Mcrae Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Mc Rae, Georgia.
- Location
- 160 South First Avenue, Mc Rae, Georgia 31055
- CMS Provider Number
- 115494
- Inspections on file
- 16
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Mcrae Manor Nursing Home during CMS and state inspections, most recent first.
The facility failed to conduct proper assessments and obtain informed consent for bed rail use for four residents. Observations and interviews revealed that residents were using bed rails without documented assessments or consent forms. The ADON confirmed that the facility did not consider side rails as restraints and did not require consent, leading to a deficiency in regulatory compliance.
The facility failed to maintain a safe environment in the 200 hall, where observations revealed two defective handrails. One handrail was loose, and another had broken brackets. The Maintenance Director confirmed the lack of a schedule or policy for checking handrails, and the Administrator acknowledged the absence of written procedures. No residents were reported to have fallen due to these deficiencies.
The facility failed to maintain cleanliness and proper storage for ice machines and expired food items, affecting 74 residents. Ice scoops were improperly stored, and the ice machine was dirty. Staff interviews revealed confusion about cleaning responsibilities, and expired drinks were found in storage.
The facility failed to uphold dignity for two residents. A CNA was observed standing while feeding a resident with severe cognitive impairment, contrary to the facility's Dignity Policy. Additionally, another resident with an indwelling urinary catheter had their catheter bag exposed without a privacy cover, visible from the hallway. The ADON confirmed that catheter bags should always be covered, and it is the responsibility of CNAs and nurses to ensure this.
A resident with dementia and anxiety disorder was found with unsecured nasal spray bottles in their room, which were not listed in their medical records. The facility's policy requires medications to be stored securely, but the Assistant Director of Nursing confirmed the oversight and removed the medications. The resident had not been assessed for self-administration, and the facility does not conduct such evaluations.
A resident with intact cognition and multiple medical diagnoses did not receive scheduled showers, as documented in the facility's policy. Observations revealed the resident had dry flaky skin and was unsure of her shower schedule. The Bath Sheets Shower book lacked documentation of showers since March, and staff interviews indicated inconsistent documentation practices, attributed to recent leadership changes.
The facility failed to prevent accident hazards for two residents. One resident's oxygen cylinder was improperly placed on the floor, contrary to policy, while another resident had access to harmful chemicals left unsecured in their room and hallway. Staff confirmed these practices, acknowledging the risks posed to residents, particularly those with cognitive impairments.
A facility failed to obtain a physician's order for a resident with an indwelling urinary catheter, leading to a lack of documented care instructions in the MAR. Observations showed the catheter tubing was coiled around the bed frame, potentially obstructing urine flow. Interviews confirmed the oversight, with the ADON acknowledging the need for monthly order updates and specific catheter care instructions.
A facility failed to ensure a stop date for a PRN antipsychotic medication, quetiapine, for a resident with Alzheimer's and severe agitation, exceeding the 14-day limit. The oversight was confirmed by an LPN and ADON, who contacted the Medical Director to address the issue, but the order remained unchanged pending the physician's response.
A resident with an indwelling urinary catheter was observed multiple times with the catheter drainage tubing dragging on the floor, contrary to the facility's infection control policy. The resident, who has a history of intellectual disability and other medical conditions, was seen in a wheelchair with the tubing on the floor. Facility staff confirmed the improper practice, acknowledging the need to keep catheter parts off the floor to prevent infection.
Deficiency in Bed Rail Assessment and Consent
Penalty
Summary
The facility failed to adhere to regulatory requirements regarding the use of bed rails for residents, as evidenced by the lack of appropriate assessments, informed consent, and consideration of alternatives. Observations and interviews revealed that four residents were using bed rails without documented assessments or consent forms. The Assistant Director of Nursing (ADON) confirmed that the facility did not conduct side rail assessments, as they did not consider them restraints, and no consent was obtained from residents. Resident 60 was observed using full side rails on a bariatric bed without any documented assessment or consent. Despite having no cognitive impairment, as indicated by a Brief Interview Mental Status Score (BIMS) of 15, the resident was fully dependent on staff for activities of daily living, except for eating. The resident reported using the bed rails for support during repositioning and care. Similarly, Resident 1, who also had intact cognition, requested full bed rails but lacked a documented assessment. The resident expressed satisfaction with the bed rails and indicated they were necessary for daily use. Resident 14, who was nonverbal but alert, was observed with bed rails up on both sides of the bed, yet no assessment was completed. Lastly, Resident 66, with a BIMS score of 14, used half bed rails for repositioning during care, but again, no assessment was documented. The facility's failure to conduct proper assessments and obtain informed consent for bed rail use was confirmed during interviews with staff, including the ADON and Maintenance Director.
