Nurse Care Of Buckhead
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Georgia.
- Location
- 2920 Pharr Court South Nw, Atlanta, Georgia 30305
- CMS Provider Number
- 115129
- Inspections on file
- 23
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Nurse Care Of Buckhead during CMS and state inspections, most recent first.
The facility's Facility Assessment did not recognize or include the secured memory unit on the fifth floor, where about 25% of residents with dementia and behavioral health needs resided. Staff interviews and documentation confirmed that this floor was secured with a keypad system to prevent elopement, but the assessment failed to address the specific care and safety needs of these residents or the required staff training.
A resident with a history of acute kidney failure, morbid obesity, and urinary retention, who was always incontinent and required substantial assistance, did not have access to incontinence pads as needed. Staff and supply managers confirmed that incontinence pads were out of stock in multiple supply closets, and the resident reported discomfort and prolonged exposure to urine due to the lack of appropriate supplies. The DON and Administrator acknowledged that incontinence supplies should always be available, but they were not at the time.
The facility did not consistently report suspected abuse or submit investigation results to authorities within required timeframes. Several incidents involving inappropriate interactions and physical contact between residents, some with cognitive impairment, were not followed by timely submission of investigation findings, as confirmed by facility leadership.
The facility did not conduct comprehensive investigations into multiple alleged resident-to-resident abuse incidents, failing to interview all involved or potentially affected residents and staff, and not fully following its abuse prevention policy. This resulted in incomplete assessments of incidents involving both physical and verbal abuse among residents with varying cognitive abilities.
A resident requiring substantial assistance for transfers was dropped during a manual transfer without the use of a mechanical lift, contrary to facility policy. Additionally, three residents at risk for elopement were inadequately supervised, resulting in two leaving the premises unsupervised and one not being promptly located after going missing. Staff communication failures, lack of physical safeguards, and incomplete adherence to protocols contributed to these deficiencies.
A resident with diabetes did not consistently receive scheduled Humulin 70/30 insulin as ordered, with multiple missed doses over several months. Nursing staff sometimes withheld the insulin without proper documentation or physician direction, often due to reasons unrelated to the scheduled medication, such as normal blood sugars or the resident not eating. The facility's policy and physician orders were not followed, and the missed doses were not consistently justified in the medical record.
Six residents did not receive comprehensive care plans addressing their specific needs, including dialysis transportation, PTSD management, ADL support, pain management, and positioning. Two residents missed multiple dialysis treatments due to inadequate transportation planning, leading to hospitalizations. Another resident with PTSD lacked a care plan for mental health needs, while a resident with mobility deficits did not receive proper nail care. Gaps in pain medication administration and lack of repositioning interventions for a resident with severe immobility were also observed.
Two residents dependent on dialysis missed multiple scheduled treatments due to unreliable transportation coordination, leading to avoidable hospitalizations for complications such as hyperkalemia and volume overload. Care plans identified transportation risks, but interventions were not effectively implemented, and staff interviews revealed confusion over responsibility for arranging dialysis transport.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as identified by surveyors. The report does not specify particular actions, events, or individuals involved in this deficiency.
Three residents were affected by the facility's failure to prevent accident hazards and ensure medication security. One resident with a history of falls was not assessed or monitored after a fall, resulting in a delayed diagnosis of a femoral neck and hip fracture. Two other residents were found with unsecured medications at their bedsides, including an inhaler, a pill bottle with an unknown substance, and vitamin supplements, without physician orders or care plans for self-administration. Staff were unaware of these medications, and required assessments and approvals were not completed.
The facility did not coordinate assessments with the PASRR program or refer residents for necessary services, resulting in a deficiency related to regulatory compliance.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not have an active Infection Prevention and Control Program or an Antibiotic Stewardship Program in place. There were no protocols or systems for monitoring antibiotic use, tracking infections, or maintaining immunization records. The newly hired ICPN had not yet implemented required tracking forms or established a committee, and previous documentation was missing, leaving the program incomplete and noncompliant.
The facility did not ensure that newly admitted residents and staff were educated about, offered, or documented for influenza and pneumococcal vaccinations. Medical records lacked evidence of vaccines being received, declined, or contraindicated, and there was no documentation of education or monitoring. Staff interviews confirmed the absence of an infection tracking system and missing immunization records, with one resident stating he was never offered vaccines or information.
The facility did not have policies or documentation to ensure COVID-19 vaccine availability, education, or administration for staff and residents. No records existed showing that the vaccine was offered, received, or declined, and no educational materials or outbreak management guidelines were present. Interviews with the ICPN and DON confirmed the absence of an active infection control program and missing documentation.
Multiple resident rooms and common areas were found with soiled PTAC air filters, dirty air vents, stained and missing ceiling tiles, torn window screens, chipped paint, broken doors, holes in walls, and non-functioning toilets. Staff and family interviews confirmed ongoing issues with cleanliness and maintenance, and the facility's grievance log documented repeated complaints about uncleanliness and odors.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility did not consistently serve meals at safe and appetizing temperatures, with multiple hot food items found below the required 135°F at the time of service. Equipment issues, such as malfunctioning steam tables and missing plate warmers, along with inconsistent food delivery and reheating practices, contributed to residents frequently receiving cold meals. Both residents and dietary staff reported ongoing problems with food temperature and service quality.
The facility did not obtain food from approved sources and failed to follow professional standards for storing, preparing, distributing, and serving food.
Surveyors observed that the facility's outdoor dumpster area was not maintained in a sanitary manner, with trash, discarded food, and debris present on multiple occasions. Staff interviews revealed confusion over departmental responsibility for the area, and both maintenance and housekeeping were identified as responsible. The presence of gnats, flies, and reports of rodents were noted, and the Administrator acknowledged awareness of the ongoing issues.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident with a diagnosis including Alzheimer's Disease and a cognitively intact BIMS score was observed self-administering medications at her bedside without a documented assessment or physician order, contrary to facility policy. Staff confirmed the presence and removal of medications from the resident's room, and the DON acknowledged that required assessments and authorizations for self-administration had not been completed.
The facility did not adequately promote or facilitate resident self-determination, resulting in a failure to support resident choice as required. This was due to actions or omissions by staff that did not encourage or honor the resident's right to make decisions about their care or daily activities.
A resident with severe cognitive impairment and multiple complex medical conditions was admitted with a care plan and physician orders indicating full code status, but the POLST form remained blank and unsigned. The resident's family was not contacted about Advance Directives, and only one attempt was made to reach them, contrary to facility expectations for timely completion.
The facility did not notify responsible parties and physicians following incidents involving two residents. One resident experienced a fall resulting in a femur fracture, but the LPN did not assess, document, or notify the physician or family at the time of the incident. Another resident with severe cognitive impairment had two falls with head injuries and hospital transfers, but there was no documentation that the guardian was notified. These actions were not in accordance with facility policy requiring prompt notification after changes in condition.
A resident with severe cognitive impairment reported being punched in the head by a CNA. While the initial abuse allegation was reported, the required follow-up investigation report was not submitted to the State Survey Agency within the facility's five-day policy window, with staff interviews confirming the delay and attributing it to administrative turnover.
The facility did not ensure that a resident received an accurate assessment, resulting in incomplete or inaccurate documentation of the resident's condition and needs.
The facility did not revise or update care plans for three residents with needs related to denture care, diabetes mellitus, and midline dressing, despite their medical histories and the facility's policy. Staff interviews revealed confusion about responsibility for care plan updates, and leadership confirmed the care plans were not revised as required.
A resident with Alzheimer's Disease, dysphagia, and no teeth was repeatedly served regular food items instead of the prescribed puree/mechanical soft diet. Despite clear physician orders and care plan interventions, the resident received meals such as chicken on the bone, waffles, and bacon, and sometimes did not receive required supplements. Staff confirmed the dietary error, and the DON acknowledged the failure to provide the correct diet.
A resident in need of pain management did not receive safe and appropriate pain management services as required.
A medication error rate of 5 percent or greater was identified, indicating that the facility did not maintain medication administration accuracy within regulatory standards.
Two cognitively intact residents with personal accounts did not receive required quarterly trust fund statements. Residents and their representatives reported not receiving statements, and staff interviews revealed no documentation or clear process for distributing these statements, resulting in a failure to provide regular account information.
Six residents did not receive or sign admission packets containing required information about Medicare and Medicaid benefits. Audits and interviews confirmed that these residents were not provided with or asked to sign the necessary paperwork, and their electronic medical records lacked the documentation. Staff interviews revealed that turnover in administrative roles and unclear responsibility contributed to the failure to obtain and maintain these essential documents.
The facility did not provide evidence of completed skills competency check offs or ongoing medication training for several Certified Medication Aide Techs, as required by policy and state regulations. Staff interviews and record reviews confirmed missing documentation and lack of observed medication passes, potentially impacting care for all residents.
Two residents, both cognitively intact and with chronic medical conditions, experienced verbal abuse from a Certified Medication Aide Tech, including the use of a racial slur and cursing following a minor incident. Staff and resident interviews indicated the aide had a history of argumentative and defensive behavior, but there was no prior documentation of her conduct before these incidents.
The facility did not complete or document required criminal background checks and GCHEXS fingerprint checks for several staff members, including RNs, LPNs, Administrators, Certified Medication Aide Techs, CNAs, a Regional Director of Business Development, and a Maintenance Director. Some employee files were missing entirely, and up-to-date fingerprint checks were not maintained for certain CNAs, resulting in non-compliance with facility policy and state regulations.
Two residents with complex medical conditions did not have physician-ordered laboratory tests completed or documented as required. Despite clear orders for PT/INR and other routine labs, results were missing from the EMR, and staff interviews revealed breakdowns in the process for ordering and tracking lab work, including improper use of the specimen log and lack of a written policy.
