Oaks - Bethany Skilled Nursing, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Vidalia, Georgia.
- Location
- 1305 East North Street, Vidalia, Georgia 30475
- CMS Provider Number
- 115705
- Inspections on file
- 18
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Oaks - Bethany Skilled Nursing, The during CMS and state inspections, most recent first.
Surveyors found that a resident room and two shower rooms were not maintained in a clean, safe, and homelike condition. One room had trash on the floor and a dark brown substance on the floor, wall, and electrical cord near the air conditioning unit over multiple days. Two shower rooms had broken and missing tiles, black substance in the corners of the walls and floors, and heavy soap scum buildup on the shower walls. The HKS, MD, CNA, and Administrator all confirmed these conditions and acknowledged that housekeeping and CNA staff were expected to perform daily cleaning and trash removal and to clean between showers.
Two residents were affected when the facility failed to follow comprehensive, person-centered care planning. One resident with COPD and acute respiratory failure had a care plan and physician order for continuous O2 at 3 L/min via nasal cannula, but surveyors repeatedly observed the concentrator set between 4.5 and 5 L/min; an LPN and the DHS confirmed the incorrect flow rate and that it had not been checked as required. Another resident with Alzheimer’s disease and a sacral fracture had an elopement assessment score indicating high elopement risk, yet no corresponding elopement problem or interventions were included in the care plan, as confirmed by the Administrator and MDS nurse.
A resident with COPD, acute respiratory failure with hypoxia, and other comorbidities had a physician order for continuous oxygen at 3 LPM via nasal cannula, supported by a care plan directing staff to administer oxygen as ordered and monitor oxygen saturations. Over multiple observations, surveyors found the resident’s oxygen concentrator set between 4.5 and 5 LPM while the resident was wearing oxygen. An LPN confirmed the concentrator setting was above the ordered rate and admitted she had not checked the oxygen flow rate or oxygen saturation that morning, despite acknowledging staff should ensure correct liter flow. The DHS also confirmed that nurses are expected to verify oxygen flow rates per orders throughout their shifts and that the resident’s oxygen had been set above the prescribed 3 LPM.
A resident with multiple chronic conditions was repeatedly found with gas relief tablets left unsecured at her bedside, despite not being care planned or assessed for self-administration of medication. Staff interviews and record reviews confirmed that medications were to be administered by staff and not left in the room, yet observations showed otherwise, resulting in a failure to ensure safe medication practices.
A resident with severe cognitive and visual impairment, and a history of falls, did not have a care-planned floor mat in place at bedside as required after a fall. Despite the care plan update, repeated observations showed the intervention was not implemented, and staff interviews revealed unclear responsibility for ensuring new interventions were put in place.
A resident with severe cognitive impairment, impaired vision, and a history of falls did not have a fall mat in place at the bedside as required by their care plan. Despite documentation that a fall mat was needed following a previous fall, multiple observations found the mat missing while the resident was in bed. The DHS confirmed the mat was not in position, attributing its absence to housekeeping staff not returning it after cleaning.
The facility failed to label and date food items, ensure dietary staff wore hair coverings appropriately, and maintain cleanliness in the kitchen, potentially affecting 89 residents. Observations revealed unlabeled cheese and ham, improper hair covering by dietary aides, and a dirty fan above the dish room, contrary to facility policies.
The facility failed to provide six residents or their representatives with written information about their right to accept or refuse medical or surgical treatment, as required by the facility's Advance Directive policy. This deficiency was identified through record reviews and staff interviews, revealing that the Admission Packet lacked necessary language to inform residents of these rights. The affected residents had various medical conditions, and there was no evidence in their records of being provided with the required information. Interviews with the Social Worker and Administrator confirmed the absence of such information and a lack of awareness of the facility's policy.
The facility failed to maintain a safe and homelike environment, with broken tiles in the E3 hall shower room, a stained privacy curtain, and a dirty motorized wheelchair for a resident on E4 hall. The laundry room had a dusty vent and an insecure entrance door, while two sinks in shared bathrooms were clogged. Staff were unclear about cleaning responsibilities, and the facility's Performance Improvement Plan did not initially address these issues.