Defective Handrails in Facility Hallway
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in one of its hallways, specifically the 200 hall. Observations on consecutive days revealed two defective handrails between certain rooms on the 200 South section. One handrail was pulling away from the wall due to loosened posts, and another had broken brackets. These deficiencies were confirmed during a walkthrough with the Administrator and Maintenance Director, who began repairs immediately. Interviews with the Maintenance Director revealed that there was no existing schedule or policy for checking the handrails, and maintenance was typically performed based on work tickets. The Administrator also confirmed the lack of written procedures for monitoring the handrails, although she expected the Maintenance Director to do so. Despite the deficiencies, there was no evidence that any residents had experienced a fall due to the loose and broken handrails.
Deficiencies in Ice Machine Maintenance and Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper storage practices for ice machines and expired food items, potentially affecting 74 out of 76 residents on an oral diet. Observations revealed that the ice machine in the dining room had an ice scoop resting in the ice, contrary to the facility's policy, which requires the scoop to be stored in a designated container. Additionally, the ice machine in the nourishment prep room was found with a dirty frame and an ice scoop resting in the ice. Interviews with staff, including the Dietary Manager, Certified Nursing Assistant, and Dietary Aid, confirmed the improper storage of ice scoops and uncertainty about the responsibility for cleaning the ice machine. The facility's policy mandates monthly cleaning of ice dispensers and daily cleaning of ice scoops, but these practices were not followed. The Dietary Manager confirmed expired thickening lemon-flavored water drinks in the dry storage room, indicating a lapse in monitoring expiration dates. The Maintenance Director stated that the ice machine should be deep cleaned every six months, but there was confusion about daily cleaning responsibilities. The Dietary Manager and staff were unsure who was responsible for maintaining the ice machine's cleanliness, highlighting a lack of clarity in roles and responsibilities regarding equipment maintenance.
Dignity Concerns: Improper Feeding and Lack of Privacy
Penalty
Summary
The facility failed to ensure dignity for two residents, as observed during a survey. For one resident with severe cognitive impairment, a CNA was observed standing while assisting the resident with eating, which is against the facility's Dignity Policy. The CNA admitted to being unaware that standing while feeding a resident was inappropriate and had not received training to sit at eye level with residents during meals. The ADON and LPN confirmed that this practice was a dignity concern and could pose a choking hazard. Another resident, who had an intact cognitive status and an indwelling urinary catheter, was observed without a privacy bag covering the catheter drainage bag, which was visible from the hallway. The ADON confirmed that the facility's policy requires catheter bags to be covered with privacy bags, and it is the responsibility of CNAs and nurses to ensure compliance. The lack of privacy bag was confirmed by an LPN during the survey.
Unsecured Medications Found in Resident's Room
Penalty
Summary
The facility failed to ensure that a resident, identified as R23, did not have unsecured medications stored at the bedside, which could potentially allow unauthorized access to medications by other residents and visitors. The facility's policy on administering medications clearly states that drugs should be returned to the medication cart or room and never left in a resident's room. However, during an observation, two bottles of Equate Nasal Spray were found in R23's room, one on a dresser and another on a bookshelf, both within visual view. R23, who has diagnoses including dementia and anxiety disorder, was observed in bed at the time. The resident's medical records did not list an order for nasal spray, indicating that these medications were not prescribed or documented for R23. Interviews with the Administrator and the Assistant Director of Nursing (ADON) confirmed the presence of the medications in the resident's room, and the ADON removed them. The ADON was unaware of the origin of the nasal spray and acknowledged that medications left unsecured posed a risk to other residents. It was also confirmed that R23 had not been assessed for self-administration of medications, and the facility does not conduct self-administration evaluations. This oversight highlights a lapse in adherence to the facility's medication administration policy, as no residents in the facility had been assessed to self-administer medications.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to ensure that Resident R44 received showers as scheduled, which is a deficiency in providing necessary assistance for activities of daily living. The facility's policy on Activities of Daily Living, last revised in March 2018, mandates that residents who cannot independently perform daily activities should receive services to maintain personal hygiene. However, R44, who has diagnoses including Hemiplegia, Hemiparesis, and a history of cerebral infarction, was observed with dry flaky skin and a dried substance around her mouth, indicating a lack of proper hygiene care. The resident, who has intact cognition as per the most recent Quarterly Minimum Data Set, expressed uncertainty about her shower schedule and stated she had not received a shower in a long time. The facility's documentation practices were found lacking, as the Bath Sheets Shower book did not reflect any recorded showers or baths for R44 since March 2024. Interviews with staff, including a CNA and the Assistant Director of Nursing, revealed that CNAs are not required to document showers unless a resident refuses, in which case the nurse is notified. The ADON acknowledged that bath sheets are not consistently placed in the bath book and attributed the lack of documentation to recent leadership changes. This lack of documentation and adherence to policy resulted in the failure to provide R44 with the necessary hygiene care.