A facility failed to verify the credentials of a Certified Medication Administration Tech by not confirming their status on the Georgia CNA registry and not maintaining an employee file, as required by facility policy and job descriptions. This deficiency was identified during a review of employee records and confirmed by both the Human Resource Director and the Regional Human Resource/Payroll Director.
Surveyors found that nurse staffing information was either not posted or was posted in a format too small to read, and staff confirmed the information was not accessible to residents or visitors. The Staffing Coordinator also discarded the daily staffing sheets and was unaware of the requirement to retain them for eighteen months, resulting in missing historical staffing records.
The facility failed to resolve resident grievances within the required 72-hour period, as ongoing issues with laundry, meals, and supplies were repeatedly discussed in Resident Council meetings. Despite a grievance process involving social services and department heads, problems persisted due to reliance on a third-party vendor and equipment failures. Interviews revealed dissatisfaction with the facility's handling of grievances, particularly regarding food quality and linen shortages.
The facility experienced significant staffing deficiencies, including the absence of RN coverage on specific dates, leading to CNAs performing duties outside their job descriptions. This was due to staff shortages in dietary and housekeeping, exacerbated by instances of unpaid work and resignations. The Resident Council noted issues like cold food and staff shortages, impacting resident care and satisfaction.
The facility failed to maintain essential equipment, including wheelchairs, ice machines, and a walk-in freezer, in a safe and operable manner. Two residents experienced prolonged issues with their wheelchairs, with one unable to use hers due to non-functional brakes and the other due to a malfunction after a nurse's attempt to operate it. Ice machines on multiple floors were inoperable, and the walk-in freezer consistently failed to maintain the required temperature, compromising food safety.
The facility's pest control program was ineffective, resulting in ongoing issues with fruit flies, flies, ants, and rodents. Observations and interviews revealed persistent pest problems, with flies and gnats in resident rooms and common areas, and mouse droppings in the kitchen. Staff and residents expressed concerns about the infestation, and the kitchen door was frequently left open, exacerbating the issue.
The facility failed to provide residents with access to their trust fund accounts after hours and on weekends, affecting 122 residents. The BOM confirmed that residents were informed to withdraw sufficient funds on Fridays for the weekend, as there was no secure personnel available to handle funds during weekends. This practice had been in place before the current BOM's tenure, and residents were notified through a memo and resident council meeting by the previous Social Service Director.
The facility failed to provide a safe and sanitary environment due to linen shortages, inadequate maintenance, and persistent odors. Staff and residents reported a lack of clean linens, leading to soiled conditions. A resident's bathroom had a drooping, stained ceiling due to water damage. Additionally, offensive odors were noted on the third floor, with inadequate cleaning contributing to the issue.
The facility faced significant deficiencies due to inadequate linen supplies, dietary staff shortages, and high staff turnover. Contracts with a care services group failed to stabilize dietary management, leading to meal service delays. Staff compensation issues resulted in high turnover, with administrators using personal funds for resident supplies. Maintenance problems, including a broken washing machine and structural issues, further impacted resident care.
The facility failed to effectively implement its QAPI Program, resulting in ongoing issues with laundry services and resident grievances. Despite identifying these issues in QAPI meetings, the facility continued to experience linen shortages and unresolved grievances. Interviews revealed that grievances were reported but not adequately addressed, and an incident of clean linen being discarded highlighted the persistent problems.
A facility failed to implement Enhanced Barrier Precautions (EBP) during high-contact care for a resident with a stage four pressure ulcer and a gastrostomy tube. Two CNAs were observed giving a bed bath without gowns, and one did not perform hand hygiene after removing gloves. An LPN performed wound care without a gown, citing a lack of available gowns. The Infection Preventionist acknowledged confusion about EBP, contributing to the deficiency.
A resident with multiple diagnoses and a BIMS score of 15 reported unauthorized charges after giving their FSA card to a Former Activities Assistant (AA) for shopping. The Former AA linked their Cash app account to the resident's card, resulting in $830 in unauthorized transactions. The facility's policy defines misappropriation as wrongful use of a resident's belongings or money. The incident was reported, and the Former AA's employment was terminated.
Facility Assessment Failed to Identify and Address Secured Memory Unit
Penalty
Summary
The facility failed to ensure that its Facility Assessment accurately and comprehensively reflected the presence and needs of a secured memory unit located on the fifth floor. The assessment, dated 4/28/2025, did not identify or recognize the secured unit, despite documentation and staff interviews confirming that the fifth floor housed residents with dementia and behavioral health needs who were at risk for elopement. Observations over four survey days confirmed that access to the fifth floor was restricted by a keypad code, which was not provided to residents, and staff consistently referred to the area as a secure or memory care unit. The facility's documentation also showed that 53 residents, approximately 25% of the facility's population, resided on this floor, but this was not reflected in the Facility Assessment. Staff interviews further revealed that the fifth floor had been used as a dementia and behavioral unit for at least three years, with residents identified as elopement risks and not given the elevator code. The Administrator and Director of Nursing acknowledged that the keypad system was installed to prevent wandering and that the residents on this floor were considered at risk for elopement. Despite these facts, the Facility Assessment did not include the secured unit or address the specific needs and protocols required for this population, resulting in a deficient practice regarding the assessment and monitoring of residents' safety and staff training requirements.
Failure to Provide Incontinence Pads for Resident with High Care Needs
Penalty
Summary
The facility failed to ensure that incontinence pads were available for a resident who required them at all times. The resident, who was admitted with diagnoses including acute kidney failure, morbid obesity, and urinary retention, was cognitively intact and required substantial to maximal assistance with toileting, being always incontinent. The care plan identified the resident as being at risk for pressure ulcers due to incontinence and limited mobility. Despite these needs, the resident reported that on multiple occasions, incontinence pads in the appropriate size were not available, and staff substituted a draw sheet, which caused discomfort, especially after bowel movements. The resident also stated that after showers, he was left without an incontinence pad and had to sit in urine for extended periods. Observations and interviews with staff confirmed that incontinence pads were not available in the central supply closets on multiple floors, and the Central Supply Manager acknowledged being out of stock. The supply manager explained that orders were placed weekly based on census and budget constraints, which often made it difficult to maintain adequate supplies. Both the DON and the Administrator confirmed that incontinence supplies should always be available for all residents, but at the time of the survey, this was not the case for the resident in question.
Failure to Timely Report and Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to report allegations of abuse within the required two-hour timeframe and did not submit timely investigation results to the appropriate governing agencies for several residents. Specifically, incidents involving inappropriate interactions and physical contact between residents were identified, and while initial incident reports were sometimes submitted on time, the final investigations were delayed. The facility's own policy requires prompt reporting and submission of investigation findings, but reviews of incident report forms and external communications showed that final investigations were submitted days or weeks after the incidents occurred. Interviews with the Administrator confirmed awareness of the delays, attributing them to the need for additional review by leadership before submission and a lack of timely follow-up. The residents involved had varying degrees of cognitive impairment, including diagnoses such as paranoid schizophrenia, dementia, and cognitive communication deficits. The delays in reporting and investigation submission were acknowledged by facility leadership, but no corrective actions or follow-up measures were described in the report.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple incidents of potential resident-to-resident abuse, as required by its own policy on the prevention of abuse, neglect, mistreatment, or misappropriation of property. In several cases, the investigations did not include interviews with all residents involved or potentially affected, nor did they consistently gather statements from all relevant staff or witnesses. For example, in an incident involving two residents observed kissing, the investigation was limited to notifying responsible parties and providing staff education, but did not include interviews with the residents involved. In another incident, a resident with severe dementia made contact with another cognitively impaired resident using a plastic utensil, resulting in a skin tear. Although the incident was reported to the governing agency, the investigation did not include interviews with the residents involved. Similarly, in a case where a resident was observed placing his hand on another resident's upper thigh, the investigation only included statements from the alleged perpetrator, a staff witness, and several CNAs, but did not include interviews with other residents to determine if they felt safe or had experienced similar incidents. Additionally, in a case of alleged inappropriate verbal comments and boundary violations, the investigation was limited to interviews with the two residents directly involved, one CNA, and the maintenance director, with no further inquiry into whether other residents or staff had observed similar behavior or felt at risk. Interviews with the facility administrator revealed a lack of awareness regarding the need to interview all potentially affected residents and staff during abuse investigations, contributing to incomplete investigative processes.
Failure to Prevent Accidents and Elopement Due to Inadequate Supervision and Unsafe Transfer Practices
Penalty
Summary
The facility failed to ensure safe transfer practices and adequate supervision to prevent accidents and elopement for several residents. One resident with muscle weakness and morbid obesity, who was cognitively intact and required substantial assistance for transfers, was dropped during a transfer from a shower to bed. Despite the resident's care plan and facility policy requiring the use of a mechanical lift for residents of his size and condition, staff attempted the transfer manually without a mechanical lift or gait belt. Multiple staff members, including CNAs, LPNs, and maintenance personnel, were involved in lifting the resident from the floor to the bed after the incident. Interviews with staff and therapy personnel confirmed that a mechanical lift should have been used, and staff could not explain why it was not utilized during the transfer. The facility also failed to provide adequate supervision and monitoring for three residents at risk for elopement. One resident with severe cognitive impairment and a history of wandering was able to leave his unit, exit the building, and was found across the street without staff supervision. The incident was attributed to failures in communication, lack of immediate staff response, and absence of physical safeguards or secure access for residents at risk of elopement. The care plan for this resident was not updated with further interventions after the incident. Another resident, moderately impaired and at moderate risk for elopement, exited the main doors and was found in the parking lot. Staff statements indicated confusion about code orange procedures, and the facility's intercom system was not fully operational, contributing to delayed response. A third resident, cognitively intact and not assessed as at risk for elopement, was reported missing from his unit overnight. Staff failed to follow required notification procedures when the resident was not found in his room, and there was a lack of timely action to locate him. The resident was eventually found to have left the facility and returned several days later. These incidents demonstrate lapses in supervision, monitoring, and adherence to established protocols for resident safety and accident prevention.