The facility failed to maintain the dignity of two residents requiring feeding assistance. A resident with severe cognitive impairment was fed by a Unit Manager who stood due to a lack of seating, despite the care plan indicating a need for maximal assistance. Another resident was fed by a CNA who stood, contrary to training that emphasized sitting at eye level. The DON confirmed the proper procedure, but the Unit Manager was unaware of any in-services on feeding protocols.
A facility failed to assess four residents for their ability to self-administer medications, resulting in unauthorized medications being left at their bedside. Despite the facility's policy requiring a licensed nurse and physician to determine if a resident can safely self-administer medications, this procedure was not followed. Residents with varying levels of cognitive impairment were found with medications in their rooms without proper authorization or assessment, leading to a deficiency.
A facility failed to complete a timely nutrition assessment for a resident with multiple health conditions, including diabetes and chronic kidney disease. The resident was admitted without an initial nutrition assessment, despite being at risk for gastrointestinal complications. Interviews revealed that the RD was overwhelmed with responsibilities, leading to incomplete assessments. The facility's policy required assessments within 14 days, which was not met, and no policy documentation was provided.
Failure to Maintain Clean and Sanitary Resident Room and Shower Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in a resident room and two shower rooms, contrary to its housekeeping and infection control policy. Surveyors observed that one resident room on the West unit had trash on the floor between the air conditioning unit and the bed on multiple days, along with a dark brown substance on the floor, electrical cord, and wall above the air conditioning unit. These conditions persisted over repeated observations. The Housekeeping Supervisor confirmed the presence of trash and the dark brown substance and stated that housekeeping staff were expected to clean high-touch areas and remove trash daily. A CNA reported that she did not pick up the trash in that room and stated that trash should be checked and removed when providing care. The Administrator also confirmed observing trash, cups, and the dark brown substance on the floor, wall, and electrical cord and stated that trash removal was everyone’s responsibility. The deficiency also includes unsanitary and poorly maintained conditions in two shower rooms. Observations of the East 2 shower room and the Garden Wing shower room revealed broken and missing tiles, a dark or black substance in the corners of the walls and floors, and a buildup of white soap scum on the shower walls. These conditions were noted on more than one day and were confirmed by the Maintenance Director, Housekeeping Supervisor, and Administrator during joint observations. The Housekeeping Supervisor acknowledged that the showers needed to be cleaned and stated that housekeeping staff were responsible for daily cleaning and that CNA staff should clean between patients, while also noting that this was her first time seeing the shower rooms.
Failure to Implement Oxygen Orders and Care Plan for Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered comprehensive care plans for two residents in accordance with physician orders and assessed risks. For one resident with COPD, acute respiratory failure with hypoxia, anxiety disorder, type 2 diabetes mellitus, heart failure, and other conditions, the care plan dated 10/13/2025 identified altered respiratory status and directed staff to administer oxygen via nasal cannula as ordered by the physician and to monitor oxygen saturations. The physician order dated 1/29/2026 specified oxygen at 3 liters per minute via nasal cannula, continuous. However, on multiple observations over several days, the resident was noted to be receiving oxygen at between 4.5 and 5 liters per minute. An LPN confirmed the concentrator was set between 4.5 and 5 liters per minute, acknowledged that the order was for 3 liters per minute continuous, and stated she had not checked the flow rate or oxygen saturation that morning. The Director of Health Services also confirmed the incorrect flow rate and stated that nurses should ensure the correct liter flow is set and check oxygen flow rates throughout their shifts. The MDS Coordinator confirmed the care plan was for oxygen as ordered and that staff should follow the care plan and physician orders. The second deficiency concerns the facility’s failure to care plan for an assessed elopement risk for another resident. This resident was admitted with diagnoses including a non-displaced fracture of zone 1 sacrum and Alzheimer’s disease. The admission MDS showed that a BIMS assessment was not performed because the resident was rarely or never understood. An Elopement Assessment dated 1/17/2026 documented a score of 17, indicating a high risk for elopement. Despite this assessment, review of the resident’s care plan revised 2/4/2026 revealed no documented care plan problem addressing elopement risk. The Administrator stated that all residents were assessed for elopement risk as part of an elopement prevention improvement plan and confirmed that all residents identified as at risk for elopement should have a care plan problem for elopement. The MDS Nurse likewise confirmed that all residents identified as a risk for elopement should have a care plan for elopement.
