Palemon Gaskins Mem Nsg Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Ocilla, Georgia.
- Location
- 710 North Irwin Avenue, Ocilla, Georgia 31774
- CMS Provider Number
- 115713
- Inspections on file
- 17
- Latest survey
- January 18, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Palemon Gaskins Mem Nsg Home during CMS and state inspections, most recent first.
Surveyors found that the facility failed to submit required PASRR Level II evaluations after new qualifying mental illness diagnoses were added for two residents. One resident had PTSD, major depressive disorder, and anxiety disorder documented in the EHR and MDS, along with use of antianxiety and antidepressant medications, but the PASRR Level I did not reflect these mental health conditions and no Level II was submitted. Another resident had schizoaffective disorder, schizophreniform disorder, anxiety, depression, and schizophrenia documented, was receiving antipsychotic, antianxiety, and antidepressant medications, yet the PASRR Level I indicated no mental illness and no Level II was submitted. Both residents were absent from the facility’s list of current Level II PASRR cases, and staff interviews confirmed that the PASRR screenings had not been accurately updated or resubmitted.
Surveyors identified multiple environmental and maintenance deficiencies affecting resident areas, including handrails on two halls with missing caps, exposed screws, and black tape on edges, as well as holes in the floor and an unattached baseboard near a dining room entrance. A resident room sink was repeatedly observed to be clogged or partially clogged, with water draining very slowly over several days. The facility did not provide a policy addressing a safe, clean, homelike environment when requested, and the MDS nurse and Maintenance Director confirmed the ongoing issues with the sink, handrails, flooring, and baseboards.
The facility did not ensure an accurate PASRR Level I screening for a resident with documented schizophrenia, depression, and dementia. Although the resident’s EHR, MDS, and physician orders showed active diagnoses of schizophrenia and depression and ongoing treatment with antidepressant and antipsychotic medications, the PASRR Level I form marked that the resident did not have schizophrenia, anxiety, or depressive disorder, and no Level II PASRR was obtained. The resident was not included on the facility’s Level II PASRR list, and the Administrator confirmed that audits had only reviewed the top three diagnoses on the DMA-6, which excluded the qualifying mental health diagnoses, resulting in the failure to submit an accurate PASRR screening.
A medication security deficiency occurred when an RN unlocked a medication cart, opened the computer to a resident’s MAR, and then walked away to discard an item, leaving the cart and computer screen unattended and unsecured. The RN returned shortly afterward to obtain the resident’s medication but later confirmed in an interview that the cart had been left unlocked and stated she believed it was acceptable because a surveyor was present, while acknowledging she should have locked the cart and closed the screen. The DON reported that her expectation is that nursing staff lock the medication cart before walking away.
The facility’s QAA program did not effectively identify and correct ongoing deficiencies related to maintaining a safe, clean, comfortable, homelike environment and completing required Level I PASRR screenings. Although a PIP had been initiated after prior citations for F644 (coordination of PASRR and assessments) and F645 (PASRR screening for mental illness and developmental disabilities), the Administrator acknowledged that it was not effective for residents who had been in the facility before the earlier survey. As a result, the same residents who previously required PASRR Level II screenings based on their diagnoses were again found to be lacking appropriate PASRR Level II reviews during the current survey.
An LPN was observed during a med pass popping multiple oral medications from blister packs into her bare hand and pouring floor stock pills into her hand before placing them into a medication cup, without performing hand hygiene between handling the pills. Another LPN present at the cart told her that pills should not be popped into the hand due to infection control concerns. In an interview, the LPN acknowledged handling the pills this way, stated she was a new grad working PRN with only one day of orientation, and reported she had been trained to do it that way. The DON later stated her expectation was that staff pop pills directly into a cup rather than into their hands.
The facility failed to notify responsible parties of wound progression for several residents, did not maintain a clean and home-like environment, and neglected to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices. Additionally, the facility did not ensure proper Level II Preadmission Screening and Resident Review (PASRR) for residents with qualifying diagnoses. These issues were not addressed in the facility's Quality Assurance Performance Improvement (QAPI) process.
A facility failed to follow infection control policies during wound care and IV antibiotic administration for a resident with pressure ulcers. A nurse did not practice hand hygiene or wear a gown as required by Enhanced Barrier Precautions (EBP). Interviews revealed staff were unaware of EBP guidelines and PPE requirements, indicating a lack of training on infection control practices.