Failure to Administer Insulin as Ordered and Inadequate Documentation
Penalty
Summary
The facility failed to administer insulin as ordered by the physician for one resident with type 2 diabetes mellitus, resulting in multiple missed doses of scheduled Humulin 70/30 insulin. Review of the resident's electronic medical record (EMR) revealed that the scheduled insulin was not administered on numerous occasions across several months, both in the morning and evening, without appropriate documentation or justification in the Medication Administration Record (MAR). In some instances, the insulin was held due to reasons not associated with the scheduled Humulin, such as blood sugar levels related to sliding scale insulin or the resident not having eaten, but these actions were not consistently documented or supported by physician parameters. Interviews with nursing staff and the Director of Nursing confirmed that the scheduled Humulin insulin should have been administered as ordered, and that holding the medication for reasons such as normal blood sugars or lack of appetite was not appropriate without physician direction. The Nurse Practitioner and other nursing staff stated that sliding scale insulin is intended to supplement, not replace, scheduled insulin doses, and that any concerns about blood sugar levels should be communicated to the provider rather than unilaterally withholding medication. The facility's policy on insulin administration also required verification and adherence to physician orders, with any discrepancies to be reported and documented. The resident involved was moderately cognitively impaired and expressed concern about the inconsistent administration of her diabetic medication, noting that nurses sometimes withheld her scheduled insulin when she did not eat well. The lack of consistent documentation and justification for missed doses, as well as the failure to follow physician orders and facility policy, constituted a significant medication error and a deficiency in medication administration practices.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six residents, each with specific medical and psychosocial needs. For two residents requiring dialysis, care plans did not adequately address transportation arrangements, resulting in multiple missed dialysis treatments. One resident missed seven out of twelve scheduled dialysis sessions, leading to hospitalizations for severe hyperkalemia and volume overload. Another resident missed two consecutive dialysis treatments due to transportation issues, which also resulted in hospitalization. The care plans for these residents lacked sufficient detail and follow-up regarding dialysis transportation, and there was no consistent process to ensure alternative arrangements when transportation failed. A resident with a diagnosis of PTSD did not have an active or comprehensive care plan addressing this condition. Interviews with the MDS Coordinator, DON, and ADON confirmed the absence of a care plan for PTSD, acknowledging that the resident was at risk of not receiving appropriate care and interventions for their mental health needs. Additionally, a resident with significant ADL deficits, including limited mobility and a history of stroke, was observed to have long, untrimmed fingernails despite repeated requests for assistance. The care plan included interventions for personal hygiene, but staff interviews revealed confusion about responsibilities for nail care, resulting in the resident's needs not being met over several days. Another resident with chronic pain and wound care needs experienced gaps in pain management due to missing or delayed pain medication. Medication administration records showed missing signatures and documentation of out-of-stock medications, with staff interviews confirming that residents sometimes ran out of medication and that reordering processes were inconsistent. Finally, a resident with severe mobility impairment and a tracheostomy did not have a care plan focus or interventions for frequent repositioning to preserve skin integrity. The family expressed concerns about prolonged periods in soiled linens and lack of movement, and the DON confirmed that no task or documentation existed to prompt staff for regular repositioning.
Failure to Ensure Reliable Dialysis Transportation Resulting in Missed Treatments and Hospitalizations
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for two residents who required dialysis three times weekly for end-stage renal disease (ESRD). Both residents experienced missed dialysis sessions due to unreliable transportation arrangements, which resulted in avoidable hospitalizations for complications such as volume overload and severe hyperkalemia. The residents' care plans identified risks related to transportation issues, but interventions were not effectively implemented to prevent missed treatments. One resident, with diagnoses including hypertensive chronic kidney disease, ESRD, and moderate cognitive impairment, had a physician's order for dialysis three times a week. Despite a care plan addressing transportation risks, the resident missed multiple dialysis sessions and was hospitalized twice for complications directly related to missed treatments. The medical record documented symptoms such as shortness of breath and elevated potassium levels, leading to ICU admission and further hospital stays. Another resident, with diagnoses including type 2 diabetes, chronic pulmonary edema, hypertension, anemia in chronic kidney disease, hyperlipidemia, hyperkalemia, and ESRD, also had a physician's order for regular dialysis. This resident missed several dialysis appointments due to transportation failures, resulting in hospital admission for hyperkalemia. Interviews with facility staff revealed a lack of clear responsibility and coordination for arranging dialysis transportation, with confusion over which department was accountable. The facility relied on a state-funded transportation company with a difficult and antiquated appointment process, and there was no proactive system to ensure residents attended their dialysis appointments.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified by surveyors, but the report does not provide specific details regarding the actions, inactions, or events that led to this finding. No information is given about particular residents, staff, or incidents directly related to the deficiency.
Failure to Prevent Accident Hazards and Secure Medications
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for three residents. One resident, with a history of falls and high fall risk, experienced a fall after tripping over a Foley catheter bag. The fall was witnessed by a CNA, who assisted the resident off the floor and reported the incident to the LPN on duty. However, the LPN did not assess, document, or report the fall, nor did she conduct a fall risk assessment or implement new interventions. The resident later complained of pain, and an x-ray revealed a left femoral neck fracture and a closed left hip fracture, which required surgical intervention. The facility's investigation confirmed that the nurse failed to follow policy regarding post-fall assessment and documentation, and the CNA moved the resident before a nurse assessment was completed. Additionally, the facility did not follow its policy on self-administration of medication for two residents. One resident was found with a pill bottle containing an unknown substance and an inhaler at the bedside, despite no physician order or care plan for self-administration. The resident reported using the inhaler multiple times daily and identified the pill bottle as eczema medication, but staff confirmed there were no orders for these medications and that the facility was unaware of their presence. The DON acknowledged that the medications should not have been at the bedside and that an assessment for self-administration was not completed. Another resident was observed with bottles of vitamin C, vitamin D3, and vitamin E at the bedside, which the resident reported taking independently. There were no physician orders, care plan, or interdisciplinary team approval for self-administration of these supplements. Nursing staff were unaware of the presence of these medications, and the DON confirmed that the process for allowing self-administration, including physician orders and care planning, was not followed. These failures resulted in unsecured medications at the bedside and a lack of oversight regarding the residents' medication regimens.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Implement Infection Control and Antibiotic Stewardship Programs
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP) and an Antibiotic Stewardship Program as required by regulation. Review of facility policies and records revealed that there were no protocols or systems in place to monitor and optimize antibiotic use, track infections, or analyze infection data. The facility lacked a line listing or infection tracing system, did not use an infection surveillance checklist, and failed to maintain or provide staff and resident immunization records, as well as data from the last COVID-19 outbreak. Additionally, the required antibiotic stewardship program policy, protocols, and committee documentation were not available for evaluation. Interviews with the Infection Control Preventionist Nurse (ICPN) and the Director of Nursing (DON) confirmed that the facility had not had an active Infection Control Program since July 2024, and that the current ICPN, who was newly hired and inexperienced in this role, had not yet implemented necessary tracking forms or established an antibiotic stewardship committee. The ICPN admitted to not maintaining an updated log of residents on antibiotics and was unaware of the full requirements for infection tracking and stewardship. The DON acknowledged awareness of the missing documentation and stated that previous records may have been lost or destroyed when the prior ICPN left, leaving the new ICPN to rebuild the program from scratch.
Failure to Provide and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to minimize the risk of influenza and pneumococcal disease by not ensuring that newly admitted residents and staff were educated on the risks and benefits of immunizations, were provided opportunities to receive immunizations, and by failing to maintain documentation of the information or education provided, the administration of, or the refusal of vaccinations. Specifically, a review of the electronic medical records for four newly admitted residents revealed no documentation of vaccines being received, offered, declined, or contraindicated, nor any indication that education was provided to residents or their representatives. Additionally, there was no documentation related to vaccine monitoring, education, or tracking for either residents or staff, and no line listing or monitoring system was in place. Interviews with facility staff, including the Staff Development Nurse/Infection Control Preventionist Nurse (ICPN) and the Director of Nursing (DON), confirmed the absence of an infection tracking system and the lack of an active Infection Control Program since July 2024. The ICPN admitted to not having any documentation of offering vaccines, resident refusals, or contraindications for the current influenza season, and stated that all previous immunization records could not be found after the departure of the previous ICPN. One cognitively intact resident confirmed that he was never offered any vaccines upon admission and was not provided with information about them. The DON acknowledged awareness of the missing information and suggested that the previous ICPN may have taken or destroyed the documentation.
Failure to Implement and Document COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the availability and proper administration of the COVID-19 vaccine to all staff and residents. There was no documentation that the COVID-19 vaccine was offered, received, or declined, nor was there evidence that education regarding the risks, benefits, and potential side effects of the vaccine was provided to residents or their representatives. A review of the Infection Prevention and Control (IPC) Program policy revealed no specific guidance or materials related to COVID-19 vaccination, education, or outbreak management. Additionally, the Infection Control Book lacked any educational materials, immunization records, or guidelines for COVID-19 management, monitoring, or prevention. For all new admissions within the last 30 days, there was no documentation in the Electronic Medical Records indicating that the COVID-19 immunization was addressed or that education was provided. Interviews with the Infection Control Preventionist Nurse (ICPN) and the Director of Nursing (DON) revealed further gaps in the facility's infection control practices. The ICPN, newly hired and inexperienced in the role, confirmed she had not developed or implemented an Infection Control Program and was unaware of any previous COVID-19 outbreaks or related policies. She also stated that the facility had not had an ICPN since the previous one left, and that all infection control records and monitoring data were missing, possibly taken or destroyed by a former interim corporate staff member. The DON acknowledged awareness of the missing documentation and the lack of an active infection control program, confirming that the ICPN was expected to rebuild the program from scratch.