Failure to Follow Physician-Ordered Oxygen Flow Rate
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of respiratory care related to failure to regulate and monitor oxygen liter flow rates according to physician orders for one resident. Facility policy titled "Oxygen Administration" revised 8/2/2023 states that oxygen is to be provided safely and accurately and that staff are to regulate liter flow to the ordered/desired flow rate. The resident involved had a recent Quarterly MDS dated 1/20/2026 showing a BIMS score of 15, indicating little to no cognitive impairment, and active diagnoses including COPD, acute respiratory failure with hypoxia, anxiety disorder, type 2 diabetes mellitus, heart failure, and functional dyspepsia. The resident’s care plan, dated 10/13/2025, documented altered respiratory status/difficulty breathing related to COPD, with interventions including administering oxygen via nasal cannula as ordered by the physician and monitoring oxygen saturations as ordered. Physician orders for this resident, dated 1/29/2026, specified oxygen at 3 LPM via nasal cannula, continuous. However, multiple observations showed the oxygen concentrator set above the ordered rate: on 2/3/2026 at 12:55 PM the flow rate was between 4.5 and 5 LPM; on 2/4/2026 at 12:10 PM it was set at 5 LPM; and on 2/5/2026 at 9:50 AM it was again between 4.5 and 5 LPM while the resident was wearing oxygen. During an observation and interview on 2/5/2026 at 10:10 AM, an LPN confirmed the concentrator was set between 4.5 and 5 LPM and stated that staff should ensure residents receive the correct oxygen liters per minute, acknowledging that this resident’s flow rate should have been 3 LPM continuous. The LPN reported she had not checked the oxygen flow rate or oxygen saturation that morning and should have done so. The Director of Health Services later confirmed that nurses are expected to ensure the correct liter flow per physician orders and to check oxygen flow rates throughout their shifts, and confirmed that the resident’s oxygen flow rate had been between 4.5 and 5 LPM.
Failure to Assess and Secure Self-Administered Medication
Penalty
Summary
A resident with multiple diagnoses, including GERD, dysphagia, chronic kidney disease, diabetes, hypertension, and atrial fibrillation, was observed on several occasions with two thick white tablets on her overbed table. The resident stated these were gas relief tablets provided by the nurses, which she took after meals. Review of the clinical record confirmed a physician's order for chewable gas relief tablets to be administered as needed. However, the care plan did not indicate that the resident was to self-administer medication or keep medications at bedside, and a prior assessment documented that the resident did not wish to self-administer medications, with staff responsible for administration. Despite this, observations confirmed that the medication was left unsecured in the resident's room on multiple dates. Interviews with an LPN and the Director of Health Services confirmed that the medication should not have been left in the room and that staff were responsible for administering it. The LPN stated she only gave the medication when requested and did not leave it in the room, yet the medication was repeatedly found at the bedside, indicating a failure to follow established protocols for medication administration and security.
Failure to Implement Care Plan Intervention for Fall Prevention
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident who was at risk for falls. The resident, who had diagnoses including dementia, chronic obstructive pulmonary disease, polyneuropathy, generalized anxiety disorder, and major depressive disorder, was assessed as having highly impaired vision, severe cognitive impairment, and required assistance with activities of daily living. Following a fall incident in which the resident was found on the floor with an abrasion to the forehead, the care plan was updated to include a floor mat at the bedside as a preventive intervention. Despite this update, multiple observations over several days showed that the floor mat was not present at the resident's bedside as specified in the care plan. Staff interviews indicated uncertainty about responsibility for implementing new interventions after a fall, with the administrator stating it could be any staff member but ultimately the unit manager's responsibility. This failure to implement the care plan intervention as documented placed the resident at risk for safety and injury.