The facility failed to notify the families of two residents about the development and progression of pressure ulcers. One resident's family discovered the wound while assisting with care, and interviews revealed a lack of documentation and communication regarding wound status changes. The facility relied on charge nurses and a visiting wound care nurse, but failed to meet the expectation of timely family notifications.
The facility failed to maintain a clean and homelike environment, with privacy curtains in several rooms found to have dirt and stains, and bathroom ceilings exhibiting a black substance due to condensation. A sink in one room was non-functional, with water turned off to prevent flooding, and leaking pipes were discovered. Staff interviews revealed a lack of awareness and communication regarding maintenance issues, and housekeeping practices were inadequate, with uncertainty about when privacy curtains were last cleaned.
A facility failed to conduct a PASARR Level II evaluation for a resident after new mental illness diagnoses were added. The resident was admitted with anxiety disorder and depression, and later diagnosed with PTSD. Despite these diagnoses, the facility did not submit for a Level II evaluation, as required by their policy. Interviews revealed challenges in obtaining accurate information from discharging facilities and a lack of responsibility taken by behavioral health services to apply for the evaluation.
A facility failed to submit an accurate PASRR Level I application for a resident with schizophrenia and depression prior to admission. The resident's PASRR assessment incorrectly marked the absence of these conditions, and the resident was not listed for a Level II evaluation. Interviews revealed an expectation for accurate PASRRs, but the necessary resubmission was not completed.
The facility failed to ensure accurate wound care documentation, as the dates on the weekly wound report reflected the report completion date rather than the actual wound identification date. This issue was noted for several months, and staff interviews revealed that the problem was identified weeks before the survey but was not documented or incorporated into the QAPI plan. The Administrator acknowledged the concern, highlighting the inability to track wound progression accurately.
Failure to Update PASRR Screenings After New Mental Illness Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to submit required PASRR Level II evaluations after new qualifying mental illness diagnoses were added for two residents. The facility’s PASRR policy dated 1/1/2024 states that all individuals seeking admission to Medicaid-certified nursing facilities must be screened for mental illness or intellectual/developmental disability, that residents will be screened prior to admission using the PASRR process, and that if the screening is positive for possible serious mental illness or intellectual/developmental disability/related condition, a Level II evaluation will be performed. Despite this policy, surveyors found that the facility did not complete or submit PASRR Level II evaluations when new mental health diagnoses were added to residents’ records. For one resident, the EHR showed admission with diagnoses including anxiety disorder, depression, and a primary diagnosis of PTSD. The resident’s MDS reflected severe cognitive impairment with a BIMS score of seven and active diagnoses of anxiety disorder, depression (other than bipolar), and PTSD, and the resident was receiving antianxiety and antidepressant medications. The medical diagnosis list showed that Major Depressive Disorder, PTSD, and anxiety disorder were added over time; however, the resident’s PASRR Level I assessment did not list other mental disorder, anxiety, or depressive disorder. Record review revealed no PASRR Level II submission after these mental illness diagnoses were added, and the resident did not appear on the facility’s list of current Level II PASRR residents. For another resident, the EHR showed admission with schizoaffective disorder, bipolar type, depression, and anxiety disorder, with additional diagnoses of schizophreniform disorder and restlessness and agitation added later. The resident’s MDS indicated they were not considered by the state Level II PASRR process to have serious mental illness or intellectual disability/related condition, showed little to no cognitive impairment with a BIMS score of 13, and listed active diagnoses of anxiety disorder, depression (other than bipolar), and schizophrenia. The resident was receiving antipsychotic, antianxiety, and antidepressant medications. The PASRR Level I assessment indicated the resident did not have a mental illness, and record review showed no PASRR Level II submission after the new mental illness diagnoses were added. The resident’s name was not on the facility’s Level II PASRR list. Staff interviews confirmed that qualifying diagnoses existed and that PASRR Level I screenings had not been accurately updated or resubmitted to trigger Level II review.