Failure to Maintain Safe and Sanitary Environment in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in 14 out of 108 resident rooms, as well as in several common areas. Observations revealed that packaged terminal air conditioner (PTAC) units in multiple resident rooms contained soiled air filters with thick accumulations of dust, dirt, and debris, causing the originally white filters to appear dark and release visible dust clouds when disturbed. Additional findings included stained and missing ceiling tiles, torn window screens, chipped paint, broken doors, holes in walls, and non-functioning toilets in various rooms. Air vents in common areas were also found to be dirty, with gray and black debris and dust present. These deficiencies were confirmed by the Maintenance Director, who acknowledged that the maintenance department was responsible for cleaning and maintaining these items. Interviews with staff and family members further corroborated the lack of cleanliness and maintenance. A family member reported that a resident's room was never cleaned, with cobwebs in the corners and sticky substances on the walls and floor, sometimes prompting her to clean the room herself. The facility's grievance log documented multiple complaints regarding uncleanliness and odors throughout the building. The Administrator stated that maintenance or housekeeping staff were expected to report and address environmental issues, but the observed conditions indicated that these responsibilities were not consistently fulfilled.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were prepared and served at safe and appetizing temperatures, as required by both facility policy and state regulations. Observations and interviews revealed that hot food items, such as eggs, sausage, omelets, waffles, grits, and oatmeal, were frequently below the required 135 degrees Fahrenheit at the time of service. Food temperature checks conducted by dietary staff showed that several items were initially served at temperatures well below the standard, necessitating reheating. Despite reheating, some items still did not reach the appropriate temperature before being delivered to residents. Additionally, sampled trays retrieved from food carts on various floors were found to be below professional guidelines for hot food temperatures. Equipment issues, such as missing or malfunctioning plate warmers and steam tables that did not maintain proper temperatures, were also observed. Resident and staff interviews corroborated these findings, with residents reporting that food was often cold, especially on weekends, and sometimes not covered during delivery. Dietary staff described challenges with maintaining food temperatures due to equipment problems and inconsistent practices in food delivery and reheating. Staff also noted that some nursing staff did not reheat or return cold food to the kitchen, further contributing to the issue. Facility records and inspection reports confirmed noncompliance with food temperature and handling standards, affecting the majority of residents receiving oral diets.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling protocols. No additional details regarding specific actions, inactions, or individuals involved are provided in the report.
Improper Disposal and Maintenance of Outdoor Garbage Area
Penalty
Summary
The facility failed to maintain the outdoor garbage and refuse area in a sanitary condition, as evidenced by multiple observations of trash, discarded food, bedding, gloves, and other debris scattered around the dumpster. Surveyors noted the presence of gnats and flies in the area during several visits. Interviews with staff revealed that there was confusion regarding departmental responsibility for the cleanliness of the dumpster area, with the Dietary Manager stating it was not her department's responsibility and the Maintenance Director confirming his department was responsible for the grounds, including the dumpster area. The Maintenance Director also acknowledged the presence of trash, debris, and pests, and mentioned having received verbal reports of rodent sightings, though he could not confirm these personally. The Administrator confirmed that both maintenance and housekeeping staff were tasked with keeping the dumpster area clean and free of debris. He was aware of the ongoing issues with trash, debris, gloves, and discarded food in the area and had communicated this to staff. The Administrator also recognized that the condition of the dumpster area could attract pests and rodents, which might allow them to enter the building, although he was uncertain about the actual risks involved. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Assess and Authorize Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, as required by its own policies and procedures. The resident, who was admitted with a diagnosis including Alzheimer's Disease and had a BIMS score indicating cognitive intactness, was observed on multiple occasions self-administering medications at her bedside. The resident reported that she typically takes her own medications at her own pace due to swallowing difficulties, with staff providing the pills for her to take. However, there was no documented assessment for self-administration in the resident's electronic medical record, nor was there a physician's order permitting self-administration, as required by facility policy. Staff interviews confirmed that medications were found at the resident's bedside and were subsequently removed and discarded by a Certified Medication Aide Technician, who stated that medications should not be left at the bedside. The Director of Nursing also confirmed that no assessment for self-administration had been completed for the resident. The facility's policies require a written physician order and approval by the interdisciplinary care team before a resident may self-administer medications, as well as an assessment of the resident's decision-making capacity. These steps were not followed in this case.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Failure to Complete and Follow Up on Advance Directives for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that the Advance Directives process was completed and followed up for one resident with severe cognitive impairment. The resident was admitted with multiple complex medical diagnoses, including vascular dementia, bipolar disorder, and schizophrenia, and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The care plan and physician orders indicated a full code status, but the Physician Orders for Life-Sustaining Treatment (POLST) form in the electronic health record was left blank and unsigned. Interviews revealed that the resident's family had not been contacted regarding Advance Directives, and the family member confirmed no communication from the facility about this matter. The Social Services Director acknowledged that the process for obtaining Advance Directives was not completed, and only one attempt had been made to reach the family, which was not typical practice. The Director of Nursing confirmed that the expectation is for Advance Directives to be completed in a timely manner, usually within the same day, but this was not achieved for this resident.
Failure to Notify Responsible Parties and Physicians of Resident Incidents
Penalty
Summary
The facility failed to notify the responsible party and attending physician of changes in condition for two residents. For one resident with a history of falls, muscle weakness, and a previous femur fracture, a fall occurred in his room. The CNA reported the fall to the LPN, but the LPN did not assess or document the incident in a timely manner. There was no documentation of notification to the resident's responsible party or physician regarding the fall on the day it occurred. The resident later complained of pain, and an X-ray revealed a fractured femur, at which point the family and physician were notified. For another resident with severe cognitive impairment, bilateral above-knee amputations, and a history of falls, there were two separate incidents where the resident fell from a Geri chair, resulting in head injuries and transfer to an acute care hospital. In both cases, the nursing notes did not document that the resident's guardian, listed as the responsible party, was notified of the change in condition. Staff interviews confirmed that the guardian was not notified following these incidents. The facility's policy requires prompt notification of the resident, attending physician, and resident representative of any changes in condition, including accidents or incidents resulting in injury. Staff interviews and record reviews confirmed that these notifications did not occur as required in the cases described.
Failure to Timely Report Abuse Allegation and Investigation Results
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation and the results of its investigation to the State Survey Agency, as required by its own policy. Specifically, an allegation was made that a staff member, a CNA, had punched a resident in the head. The initial report of the incident was submitted, but the required follow-up investigation report was not submitted within the five business days stipulated by facility policy. Instead, the follow-up report was submitted more than two months after the initial allegation. The resident involved had severe cognitive impairment, as indicated by a BIMS score of four, and diagnoses including aphasia and hemiplegia following a nontraumatic intracerebral hemorrhage. Interviews with staff confirmed the delay in reporting, with the DON acknowledging the late submission and attributing it to recent administrative turnover. The administrator, who was newly hired, also confirmed the dates of the reports and identified the missing five-day report upon starting employment.
Failure to Provide Accurate Resident Assessment
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that the required assessment process was not properly completed for one or more residents, resulting in inaccurate or incomplete documentation of their condition and needs at the time of the survey. This inaction led to a lack of reliable information necessary for planning and delivering appropriate care to the affected resident(s).
Failure to Revise and Update Care Plans for Multiple Residents
Penalty
Summary
The facility failed to revise and update care plans for three residents in accordance with its own policy and federal regulations. Specifically, there was no evidence of revised care plans for one resident regarding denture care, another resident regarding diabetes mellitus, and a third resident regarding midline dressing care. Record review showed that these residents had significant medical histories, including Alzheimer's disease, type 2 diabetes mellitus, and sepsis. The facility's policy requires that care plans be created and updated to reflect each resident's needs, including physician's orders, diagnoses, and rehabilitative potential, but this was not done for the identified care areas. Interviews with staff, including LPNs, the MDS Coordinator, the DON, and the ADON, confirmed that care plans were not updated as required. Staff reported confusion or lack of clarity regarding responsibility for updating care plans, with some stating that only baseline care plans were completed at admission and not revised thereafter. The MDS Coordinator and nursing leadership acknowledged the lack of updated care plans and recognized that this failure could result in residents not receiving appropriate care for their conditions.
Failure to Provide Prescribed Puree Diet to Resident with Dysphagia
Penalty
Summary
The facility failed to provide the correct prescribed diet to a resident with a documented swallowing problem and edentulism. Despite physician orders and care plan interventions specifying a puree/dysphagia puree diet with mechanical soft and pureed meats, the resident was observed receiving and served regular food items such as chicken on the bone, a roll, whole waffles, and bacon, which were not consistent with her dietary requirements. The resident reported difficulty consuming these foods and stated that the kitchen sometimes failed to provide the prescribed items like magic cup and mighty shake, as indicated on her meal ticket. Staff interviews confirmed that the resident was served a regular diet instead of the required puree diet, and the Director of Nursing acknowledged that the correct diet was not provided. The resident's medical record indicated a diagnosis of Alzheimer's Disease, a swallowing problem related to dysphagia, and edentulism, all of which necessitated a specialized diet to prevent choking and ensure adequate nutrition. Observations and interviews revealed that the facility's food and nutrition services policy, which requires inspection of food trays and prompt correction of errors, was not followed. The resident's care plan and physician orders were not adhered to, resulting in the resident being served inappropriate meals on multiple occasions.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct observation and calculation of medication administration errors, as required by regulatory standards. No additional details about specific residents, staff, or the types of medication errors were provided in the report.