Failure to Ensure Fall Mat in Place for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a fall mat, identified as a necessary intervention, was in place for a resident with significant risk factors. The resident had diagnoses including dementia, chronic obstructive pulmonary disease, polyneuropathy, generalized anxiety disorder, and major depressive disorder. Clinical assessments documented highly impaired vision, severe cognitive impairment, and a need for assistance with activities of daily living. After a fall incident in which the resident was found on the floor with an abrasion to the forehead, the interdisciplinary team determined that a fall mat should be placed at the bedside to reduce the risk of injury from future falls. Despite this intervention being documented in the care plan, multiple observations over several days showed that the fall mat was not present at the resident's bedside while the resident was in bed. During an interview, the Director of Health Services acknowledged that the fall mat was in the room but had been moved behind a chair, possibly by housekeeping staff after cleaning, and was not returned to its proper place. This lapse in ensuring the fall mat was in position constituted a failure to provide adequate supervision and accident hazard prevention as required.
Deficiencies in Food Labeling, Staff Hygiene, and Kitchen Cleanliness
Penalty
Summary
The facility failed to adhere to its policies regarding food labeling, staff hygiene, and cleanliness in the kitchen, which could potentially affect 89 out of 96 residents receiving an oral diet. During a kitchen tour, it was observed that a package of cheese and a bag of diced ham were not labeled or dated, contrary to the facility's policy that requires all food and beverage items to have an identifying label, received date, and opened date. This oversight was confirmed by a staff member, who acknowledged that without proper labeling, there would be no way to determine when to discard the items, potentially leading to foodborne illness. Additionally, the facility did not ensure that dietary staff wore hair coverings appropriately, as observed with two dietary aides who did not have their hair completely covered. This was against the facility's hygiene policy, which mandates that hair be covered with a hair net or cap. Furthermore, a fan mounted above the dish room was found to be covered in dirt, dust, and grime, which could contaminate food or dishes. The Dietary Manager confirmed these findings and acknowledged the importance of maintaining cleanliness and proper hygiene practices in the kitchen.
Failure to Provide Residents with Information on Treatment Rights
Penalty
Summary
The facility failed to provide six residents or their representatives with written information regarding their right to accept or refuse medical or surgical treatment, as required by the facility's Advance Directive policy. This deficiency was identified through record reviews, staff interviews, and examination of the facility's policy. The facility's Admission Packet did not contain the necessary language to inform residents or their representatives about these rights, which is a critical component of the admission process. The deficiency affected residents with various medical conditions, including anoxic brain damage, chronic respiratory failure, hemiplegia, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, chronic kidney disease, diabetes mellitus, heart failure, and malignant neoplasm of the prostate. Despite the presence of these conditions, there was no evidence in the medical records of these residents that they or their representatives were provided with the required written information about their rights to accept or refuse treatment. This lack of documentation was confirmed through interviews with the Social Worker and the Administrator, who acknowledged the absence of such information in the admission packets. The Social Worker and Administrator interviews revealed a lack of awareness and understanding of the facility's Advance Directive checklist and the residents' rights to accept or refuse treatment. The Administrator admitted to being unfamiliar with the checklist and indicated that it was being revised by corporate. This oversight resulted in all residents in the facility not receiving the necessary materials on their rights, highlighting a systemic issue in the facility's admission process and policy implementation.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment in several areas, including the E3 and E4 halls, the [NAME] wing, and the laundry room. On the E3 hall, the shower room had broken wall tiles with sharp edges, posing a hazard to residents. The facility's Performance Improvement Plan (PIP) did not identify the need for tile replacement, and the issue was only acknowledged after being pointed out by a surveyor. Additionally, the laundry room had a ceiling vent coated with a dark greyish substance, and the entrance door could not close securely due to a large space, potentially allowing contaminants to enter. Resident R19, who has a primary diagnosis of malignant neoplasm of the lung and mild-moderate cognitive impairment, was found to have a stained privacy curtain and a motorized wheelchair with a build-up of brownish-black debris. The care plan for R19 did not initially address the cleaning of the motorized wheelchair, and there was confusion among staff regarding responsibility for cleaning wheelchairs. Interviews with housekeeping aides and nursing staff revealed inconsistencies in the cleaning schedule and procedures for wheelchairs, with the housekeeping supervisor confirming that motorized wheelchairs were only sanitized and not thoroughly cleaned. Furthermore, two sinks in shared bathrooms on the [NAME] wing were clogged and holding water, which was confirmed during an observation and interview with the Administrator. The facility's failure to address these maintenance and cleanliness issues contributed to an environment that did not meet the standards for safety and homeliness, as required for resident care.