summary concluded that there was no substantiated evidence that the injury occurred at the facility, but the delay in reporting the incident to the SSA constituted a failure to comply with the facility's own policy and regulatory requirements.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of injury of unknown origin for one resident. According to the facility's Abuse Prevention Policy, injuries of unknown source require a comprehensive investigation, especially when the injury is suspicious due to its extent, location, or frequency. In this case, the resident was transported from the facility to a dialysis center without any apparent injury, but later developed a bleeding scalp laceration and was sent to the emergency room, where he was diagnosed with a subarachnoid hemorrhage and subsequently died. The facility's investigative summary concluded that there was no substantiated evidence the injury occurred at the facility. However, there was no documentation that the facility obtained critical information necessary for a thorough investigation, such as the emergency room medical record, the County Sheriff's report, the supplemental report from the Sheriff's Department Investigator, or statements from the dialysis clinic. The facility relied on the County Investigator to gather information from the dialysis clinic and did not pursue further contact or visit the clinic after initial attempts to reach them by phone were unsuccessful. Interviews revealed that the facility administrator did not follow up in person with the dialysis clinic or persistently seek out the necessary records and reports. The administrator deferred the investigation to the County Investigator and did not obtain the investigator's report, despite being informed it was available for pickup. As a result, there was no evidence of a complete and thorough investigation into the resident's injury of unknown origin, as required by facility policy.
Failure to Follow Enhanced Barrier Precautions During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing aide (CNA) failed to follow the facility's infection prevention and control policy while providing care to a resident on Enhanced Barrier Precautions (EBP). The resident had multiple diagnoses, including a stage 3 pressure ulcer, was always incontinent of bowel and bladder, and required substantial to maximal assistance with toileting hygiene. Facility policy required staff to wear appropriate personal protective equipment (PPE), including gowns and gloves, when providing care to residents on EBP to prevent exposure to potentially infectious materials. During an observation, the CNA was seen providing incontinent care to the resident without wearing a protective gown, contrary to facility policy and the resident's EBP order. The CNA confirmed in an interview that she did not wear a gown and acknowledged that she should have done so. The Director of Nursing (DON) also confirmed that the expectation was for staff to wear gowns and gloves during such care for residents on EBP.
Failure to Implement and Update Care Plans
Penalty
Summary
The facility failed to ensure a care plan was developed or implemented for six residents, leading to various deficiencies in their care. For instance, one resident with an ADL self-care performance deficit due to a cerebral vascular accident was observed with a full beard containing food and long fingernails with a brown substance underneath, despite the care plan's goal for a clean and neat appearance. Another resident with moderate cognitive impairment had long fingernails with a thick brown substance underneath, contrary to her preference for clean nails, which was documented in her care plan but not followed by the staff. A resident with an indwelling catheter was observed with an uncovered catheter drainage bag filled to the top and visible from the door, despite the care plan's intervention to provide a privacy device and ensure the bag is emptied when under 3/4 full. Additionally, a resident receiving oxygen therapy was observed with varying oxygen flow rates that did not align with the physician's orders, and there were no documented oxygen saturations to justify the use of oxygen according to the care plan. Another resident on continuous tube feeding was observed receiving a different nutritional product than what was ordered by the physician, indicating a failure to follow the care plan. Lastly, a resident recently readmitted from hospitalization had no care plan areas or interventions for the use of antipsychotic, antidepressant, and anticoagulant medications, as the care plan had not been updated since the readmission. These deficiencies highlight the facility's failure to develop and implement appropriate care plans, potentially placing residents at risk for medical complications and unmet needs.
Failure to Provide Adequate Personal Care and Hygiene
Penalty
Summary
The facility failed to provide necessary care and services to five residents, leading to unmet personal needs and diminished quality of life. Specifically, the facility did not ensure that two residents had clean and trimmed nails, one resident had a trimmed and clean beard without food particles, and two residents received baths and removal of facial hair. These deficiencies were observed through resident and staff interviews, record reviews, and direct observations by surveyors. One resident with moderate cognitive impairment had long fingernails with a thick brown substance underneath. The resident expressed a preference for having her nails cleaned but could not recall the last time staff cleaned them. Another resident with moderate cognitive impairment had a full beard with food particles and long fingernails with a brown substance. Despite expressing a desire for a trimmed beard, the resident was observed in the same clothes with food particles in his beard on consecutive days. Two other residents did not receive their scheduled baths and had long facial hair. One resident with Alzheimer's disease and muscle weakness received only four bed baths in 20 days, and staff did not document any facial hair removal. Another resident with morbid obesity and decreased mobility received only one bath in 20 days and expressed frustration over inconsistent shower schedules. Additionally, a resident with Alzheimer's disease and depression had long fingernails and broken nails, and staff did not provide nail care during scheduled baths or approach the resident for nail care activities.
Failure to Provide Urinary Catheter Privacy Bag
Penalty
Summary
The facility failed to ensure a urinary catheter privacy bag was provided for a resident with a urinary catheter, which had the potential to diminish the resident's quality of life. The facility's policy on urinary catheter care, revised April 2, 2024, stated that catheter drainage bags should be covered when residents are in public areas. However, observations on two separate occasions revealed that the resident's urinary catheter drainage bag was uncovered and visible from the hallway, allowing the resident's urine to be seen by other residents, staff, and visitors. Interviews with a CNA and an LPN confirmed that the catheter drainage bag was not in a privacy bag and its contents were visible from the hallway. Further interviews with the Director of Nursing (DON) revealed that the resident often removes the privacy bag and places it in the top drawer. The DON stated that staff should make attempts to ensure the bag is covered to provide privacy for the resident. The deficiency was identified for one of four residents with a urinary catheter in the facility, highlighting a failure to adhere to the facility's policy and ensure the resident's dignity and privacy.