Failure to Provide Quarterly Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly resident trust fund statements to two cognitively intact residents who maintained personal accounts with the facility. According to interviews with residents and their representatives, as well as a review of facility policy, residents were only made aware of their account balances upon request and had not received regular quarterly statements as required. The Resident Council confirmed that quarterly statements had not been distributed for some time, and both residents and their representatives reported not receiving these statements. Interviews with facility staff revealed a lack of clarity and documentation regarding the process for distributing quarterly statements. The Interim Business Office Manager was unaware of how statements were provided to residents and confirmed there were no records showing that statements had been given. The Regional Medicaid Specialist also confirmed that no statements had been mailed and that there was no documentation from the previous Business Office Manager regarding the distribution of statements. This lack of documentation and process resulted in residents not receiving required quarterly trust fund statements.
Failure to Obtain Signed Admission Packets with Medicare/Medicaid Information
Penalty
Summary
The facility failed to provide and obtain signed admission packets containing written information about how to apply for and use Medicare and Medicaid benefits for six of thirty-one sampled residents. Record review and interviews revealed that these residents did not receive or sign the required admission paperwork, which should have included information on Medicare and Medicaid programs, admission agreements, and resident rights. The absence of these documents was confirmed through audits of the residents' electronic medical records, which showed no signed admission paperwork under the miscellaneous tab for the affected individuals. Interviews with the residents confirmed that they had not been approached to sign any admission paperwork since their admission to the facility. Some residents could not recall being informed about the admission process or being asked to sign any documents. The primary payer sources for these residents included Medicare Part A, Medicaid pending, and Medicare replacement, indicating that the missing documentation affected residents with various types of coverage. Facility staff interviews and document reviews indicated that the responsibility for obtaining signed admission packets fell to the Admission Director, or in their absence, the Regional Director of Business Development and the facility Administrator. Audits conducted by the Medical Records Director and the Regional Director of Business Development identified a significant number of residents without signed admission packets. The issue was further complicated by frequent turnover in key administrative positions, which contributed to lapses in ensuring that all required admission documentation was completed and maintained.
Lack of Documented Medication Aide Competency and Training
Penalty
Summary
The facility failed to provide evidence of implementation and maintenance of an effective training program for Certified Medication Aide Techs (CMATs). Specifically, for three of thirty CMATs selected for review, there were no completed clinical skills competency check offs available. The facility's policies require annual competency reviews and ongoing medication training for CMATs, as well as quarterly unannounced medication administration observations by a registered nurse or pharmacist. However, the surveyor was unable to obtain the required documentation for the selected CMATs, and the Human Resource Director confirmed that one employee file could not be located and that the other two files lacked the necessary competency check offs. Interviews with staff further revealed that at least one CMAT did not recall signing a skills competency check off, and the Consultant Pharmacist stated she had not observed medication passes with the CMATs, indicating that this was not routinely performed unless specifically requested by the facility. The Regional Director of Human Resource and Payroll also confirmed the absence of required documentation. The facility census at the time was 208 residents, and the lack of evidence for proper training and competency assessment had the potential to adversely affect the care provided to all residents.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a Certified Medication Aide Tech (CMAT). One resident, who was cognitively intact and had diagnoses including depression and hypertension, reported that the CMAT entered her room and called her an inappropriate racial slur during a verbal altercation. The incident was reported to the Social Worker, who subsequently interviewed nearby residents and staff. Residents described the CMAT as angry, while coworkers noted she was defensive, argumentative, and did not get along with others. There was no documentation that the CMAT's behavior had been reported prior to this incident. Another cognitively intact resident with diagnoses including hypertension and heart failure reported that his wheelchair accidentally bumped into the same CMAT, who then verbally abused him by cussing at him. The resident apologized and did not report the incident immediately, but later informed the Director of Nursing. Staff interviews confirmed that the CMAT was known for having a quick temper and being argumentative with residents. Both incidents demonstrate that the facility did not ensure residents were free from verbal abuse as required by policy.
Failure to Complete Required Background and Fingerprint Checks for Staff
Penalty
Summary
The facility failed to ensure that required criminal background checks and fingerprint checks were completed for multiple employees, as mandated by both facility policy and state regulations. Specifically, two of fourteen employee files reviewed did not have evidence of a criminal background check, including one Registered Nurse and one Licensed Practical Nurse. Additionally, several staff members, including two Administrators, three Certified Medication Aide Techs, one Certified Nursing Assistant, one Regional Director of Business Development, and one Maintenance Director, did not have documentation of a Georgia Criminal History Check System (GCHEXS) fingerprint check. Two Certified Nursing Assistants also lacked up-to-date fingerprint checks, as their previous checks had not been retained under the Rap Back program. The review of facility policies indicated that all employees were required to undergo criminal background checks and fingerprinting as part of the hiring process, with checks to be completed prior to employment. However, employee files revealed missing or incomplete documentation for these checks, and in some cases, entire employee files could not be located for review. The Human Resource Director and Regional Human Resource/Payroll Director confirmed these deficiencies during interviews, acknowledging that background checks and fingerprinting had not been consistently performed or documented. Further, the facility was unable to produce an employee roster for surveyor review, and the system showed no background checks had been completed for the facility. The lack of proper screening and documentation was attributed to previous failures in the human resource department, as confirmed by facility leadership during interviews. These lapses resulted in non-compliance with both facility policy and state requirements for employee background screening.
Failure to Follow Physician Orders for Laboratory Testing
Penalty
Summary
The facility failed to ensure that physician orders for laboratory tests were followed for two residents. One resident, who was admitted with diagnoses including nonrheumatic aortic insufficiency and chronic systolic heart failure, had multiple physician orders for PT/INR testing associated with her anticoagulant therapy. Despite these orders, there was no documentation in the electronic medical record (EMR) of the required PT/INR results on several specified dates. The resident was cognitively intact, and a nurse practitioner noted that the facility lab had not been performing the INR draws as ordered, prompting a discussion with the nurse manager. Another resident, admitted with diagnoses including bipolar disorder, depression, and diabetes mellitus, also had physician orders for various laboratory tests such as UA/CS, CBC, CMP, and other routine labs. There was no documentation of these laboratory results in the resident's EMR, despite the orders being present. Both residents were assessed as cognitively intact on their most recent quarterly Minimum Data Set (MDS) assessments. Interviews with facility staff revealed that the process for obtaining laboratory tests involved entering orders into both the EMR and the laboratory's electronic system, with requisitions placed in a lab book for the phlebotomist. However, staff acknowledged that the specimen log was not being used correctly, and the required information was often missing. The interim Director of Nursing (DON) confirmed awareness of the issue and stated that the facility did not have a written policy or process for obtaining laboratory tests at the time the deficiencies occurred.
Failure to Verify Nurse Aide Credentials and Maintain Employee File
Penalty
Summary
The facility failed to ensure that one of six employee files reviewed contained evidence of verification with the State of Georgia's Nurse Aide Registry. According to the facility's policy on Abuse, Neglect and Exploitation of Residents, as well as the Human Resource Director's job description, it is required to confirm the enrollment and status of nurse aides on the CNA registry prior to employment. During the review, the facility was unable to locate an employee file for a Certified Medication Administration Tech (CMAT) identified as LL. The Human Resource Director confirmed that there was no identification, hire date, timecard, separation notice, or certification for either CNA or CMAT available for this individual. Further investigation revealed that a search of the Georgia CNA registry did not show any certifications under the name provided for CMAT LL. The Regional Human Resource/Payroll Director II also confirmed the absence of an employee file and the lack of registry verification for this staff member. This failure to verify the credentials and maintain proper documentation for the employee constitutes a deficiency in the facility's hiring and screening process.
Failure to Post and Retain Readable Nurse Staffing Information
Penalty
Summary
The facility failed to post up-to-date nurse staffing information in a prominent and accessible location on two consecutive days, as observed by surveyors. On one occasion, no staffing information was posted upon entry, and on another, the posted information was present but printed in a font size too small to be read by staff or visitors. Interviews with the Staffing Coordinator and an employee at the receptionist area confirmed the posted information was unreadable. Additionally, the Staffing Coordinator admitted to discarding the daily posted staffing sheets and was unaware of the requirement to retain these records for at least eighteen months, resulting in the facility's inability to provide historical staffing data for review.
Failure to Resolve Resident Grievances Timely
Penalty
Summary
The facility failed to resolve resident grievances within the stipulated 72-hour period as per their policy. The policy, revised in December 2020, mandates that grievances should be reviewed and resolved within 72 hours unless an extension is communicated to the resident. However, multiple grievances related to laundry, meals, facility cleanliness, and supply shortages were repeatedly discussed in Resident Council meetings from September 2023 to May 2024, indicating unresolved issues over several months. Interviews with staff and residents further highlighted ongoing problems with food quality, cold meals, and inadequate dining experiences due to the dining room being out of service since October 2023. The facility's grievance process involved social services filling out grievance forms and notifying department heads, with an expectation of resolution within 48 hours. Despite this, grievances related to linen shortages, missing personal clothing, and inadequate supplies persisted, as noted by the Former Social Service Director and other staff members. The facility's reliance on a third-party vendor for housekeeping, laundry, and dietary services since September 2023 was identified as a contributing factor to these issues, compounded by equipment failures such as a broken washing machine. Interviews with the Facility Ombudsman, Resident Council President, and other staff members revealed dissatisfaction with the facility's handling of grievances, particularly regarding food and laundry services. Residents expressed concerns about the lack of progress in resolving these issues, with some improvements noted only during the survey team's presence. The persistent problems with food quality, linen shortages, and inadequate staffing were attributed to organizational issues and the facility's failure to address grievances effectively.