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to promote and maintain the dignity of two residents who required assistance with feeding. Resident 11, diagnosed with Parkinson's disease, moderate protein-calorie malnutrition, and other conditions, was observed being fed by the Unit Manager while standing beside the bed on two separate occasions. The resident's care plan indicated a need for substantial maximal assistance with feeding due to severe cognitive impairment. Despite this, the Unit Manager admitted to standing while feeding the resident because there was no extra chair in the room and was unsure of the proper procedure for feeding residents. Similarly, Resident 67, who had severe cognitive impairment and was dependent on assistance for eating, was observed being fed by a CNA who was also standing. The CNA acknowledged that training had been provided on the proper feeding procedure, which includes sitting at eye level with the resident. The Director of Nursing confirmed that staff should sit at eye level and elevate the head of the bed when feeding residents. However, the Unit Manager was unaware of any in-services on feeding procedures, and the Administrator noted that while sitting with the resident is not required, it is considered best practice.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess four residents for their ability to self-administer medications before leaving medications at their bedside. This oversight was identified during observations, interviews, and record reviews, revealing that medications were accessible to residents without proper authorization or assessment. The facility's policy requires a licensed nurse and physician to determine if a resident can safely self-administer medications, but this procedure was not followed for the residents in question. Resident 55, who has mild cognitive impairment and several medical conditions, was found with over-the-counter eye drops and pain relief cream at her bedside, which her daughter had brought from home. There was no physician's order for these medications, nor was there an assessment or care plan for self-administration. Similarly, Resident 37, with moderate cognitive impairment, had unauthorized medications, including acetaminophen and medicated chest rub, visible in her room. Resident 75, with severe cognitive impairment, had lidocaine pain medication at his bedside, which he used without staff supervision. Resident 82, despite having no cognitive impairment, also had unauthorized medications, including inhalation powder, in her room. The Licensed Practical Nurse (LPN) confirmed the presence of unauthorized medications in the residents' rooms and acknowledged that the residents had not been assessed or approved for self-administration. The facility's protocol requires an evaluation and care plan for any resident approved to self-administer medications, but this was not adhered to, leading to the deficiency. The administrator confirmed that residents should not have medications in their rooms without proper assessment and approval.
Failure to Complete Timely Nutrition Assessment for Resident
Penalty
Summary
The facility failed to provide evidence that a nutrition assessment was completed by a Registered Dietitian (RD) for a resident, identified as R88, upon admission. R88 was admitted with multiple diagnoses, including gastro-esophageal reflux disease, chronic obstructive pulmonary disease, chronic kidney disease, and type 2 diabetes mellitus with diabetic nephropathy. Despite these conditions, which necessitate careful nutritional management, there was no admission nutrition assessment documented. The resident's care plan noted a risk for gastrointestinal complications and altered nutrition, highlighting the importance of a timely nutritional assessment. Interviews with facility staff revealed systemic issues contributing to the deficiency. The prior RD, who left the facility in December 2024, indicated that managing nine buildings was overwhelming, leading to incomplete assessments. The RD acknowledged that some admission assessments were not completed and that she attempted to catch up on overdue assessments. The Regional Nurse Consultant and the Administrator both confirmed that the facility's policy required nutritional assessments within 14 days of admission, which was not met for R88. The facility was unable to provide a policy on nutrition assessments when requested, further indicating a lapse in adherence to established protocols.
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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