Failure to Update Care Plan for Discontinued Urinary Catheter
Penalty
Summary
The facility failed to update the care plan for a resident (R56) related to an indwelling urinary catheter that had been removed and discontinued. The care plan still included goals and interventions for the catheter, despite it being removed five months prior. This discrepancy was identified during a review of the resident's records and confirmed through staff interviews and direct observation. The facility's policy requires care plans to be reviewed and updated as necessary, but this was not adhered to in this case, leading to a risk of unmet needs and diminished quality of life for the resident. The resident's Quarterly Minimum Data Set (MDS) assessment indicated no cognitive impairment and documented that there was no indwelling urinary catheter. However, the care plan had not been updated to reflect this change. Interviews with the MDS Director and the Director of Nursing revealed that care plan revisions were behind schedule, and the staff was unaware of the catheter removal. The Director of Nursing confirmed that the catheter had been discontinued and removed on November 1, 2023, but the care plan had not been updated accordingly.
Failure to Obtain Podiatry Appointment for Resident
Penalty
Summary
The facility failed to obtain a podiatry appointment for a resident (R39) who required toenail care, as observed and confirmed through interviews and record reviews. The facility's policy on nail care mandates reporting any issues with nails, including when they are too hard or thick to cut. R39, who has intact cognition and is dependent on staff for all activities of daily living, had requested a podiatry appointment multiple times but did not receive one. On 4/19/2024, R39 asked about seeing a podiatrist and showed a thick, long toenail with jagged edges on her left great toe. She had previously informed a CNA about her need for toenail care, but no action was taken until she spoke with the Social Worker on 4/19/2024. The Social Services Director (SSD) confirmed that R39 had asked to be put on the list to see the podiatrist on 4/19/2024. The SSD relies on staff, residents, and family members to notify her when someone needs podiatry care, and admitted that R39 fell through the cracks. A CNA revealed that she had informed a nurse a few weeks ago about R39's need for a podiatry appointment and had also informed the SSD. Despite these notifications, no appointment was made, leading to the resident's discomfort and potential decrease in quality of life.
Failure to Administer Correct Enteral Nutrition
Penalty
Summary
The facility failed to provide enteral nutrition according to physician orders for a resident (R54) who was receiving tube feeding. The resident's medical record indicated a physician's order for continuous Nepro formula at 65 cubic centimeters (cc) per hour for 22 hours. However, observations on April 19, 2024, revealed that Glucerna, instead of Nepro, was being administered via a pump at the prescribed rate. This discrepancy was confirmed by the Director of Nursing (DON), who acknowledged that the nursing staff had administered the wrong tube feeding product. R54's medical history included cerebrovascular accident, dysphagia, type 2 diabetes, and mild protein-calorie malnutrition. The facility's policy on enteral nutrition, last reviewed on April 16, 2024, stated that adequate nutritional support would be provided to residents as ordered. Despite this policy, the incorrect administration of Glucerna instead of Nepro placed R54 at risk for medical complications and a diminished quality of life.
Deficiencies in Tracheostomy and Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure that two residents had written physician orders for the tracheostomy tube sizes in use. Specifically, Resident 71 did not have a written order for the tracheostomy tube size of 6.5 mm or the previous size of 7.5 mm. Additionally, tracheostomy supplies were not available at the bedside for Resident 71. The Director of Nursing (DON) confirmed that the supplies, including a resuscitator, oxygen, suction machine, and a replacement tracheostomy tube, were not properly stocked. The Central Supply Clerk (CSC) was responsible for restocking these supplies but failed to do so due to being off on the scheduled restocking day. Similarly, Resident 14 had a tracheostomy tube size change that was not documented in the physician's orders until two days later, indicating a lapse in proper documentation and communication between the Respiratory Therapist (RT) and the nursing staff. The facility also failed to ensure that two residents receiving oxygen therapy had written physician orders for oxygen use and that oxygen was administered as ordered. Resident 4 had an order for oxygen at 2 liters per minute (LPM) if oxygen saturation was less than 92 percent, but observations revealed the resident was receiving oxygen at 3 LPM without a humidification bottle, and the oxygen concentrator was dirty. The DON and LPN confirmed that the current oxygen order was not being followed and that there was confusion about who was responsible for cleaning the concentrator filters. Similarly, Resident 24 was observed using oxygen without a current physician's order, and the oxygen concentrator was also found to be dirty. The DON confirmed that the oxygen order was not reinstated after the resident's recent hospital readmission. These deficiencies indicate a lack of adherence to the facility's policies on tracheostomy care and oxygen therapy. The failure to maintain proper documentation, ensure the availability of necessary supplies, and follow physician orders for oxygen therapy could lead to medical complications and a diminished quality of life for the residents involved. The DON and other staff members acknowledged these lapses during interviews, highlighting systemic issues in communication and responsibility within the facility.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