Staffing Deficiencies and Inadequate RN Coverage
Penalty
Summary
The facility failed to maintain sufficient direct care staff coverage to meet the needs of its residents, as evidenced by the absence of Registered Nurse (RN) coverage on specific dates in January 2024. The facility's staffing plan, as outlined in their Assessment Tool, was not adhered to, resulting in inadequate staffing levels. Interviews with staff, including the Administrator and Director of Nursing (DON), revealed that Certified Nursing Assistants (CNAs) were often required to perform duties outside their job descriptions, such as working in the kitchen or laundry, due to staff shortages in those areas. This situation was exacerbated by instances of staff not being paid for their work, leading to resignations and further staffing challenges. The Resident Council minutes highlighted issues such as cold food, offensive odors, and staff shortages, indicating a broader impact on resident care and satisfaction. The facility's reliance on CNAs to fill gaps in other departments, such as dietary and housekeeping, compromised their ability to provide direct patient care. Interviews with former staff members, including the Former Director of Nursing and Social Services Director, confirmed ongoing staffing issues and attempts to address them with the management company. Despite these efforts, the facility continued to experience significant staffing deficiencies, affecting the overall well-being of the residents.
Failure to Maintain Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable manner, affecting wheelchairs, ice machines, and the walk-in freezer. Two residents reported issues with their wheelchairs; one resident was unable to use her wheelchair for months due to non-functional brakes, despite notifying the maintenance department. Another resident's electric wheelchair malfunctioned after a registered nurse attempted to operate it, rendering it unusable. The maintenance director acknowledged that the resident's wheelchair was beyond repair, and the facility did not assist with electric wheelchair concerns. The social worker confirmed the grievance process was initiated, but the facility did not address the specific repair needs. Additionally, the facility's ice machines on multiple floors were inoperable for extended periods, with staff relying on a single functional machine. The maintenance department was aware of these issues, but repairs were delayed. Furthermore, the walk-in freezer in the kitchen consistently failed to maintain the required temperature, as observed over several days. The dietary manager confirmed the freezer's inability to hold the necessary temperatures, indicating a failure to ensure food safety and equipment operability.
Ineffective Pest Control Program Leads to Ongoing Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing issues with various pests, including fruit flies, flies, ants, and rodents. The facility's pest control policy aimed to minimize pests, but observations and interviews revealed persistent pest problems. The pest control company conducted regular treatments for different pests, but the issues persisted, particularly with fruit flies and flies in resident rooms and common areas. Observations noted flies and gnats in resident rooms, the kitchen, and the conference room, indicating that the pest control measures were insufficient. Interviews with staff and residents highlighted concerns about the pest infestation. Residents reported being unable to enjoy meals due to fruit flies, and staff confirmed the presence of mice and flies in the facility. The Maintenance Director and Assistant Maintenance Director acknowledged the infestation issues, with reports of mice in the kitchen and hallways and fruit flies in resident rooms. The Ombudsman also noted previous issues with rats in the kitchen and the kitchen door being left ajar, which could contribute to the pest problem. Observations further revealed that the kitchen door leading to the outside was frequently left open, providing easy access for pests. This was confirmed by multiple observations of the door being propped open with a rock. The presence of mouse droppings in the pantry and kitchen area further indicated a rodent infestation. Despite the pest control company's efforts, the facility's pest control program was ineffective in addressing the ongoing pest issues, leading to resident complaints and concerns about the living conditions.
Lack of Weekend Access to Resident Funds
Penalty
Summary
The facility failed to provide residents with access to their trust fund accounts after hours and on weekends, affecting 122 residents with such accounts. The Business Office Manager (BOM) confirmed that residents were informed to withdraw sufficient funds on Fridays to cover their weekend needs, as there was no secure personnel available to handle funds during weekends. This practice had been in place before the current BOM's tenure, and residents were notified through a memo and resident council meeting by the previous Social Service Director. The Former Administrator (FA) mentioned that after the resignation of a long-term Business Office Manager, the facility struggled to find a replacement. During the interim, funds were left with the receptionist, who was available 24/7 until January 2024. However, the current business office hours are limited to weekdays from 9:30 am to 4:30 pm, as observed on the Accounts Receivable door. The Former Social Service Director also noted that residents could not access their funds after 3:00 pm and on weekends.
Deficiencies in Linen Supply, Maintenance, and Odor Control
Penalty
Summary
The facility failed to provide a safe and sanitary homelike environment, as evidenced by multiple deficiencies observed and reported by staff and residents. There was a significant issue with linen shortages, which resulted in residents not having access to clean bedding, clothing, and bath linens. Interviews with several Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) revealed that the linen shortage had been a persistent problem, with staff often unable to access clean linens due to restricted access to the laundry room and inconsistent laundry staff availability. This led to residents being kept in soiled conditions for extended periods, as confirmed by both staff and residents. Additionally, the facility failed to maintain the ceiling/roof in good repair, particularly in a resident's bathroom on the second floor, where the ceiling was observed to be drooping and stained due to water damage. The Maintenance Director acknowledged the need for roof replacement and confirmed the presence of water damage in the resident's room. This issue had been ongoing since at least February 2024, as reported by the resident. Furthermore, the facility did not provide an environment free of persistent odors on the third floor. Observations noted an offensive odor permeating the area, which was confirmed by both residents and housekeeping staff. Despite scheduled deep cleaning, the third floor had not been adequately cleaned, contributing to the persistent odor problem. The Administrator was unaware of current complaints regarding the odor, although deep cleaning was supposed to occur weekly.
Deficiencies in Linen, Dietary, and Staffing at LTC Facility
Penalty
Summary
The governing body of the facility failed to ensure adequate linen supplies, briefs, and staffing in dietary and laundry services, leading to significant deficiencies in resident care. The facility had a contract with a care services group for dietary and housekeeping services, but there were frequent changes in dietary managers, with five different managers since September 2023. This instability contributed to a shortage of dietary staff, causing delays in meal services. Additionally, the facility struggled with maintaining adequate linen supplies, as evidenced by multiple requests for linen orders and approvals, which were often delayed or not fulfilled. Interviews with various staff members, including the Assistant Environment Services, Administrator, and previous administrators, revealed ongoing issues with staffing and compensation. Staff members frequently left due to inadequate pay and delayed payments, resulting in a high turnover rate and reliance on overtime. The facility's administrators reported using personal funds to purchase necessary supplies for residents, indicating a lack of support from the corporate level. The facility also faced challenges with laundry services, with reports of dirty linens piling up and residents lacking clean clothes and bed sheets. The facility's maintenance issues further compounded the problems, with reports of a broken washing machine and delayed repairs affecting laundry services. The facility also faced structural issues, such as the need for roof replacement and flooring repairs, which impacted the residents' dining experience. Despite multiple requests and grievances submitted to the corporate level, these issues remained unresolved, leading to a decline in the quality of care provided to the residents.
Ongoing Deficiencies in Laundry and Grievance Management
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) Program to address ongoing issues related to resident grievances and laundry services. The facility's policy intended to systematically monitor and evaluate the quality of resident care, but continued concerns were noted in Resident Council minutes from September 2023 to May 2024. These concerns included issues with laundry, missing clothing items, linen and diaper shortages, and a lack of personnel and supplies. Despite these ongoing issues, the facility's QA Committee minutes from May 2024 only noted the need to order extra linen. Interviews with staff revealed that the linen shortage had been a persistent problem since November 2023, with grievances being reported but not adequately addressed. The previous Social Services Director (SSD) noted that grievances were provided to the housekeeping manager, but no follow-up occurred. The Administrator acknowledged that issues with laundry, linen, supplies, maintenance, and dietary services were identified in QAPI meetings from January to July 2024. Despite these meetings, the facility continued to experience shortages, with an incident of clean linen being discarded in the trash, indicating a lack of effective resolution to the identified problems.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during high-contact care for a resident with a stage four pressure ulcer, a gastrostomy tube, and dementia. The resident was dependent on staff for all activities of daily living. During an observation, two Certified Nursing Assistants (CNAs) were seen preparing to give the resident a bed bath without wearing gowns, as required by EBP. One CNA did not perform hand hygiene after removing gloves and continued to provide care with the same gloves. When questioned, the CNA was unaware of the EBP requirements. Additionally, a Licensed Practical Nurse (LPN) was observed performing wound care on the same resident without wearing a gown, despite being aware of the EBP requirements. The LPN mentioned that there were no gowns available on the cart outside the resident's room, although the facility reportedly had enough personal protective equipment. The Infection Preventionist acknowledged confusion regarding EBP and indicated a need to reevaluate the policy. The lack of gowns on the linen cart and the absence of a PPE cart outside the resident's room contributed to the deficiency.
Misappropriation of Resident's Funds by Staff Member
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property by a staff member. The incident involved a resident, identified as R32, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R32 had multiple diagnoses, including chronic obstructive pulmonary disease, heart failure, anxiety, hypertension, type II diabetes, and chronic pain. The deficiency occurred when R32 reported unauthorized charges on their account after giving their FSA card to a Former Activities Assistant (AA) for shopping. The Former AA did not return the card and linked their Cash app account to R32's card, resulting in unauthorized transactions totaling $830. The facility's policy on abuse, neglect, and exploitation defines misappropriation as the wrongful use of a resident's belongings or money. The incident was reported to the facility's social services, and an investigation revealed that the Former AA claimed to have permission from R32, which R32 denied. The police were involved, but no final report was available at the time of the survey. The Former AA's employment was terminated on the same day the incident was reported, and they did not return to the facility afterward.