Environmental Hazards and Maintenance Failures in Resident Areas
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment on two hallways and in certain common and resident-use areas. Surveyors observed that handrails on Hall 1 and Hall 2 had multiple missing end caps, with screws protruding, and some handrails had black tape wrapped around the edges. At the entrance to Hall 1 near the dining room, the flooring by the double doors had six holes remaining from old fire doors that had been replaced, and the baseboard in that same area was unattached to the wall. When the state surveyor requested a policy addressing a safe and clean homelike environment, the facility did not provide one. In a resident room, surveyors observed on multiple occasions that the sink was clogged or partially clogged. On one observation, the sink water was running and draining very slowly while the basin filled quickly. On subsequent observations, the sink remained clogged or partially clogged, with slow drainage persisting over several days. During a concurrent observation and interview, the MDS nurse confirmed that the sink continued to drain slowly and remained partially clogged. In a walking tour, the Maintenance Director confirmed that the handrails on both halls needed cap replacements, that the holes in the floor were from removed fire doors and needed to be filled, that the baseboards needed to be reattached, and that the resident room sink required service due to a clog.
Failure to Accurately Complete PASRR Screening for Resident With Schizophrenia and Depression
Penalty
Summary
The facility failed to ensure that a complete and accurate PASRR Level I screening was submitted prior to or on admission for a resident with documented mental health diagnoses. Facility policy required that all residents be screened prior to admission using the PASRR process, that the facility obtain a copy of the PASRR and approval number, and that a Level II evaluation be performed if the screening was positive for serious mental illness or intellectual/developmental disability. The resident’s electronic health record showed admission with diagnoses including unspecified mild dementia with anxiety, schizophrenia (unspecified), and unspecified depression. The admission MDS documented active diagnoses of non-Alzheimer’s dementia, Parkinson’s disease, and schizophrenia, and indicated the resident received antidepressant medications. Physician orders showed ongoing treatment with escitalopram and mirtazapine for depression and risperidone for schizophrenia. Despite these documented conditions, the resident’s PASRR Level I assessment indicated “No” for diagnoses of schizophrenia, anxiety, or depressive disorder, and the resident was not listed on the facility’s roster of residents with Level II PASRR determinations. During interview, the Administrator confirmed that the Social Services Director was primarily responsible for submitting Level I PASRR screenings and acknowledged that the resident did not have a Level II PASRR, despite having qualifying diagnoses. The Administrator further confirmed that the Level I PASRR screening had not been resubmitted with the qualifying diagnoses and explained that prior PASRR audits only reviewed the top three diagnoses on the DMA-6 form, which did not include the qualifying mental health diagnoses.
Unlocked and Unattended Medication Cart Left Accessible by RN
Penalty
Summary
The deficiency involves failure to ensure medications were securely stored on one of two medication carts when a nurse left the cart unlocked and unattended. On 1/16/2026 at 8:16 AM, observation of the short hall medication cart showed it was unlocked and unattended after RN DD had unlocked the cart, opened the computer screen, and pulled up Resident 5’s list of medications. RN DD then walked away from the cart to throw something away, leaving the cart unlocked with the computer screen open, and returned at 8:17 AM to remove Resident 5’s medication from the cart. In an interview at 8:21 AM, RN DD confirmed she had walked away from the unlocked cart and stated she thought it was acceptable because the surveyor was standing nearby, acknowledging she should have locked the cart and closed the computer screen before leaving. In a separate interview at 10:29 AM, the DON stated it was her expectation that nursing staff lock the medication cart before walking away from it. This deficient practice created the potential for unauthorized entry and diversion of medications, as documented in the survey findings.
Ineffective QAA Program Fails to Correct Ongoing PASRR Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA) program that identified and corrected deficiencies related to providing a safe, clean, comfortable, homelike environment and ensuring completion of Level I PASRR screenings. Review of the facility’s QAPI purpose statement showed that the program was intended to monitor and sustain operational performance of clinical and non-clinical systems through self-identification and improvement of opportunities for improvement. However, record review of the Monthly QA/PI meeting agenda showed that although a Performance Improvement Plan (PIP) had been established for previously cited deficiencies involving F644 (Coordination of PASRR & Assessments) and F645 (PASRR Screening for Mental Illness and Developmental Disabilities) from a prior survey, the underlying issues were not effectively resolved. During a post-survey interview, the Administrator reported that the QAPI team had created a PIP in response to a previously identified PASRR system failure, but acknowledged that this PIP was not effective for residents who were already in the facility prior to the earlier survey. The Administrator stated that residents residing in the facility before that survey, whose diagnoses clearly qualified them for PASRR Level II reviews, had not been adequately addressed under the existing PIP. The Administrator confirmed that the same residents who had been identified as needing PASRR Level II screenings during the prior survey were again identified during the current recertification survey, demonstrating that the QAA program did not successfully implement corrective actions to resolve the PASRR-related deficiencies.