Failure to Prevent Accident Hazards for Residents
Penalty
Summary
The facility failed to ensure that two residents were free from accident hazards, as observed during a survey. Resident 49, who has chronic obstructive pulmonary disease, hypertension, and atrial fibrillation, was found with an oxygen cylinder placed on the floor next to his wheelchair in a dining area. This was contrary to the facility's Oxygen Delivery Policy, which mandates that oxygen cylinders must be in a portable carrier or wheelchair holder and not placed on the floor. The resident reported that a staff member had removed the oxygen from the wheelchair holder and placed it on the floor, a routine practice before smoke breaks. Housekeeping staff confirmed observing the oxygen on the floor but were unaware of the associated risks. Another deficiency was noted with Resident 65, who has Alzheimer's disease, glaucoma, unspecified dementia with severe agitation, and other conditions. Harmful chemicals, including Micro Kill bleach, were found in the resident's bathroom and on a PPE cart outside the room. The facility's Chemical Safety and Storage policy requires chemicals to be stored in locked cabinets and not left in resident areas. The Housekeeper Supervisor and ADON confirmed the presence of these chemicals and acknowledged that leaving them accessible posed a risk to residents, especially those with cognitive impairments and a history of wandering. The ADON, who also serves as the Infection Control Preventionist, confirmed that the facility's policy does not allow for chemicals to be left outside resident doorways. The chemicals should be stored securely, either on the nurses' cart or in a designated secure place. The presence of these chemicals in accessible areas was attributed to a possible oversight by a Certified Nursing Assistant, and the facility acknowledged the risk of harmful ingestion by residents due to this oversight.
Failure to Obtain Physician's Order for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to obtain a physician's order for a resident, R62, who had an indwelling urinary catheter. This oversight was identified during a survey, revealing that the order for the catheter, including its size, balloon size, type, and change frequency, was not documented. Additionally, the Medication Administration Record (MAR) for several months did not include any instructions for the care and monitoring of the indwelling urinary catheter. This lack of documentation and oversight had the potential to compromise the resident's urinary health and increase the risk of urinary tract infections. Observations during the survey showed that the catheter tubing was coiled around the bed frame, which could obstruct urine flow. Interviews with the LPN and ADON confirmed that no order was in place until it was identified during the survey. The ADON acknowledged that the order should have been carried over each month and that the nursing staff were responsible for monitoring all orders. The absence of a specific order for catheter care and monitoring was noted, despite a general statement about urinary output being present in the February MAR.
Failure to Ensure Stop Date for PRN Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a stop date for the use of a PRN antipsychotic medication, quetiapine, was not over 14 days for a resident reviewed for unnecessary medications. The facility's policy on Medication Monitoring and Management specifies that PRN orders for antipsychotic medications should have a time limitation of 14 days. However, the medical record of a resident with multiple diagnoses, including Alzheimer's Disease and severe agitation, showed a PRN order for quetiapine with a start date of 3/6/2024, and the medication was last administered on 7/1/2024, exceeding the 14-day limit. During an interview, both a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON) confirmed the oversight in ensuring a stop date for the quetiapine order. The LPN reported contacting the Medical Director after being instructed by the ADON to address the issue. The ADON noticed the PRN medication order during a review of the resident's record and instructed the nurse to contact the Medical Director, but the order had not been changed at the time of the interview due to awaiting the physician's response.
Infection Control Deficiency: Catheter Bag Dragging on Floor
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by the observation of an indwelling urinary catheter bag dragging on the floor for a resident. The facility's policy on the maintenance of indwelling urinary catheters emphasizes the importance of maintaining good hygiene to reduce infection risks. However, during multiple observations on the same day, the resident was seen with the catheter drainage tubing on the floor while sitting in a wheelchair and propelling herself through the halls. The resident involved had a medical history that included intellectual disability, a colostomy, peritoneal debridement, and vulva cancer. The resident's cognitive assessment indicated mildly impaired cognition. Interviews with the Assistant Director of Nursing and the Unit Manager confirmed the improper positioning of the catheter tubing and acknowledged that it should not touch the floor to prevent infection.
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.