Latest citations in Georgia
The facility failed to follow its abuse investigation policy when responding to an allegation that a male resident wandered into a female shared room, allegedly sat on a resident’s bed, inappropriately touched her leg, stared at another resident, and opened the bathroom door to watch a third resident brushing her teeth. The allegation was reported by a cognitively intact resident and involved residents with varying levels of cognitive impairment. The investigation, conducted by the Administrator and former DON, relied only on interviews with a RN and a CNA, did not obtain required written, signed, and dated witness statements, and did not include interviews with other residents to assess their sense of safety. Despite these omissions and incomplete documentation, the facility’s final report concluded the allegation was unsubstantiated.
A resident with protein calorie malnutrition and a terminal prognosis was admitted on hospice with corresponding physician orders and a care plan, but hospice services were not coded on either the admission or quarterly MDS assessments. The MDS Coordinator and two MDS LPNs confirmed that, despite the resident receiving hospice care, Section O of both MDS assessments incorrectly indicated the resident was not on hospice, which the Administrator and DON acknowledged resulted in inaccurate MDS data.
Surveyors found that PTAC unit filters in two resident rooms on one hallway were not maintained free of visible grey, fuzzy debris, despite facility policy requiring regular inspection and cleaning or replacement at least every three months. Across multiple observations on different days, the condition of the dirty filters remained unchanged. The Maintenance Director reported he is responsible for monthly cleaning and checks, including spot checks and inspections in construction areas, and did not dispute the observed dust accumulation when shown. The Administrator confirmed that maintenance staff are responsible for monthly PTAC filter cleaning as part of preventative maintenance and acknowledged that this issue could negatively affect residents’ health and well-being.
A resident with intact cognition and known skin integrity risks reported being left on a bedpan for an extended period and not being adequately cleaned by a CNA. The following shift, another CNA found the resident on soiled linens with a blister on the left upper thigh but did not report this new skin issue to the charge nurse or DON. Subsequent documentation showed development of an open area on the thigh associated with pain, and later NP evaluation identified a larger wound requiring sharp excisional debridement. These events show failure to provide adequate incontinent care and to promptly assess and report a new wound, contrary to the facility’s abuse/neglect prevention policy and CNA responsibilities.
A cognitively intact resident with skin-related diagnoses reported delayed and inadequate incontinent care after using a bedpan, describing prolonged waits for staff response and feeling not properly cleaned by a CNA. The next morning, another CNA found feces-soiled linen and a blister on the resident’s left upper thigh, later documented as a new open area. The resident texted the Administrator stating that a CNA had left feces on her and that she had developed a painful blister, but the Administrator did not report this allegation of neglect to the State Survey Agency as required by facility policy.
A resident with lymphedema and identified risk for pressure ulcers developed a new open wound on the upper thigh, documented by a NP with specific wound measurements. Although the existing care plan included interventions to observe and document skin changes, the care plan was not updated to include this new wound. The Wound Care Nurse and the resident confirmed the wound location, while the MDS Coordinator reported not receiving recent weekly wound reports and only recently learning of the wound. The MDS Coordinator confirmed that the care plan had not been revised in real time as required by facility procedures, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
The facility did not complete a required Georgia Criminal History Check System (GCHEXS) fingerprint background check for a CNA, as identified during review of ten employee files with a census of eighty residents. The facility’s abuse-prevention policy required criminal background checks for all employment candidates, but there was no documentation of a fingerprint records check for this CNA. The HR manager, who is responsible for background and fingerprint checks and maintaining employee files, confirmed that the GCHEXS fingerprint check had not been conducted, resulting in a deficiency under F-Tag 600.
Surveyors found that four of six resident shower rooms were not kept free of hazards or adequately cleaned. On one floor, razors were on the floor, dirty gloves and a comb were on a shower bed, floors were stained, an opened gallon of bath soap and a bottle of chemical-resistant spray were present, and a razor and hair clippers were in a bag on the floor along with a shower cap and toothbrush. On other floors, surveyors observed multiple opened containers of skin and hair cleaner, conditioner, and skin ointment, along with a strong urine odor. Unit managers and the Environmental Senior Director stated that CNAs were responsible for cleaning after each resident and that environmental services cleaned shower rooms daily, and acknowledged that items should not be left on the floor and that product containers should be closed.
Surveyors found that staff did not follow standard and transmission-based precautions when handling ice on two floors. On one floor, the ice scoop cover on top of the ice machine had visible black specks near the end of the scoop used to dispense ice. On another floor, the ice scoop was observed submerged in ice and water inside the cooler used to serve residents, despite the unit manager acknowledging that the scoop should not be left in the cooler. The Maintenance Director reported that maintenance cleaned and checked ice machines regularly, while nursing staff were responsible for cleaning scoops and covers. The SDC/Infection Control nurse stated that all staff had been in-serviced on hand hygiene and ice scoop protocol, including that scoops should be stored in a holder after use and never left in the ice.
A resident with multiple serious conditions, moderate cognitive impairment, and total dependence for ADLs was placed in bed with side rails intended to assist with positioning, despite the MDS indicating no bed rail use. Facility records showed no evidence of safe rail spacing or regular inspection of the bed and rails. The assigned CNA, who came on duty late in the evening, last saw the resident around the start of the shift and did not check on him again for several hours, relying on the resident to use a call light. In the early morning, the CNA and an RN found the resident partially out of bed, entrapped in the half side rail, requiring multiple staff to free and reposition him. The resident was unresponsive except for moaning, with altered mental status and respiratory failure documented by EMS and the ER, and later expired at the hospital. The facility’s failure to provide required monitoring and to ensure safe side rail use resulted in neglect and Immediate Jeopardy.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of sexual abuse in accordance with its policy titled “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating.” The policy required that all allegations be thoroughly investigated, including reviewing documentation and evidence, interviewing any witnesses, interviewing staff on all shifts who had contact with the resident, and completely documenting the investigation, with written, signed, and dated witness statements. A facility-reported incident documented that a male resident was wandering into a female three-bed room, allegedly inappropriately touching one resident, staring at another for a length of time, and then opening the bathroom door and staring at a third female resident while she was brushing her teeth. The allegation was initially reported by a cognitively intact resident (BIMS score 15) and involved another resident with moderate cognitive impairment (BIMS score 8) and a resident with severe cognitive impairment (BIMS score 99). The Administrator reported that the investigation of this incident was conducted by the former DON and herself after the allegation was reported by a RN. She stated that this was not the first time the alleged male resident had wandered into other residents’ rooms and described the allegation as the male resident entering a resident’s room, sitting on the resident’s bed, and allegedly touching the resident’s leg. Staff interviews for the investigation were limited to the RN and a CNA, and the Administrator acknowledged that no written witness statements were obtained, contrary to facility policy. She also confirmed that no additional residents were interviewed to assess their sense of safety following the incident. The facility’s final investigation report concluded that the allegation was unsubstantiated, despite the lack of comprehensive interviews, written statements, and full documentation required by the facility’s abuse investigation policy.
Failure to Accurately Code Hospice Services on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for a resident receiving hospice services. The facility’s policy on Certification of Accuracy of the MDS requires that appropriate health professionals correctly document residents’ medical, functional, and psychosocial problems using the Resident Assessment Instrument. The resident in question was admitted with diagnoses including protein calorie malnutrition and had a care plan dated 01/09/2026 indicating a terminal prognosis and admission to hospice, with a goal to honor advance directives and provide comfort with dignity. Physician’s orders dated 12/09/2025 also included an order to admit the resident to hospice. Despite this, review of the admission MDS and a subsequent quarterly MDS showed that hospice services were not coded in Section O (Special Treatments, Procedures and Programs), even though both assessments documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. Interviews with the MDS Coordinator and two MDS LPNs confirmed that the resident had been on hospice since admission and that both the admission and quarterly MDS assessments were incorrectly coded as not on hospice. The MDS Coordinator acknowledged that the MDS should present an accurate clinical picture for a given period and stated that this was a clerical error, resulting in CMS not receiving correct hospice coding for the resident. The Administrator and DON stated their expectation that MDS assessments accurately reflect residents’ services and confirmed that failure to code hospice in the MDS results in an inaccurate reflection of the data.
Failure to Maintain Clean PTAC Unit Filters in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain Packaged Terminal Air Conditioner (PTAC) unit filters in a safe, clean condition in two resident rooms on the Sapphire Hallway. The facility’s written policy titled "Instructions" requires that air filters be removed and inspected for cleanliness, washed or replaced if dirty, and at a minimum replaced or thoroughly cleaned every three months. During multiple observations in one room on 3/22/2026, 3/24/2026, and 3/25/2026, the PTAC unit filter was noted to have visible grey, fuzzy debris accumulation, with no change in condition across all three observations. Similar repeated observations on those same dates in another room showed the PTAC unit filter also contained visible grey, fuzzy debris accumulation that remained unchanged. In an interview, the Maintenance Director stated he is responsible for cleaning and checking the PTAC filters monthly, including conducting monthly checks and random inspections in areas where construction is occurring, and confirmed that the maintenance department is responsible for ensuring filters are clean and functioning properly. He also stated that expectations include spot checks of PTAC units. However, during an observation of one of the affected rooms in his presence, dust accumulation was again observed on the PTAC unit filter, and he did not dispute the finding. In a separate interview, the Administrator stated that the maintenance department is responsible for cleaning PTAC filters, which are supposed to be cleaned monthly, and that her expectation is for preventative maintenance to be completed monthly and as needed, noting that a potential negative outcome is the impact on residents’ health and well-being.
Neglect of Incontinent Care and Delayed Wound Reporting Leading to Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to prevent neglect and to assess and provide timely wound and incontinent care to a cognitively intact resident with known skin integrity risks. The resident, who had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema, was care planned as being at risk for pressure ulcer development and skin integrity issues, with interventions directing staff to observe, document, and report any changes in skin status. On a night shift, the resident reported being left on a bedpan for approximately an hour and a half. When the CNA on that shift (CNA BB) assisted with post-toileting care, the resident told her she did not feel adequately cleaned; CNA BB did not recheck or further clean the resident and left the room. The next morning, the resident reported burning in the left upper thigh and informed another CNA (CNA EE) that she had not been cleaned well. During morning care, CNA EE found the pad under the resident soiled with feces and wet with urine and observed a blister on the resident’s left upper thigh, but did not report the new blister to the charge nurse or DON. A subsequent Skin Wound Note documented a new open area on the left posterior thigh with the resident reporting pain while sitting on the bedpan. Later, an NP wound care consult documented that the thigh wound had been present for approximately two weeks per nursing report and measured 3.5 cm x 4.0 cm x 0.2 cm, requiring sharp excisional debridement to remove necrotic tissue and decrease bacterial burden. On observation by the surveyor with the Wound Care Nurse, the left upper thigh area was open to air, shiny pink and granular, about the size of a half dollar. These findings demonstrate that the facility did not follow its abuse/neglect prevention policy and CNA job responsibilities to provide necessary care and to report changes in condition, resulting in neglect of incontinent care and delayed wound assessment and treatment for this resident.
Failure to Report Allegation of Neglect to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the State Survey Agency (SSA) as required by its own abuse and neglect reporting policy. The facility’s policy, dated 1/2025, states that any complaint, allegation, observation, or suspicion of resident neglect must be immediately communicated to the Abuse Coordinator and promptly investigated and documented, and that all alleged violations involving mistreatment, abuse, or neglect will be thoroughly investigated under the direction of the Administrator in accordance with state and federal law. Despite this, the Administrator acknowledged that an allegation of neglect reported by a resident was not reported to the SSA. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. The resident reported that during a night shift she requested assistance for incontinent care after using a bedpan and experienced multiple delays before a CNA assisted her. She stated that when the CNA finally provided care, she did not feel adequately cleaned, and the CNA did not verify cleanliness before leaving. The next morning, another CNA found soiled linen with feces and a blister on the resident’s left upper thigh, which the resident reported as burning. A subsequent skin/wound note documented a new open area on the left posterior thigh. The resident texted the Administrator describing that a CNA had left feces on her and that she had developed a painful blister. The Administrator confirmed receiving this text but did not report the allegation of neglect to the SSA, despite being aware it should have been reported.
Failure to Update and Implement Care Plan for Newly Developed Pressure Ulcer
Penalty
Summary
Surveyors identified a failure to implement and update the care plan for a newly developed pressure ulcer for one resident. The facility’s policy "RAI Care Planning Management" requires a comprehensive, accurate assessment and real-time modification of the care plan when changes occur. The resident was admitted with diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. A recent MDS quarterly assessment showed the resident was cognitively intact (BIMS 15), at risk for pressure ulcer development, and had no unhealed pressure ulcers at that time. The existing care plan, dated 6/6/2024, identified potential for pressure ulcer development and skin integrity issues related to immobility and lymphedema, with interventions to observe, document, and report changes in skin status, including wound size, stage, and signs of infection. Subsequently, a NP wound report documented a new open wound on the resident’s thigh that had been present for approximately two weeks, with specific measurements recorded. During observation and interview, the Wound Care Nurse and the resident confirmed the wound was on the left upper thigh, which differed from the NP report that referenced the right thigh. The MDS Coordinator reported she previously received weekly wound sheets from the Wound Care Nurse but had not received one in about a month, and that the DON was now responsible for emailing the weekly wound report. She verified that the last wound report she received did not include this resident and stated that new wounds should be discussed in the morning management meeting and the care plan updated in real time. The MDS Coordinator confirmed she only recently became aware of the upper left thigh wound and that the resident’s care plan had not been updated to reflect this new wound, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
Failure to Complete Required GCHEXS Fingerprint Check for CNA
Penalty
Summary
The facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for one CNA among ten employee files reviewed, despite a census of eighty residents and a written policy requiring criminal background checks for all employment candidates. The policy titled "Freedom of Abuse Abuse Prevention Fast Alert" dated 1/2025 states that, as part of pre-employment screening, all candidates must authorize a criminal background check for conviction of crimes. During record review with the Human Resources Manager (HRM), there was no documentation of a fingerprint records check for CNA BB, and the HRM confirmed that this CNA did not have a GCHEXS fingerprint check conducted. The HRM also stated that she is responsible for background checks, fingerprint checks, reference checks, and maintaining employee files. This failure to complete the required fingerprint background check for CNA BB resulted in noncompliance cited under F-Tag 600. No resident-specific medical histories, conditions, or direct resident care events were described in the report related to this deficiency.
Failure to Maintain Safe and Clean Conditions in Multiple Resident Shower Rooms
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate environmental controls in multiple resident shower rooms. On the 4th floor, observation with the Unit Manager showed four razors on the floor, dirty gloves and a dirty comb on a shower bed, stained/dirty floors, an opened gallon bottle of complete bath soap, and a bottle of chemical resistant spray in the shower room. A razor and hair clippers were found in a black bag on the floor, and a shower cap and toothbrush were lying on the floor. The 4th floor Unit Manager stated that CNAs were supposed to clean up before showering residents and acknowledged that the items found should not be on the floor. The Environmental Senior Director reported that shower rooms were cleaned daily, with responsibilities including cleaning high-touch areas, sweeping and mopping floors, removing linen, and cleaning the area, and stated there had been no complaints about showers not being cleaned. On the 3rd floor, observation with the Unit Manager revealed an open bottle of skin and hair cleaner, an open bottle of conditioner, and an open bottle of skin ointment in the resident shower room. The 3rd floor Unit Manager stated that items in the shower room should be closed and that CNAs were to clean after each resident. On the 2nd floor, observation with the Unit Manager revealed two opened gallon containers of skin and hair cleaner and a strong urine odor in the shower room. The 2nd floor Unit Manager stated that the soap should have a top on it and that CNAs were responsible for cleaning after each resident. These observations and interviews showed that four of six resident shower rooms were not maintained free of hazards and were not cleaned as expected by facility staff, creating the potential for injury and spread of infection as stated in the report.
Improper Ice Scoop Handling and Storage Breaches Infection Control Protocol
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper handling and storage of ice scoops on two of four floors. On the 4th floor, observation of the ice scoop and scoop cover showed black specks near the end of the scoop used to put ice in cups, and the scoop cover was located on top of the ice machine. The 4th floor Unit Manager stated that kitchen staff cleaned the scoops once a week and acknowledged that the scoop should be clean. On the 3rd floor, observation of the ice chest/cooler used to serve residents revealed the ice scoop submerged in ice and water. The 3rd floor Unit Manager later confirmed that the ice scoop was not supposed to be left in the cooler. The Maintenance Director reported that maintenance staff were responsible for cleaning the ice machines, which were checked weekly and monthly, while nursing staff were responsible for cleaning the ice scoops and covers. The Staff Development Coordinator/Infection Control staff stated that all staff had been trained in infection control procedures, including hand hygiene and handling of the ice scoop and holder, and that staff had been educated that the ice scoop should be placed in the scoop holder after use and never left in the ice. Documentation in the maintenance logbook showed monthly checks and cleaning of all four ice machines, and the ice machine cleaning log showed that the ice machines on the 2nd, 3rd, and 4th floors and in the kitchen had been cleaned on specific dates. Staff training records indicated that an in-service on handwashing and ice scoop protocol had been provided for all staff.
Neglect Related to Inadequate Supervision and Unsafe Side Rail Use Leading to Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to inadequate supervision and oversight of side rail use, resulting in entrapment. Facility policies on Abuse, Neglect and Exploitation required protections to prevent neglect, defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy on Proper Use of Bed Rails required a person-centered approach, attempts at alternatives before bed rail use, and ensuring correct installation, use, and maintenance of bed rails, including attention to entrapment risk. For this resident, the Medicare 5-day MDS indicated moderate cognitive impairment (BIMS score of 8), total dependence on staff for all ADLs, and documented that bed rails were not used, while an admission assessment documented side rails were placed to assist with movement in bed. Facility records showed no evidence that safe rail spacing and regular inspection of side rails and beds had been completed. The resident had multiple serious medical diagnoses, including acute and subacute infective endocarditis, end stage renal disease, hemiplegia and hemiparesis following cerebral infarction, bacteremia, and cervical disc degeneration, and was dependent on staff for all ADLs. Nursing staff last observed the resident at 12:46 am when a sponge bath was provided; there was no documented monitoring or ADL assistance between 12:46 am and 4:30 am. The assigned CNA reported coming on duty at 11:00 pm, seeing the resident up with the bed in a low position, placing the call light in the resident’s hands, and not seeing or checking the resident again until approximately 4:30–5:00 am, stating that the resident did not press the call light during that time. Around 5:00 am, the CNA requested help from the RN, reporting that the resident needed assistance. The RN found the resident with the lower part of his body hanging off the bed and the upper body still on the bed, with his elbow wedged into the half side rail, requiring three staff to reposition him back into bed. The RN stated the resident, who was quadriplegic, was no longer as alert as when put to bed, did not respond to sternal rubs, had open but unfocused eyes, and was not verbally interactive. The CNA described finding the resident on his knees, all the way out of bed, with one hand tangled in the side rail, and noted that he was moaning but not talking after being returned to bed. Progress notes documented that EMS was called for evaluation and treatment due to the resident’s condition, and hospital ER records indicated he arrived with altered mental status and respiratory failure, agonal respirations, and a GCS of 3. The facility’s Maintenance Director stated bedrails had been checked the prior year but could not provide proof, and requested documentation of safe rail spacing and regular inspection was not provided.
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