Improper Handling of Oral Medications During Med Pass
Penalty
Summary
Surveyors observed that during a morning med pass, LPN BB removed multiple blister-pack medications from the cart and repeatedly popped six pills from six separate blister packs into her bare hand before transferring them into a medication cup, without performing hand hygiene between handling the pills. LPN BB also removed floor stock medication from the cart and poured those pills from the bottle into her hand before placing them into the same medication cup. Another nurse, LPN CC, was present near the medication cart, witnessed the interaction, and verbally told LPN BB that pills should never be popped into the hand because it was an infection control issue. In a subsequent interview, LPN BB confirmed she had popped the pills into her hand, stated that this was how she had been trained, and reported she was a new graduate and new nurse, licensed in November 2025, working PRN with only one day of orientation before passing medications. The DON later stated that her expectation was for nursing staff to pop pills directly into a cup and not into their hands. The deficient practice identified was the failure to follow infection control practices during medication administration for one of three residents observed, specifically by handling oral medications in a manner inconsistent with the facility’s stated expectations for infection prevention and control.
Deficiencies in Resident Notification, Environment, and Screening
Penalty
Summary
The facility failed to notify responsible parties and family representatives of wound progression and treatment for four residents. The facility's Quality Assurance Performance Improvement (QAPI) process did not monitor or address the issue of notifying responsible parties about the residents' wound status. Interviews with the Director of Nursing (DON) revealed that the concern of notification was not identified as a problem by the administrative staff and was not being monitored through the QAPI process. The facility did not ensure a clean and home-like living environment for residents. During the survey, privacy curtains were observed to be visibly soiled, unidentified black substances were found on the ceilings and walls of residents' bathrooms, and a nonfunctioning sink was noted in one of the residents' rooms. The Administrator in Training (AIT) mentioned that the facility planned renovations to address these concerns but had not incorporated them into the QAPI program. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices and wounds, as staff had not been educated on their use. Additionally, the facility did not ensure that residents requiring Level II Preadmission Screening and Resident Review (PASRR) were properly screened. The AIT, previously the Social Services Director, acknowledged that they struggled to get accurate information from discharging facilities and had not applied for Level II PASRRs when necessary. The facility was in the process of auditing PASRRs for accuracy but had not included this concern in their QAPI monitoring.
Infection Control Deficiencies in Wound Care and IV Therapy
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during wound care and intravenous antibiotic therapy for a resident with pressure ulcers. Specifically, a registered nurse did not practice hand hygiene before, during, or after wound care, despite the facility's policy requiring handwashing at these times. The nurse also failed to wear a gown while administering intravenous antibiotics, as required by the facility's Enhanced Barrier Precautions (EBP) policy for residents at risk of carrying or transmitting multidrug-resistant organisms. Interviews with staff, including the Director of Nursing and other nursing staff, revealed a lack of awareness and understanding of the EBP guidelines and the necessity of wearing personal protective equipment (PPE) during care for residents with indwelling medical devices or wounds. The Director of Nursing and other staff members admitted to not being aware of the requirement to wear PPE, such as gowns, during certain procedures, indicating a gap in training and education on infection control practices within the facility.
Failure to Notify Families of Pressure Ulcer Changes
Penalty
Summary
The facility failed to notify the family representatives of two residents, R13 and RA, about the development and progression of pressure ulcers. R13 was admitted with multiple diagnoses, including a pressure ulcer on the heel. A progress note indicated a change in the condition of R13's sacral area wound, which was not communicated to the family. Similarly, RA, who was admitted with a pressure ulcer in the sacral region, had a documented open wound that was not reported to the family. The family member of RA discovered the wound while assisting with care and expressed that they were not informed by the facility staff about the wound or any changes in RA's condition. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility lacked a dedicated wound care nurse, relying instead on charge nurses and a visiting wound care nurse from a hospital. The DON acknowledged the absence of documentation regarding family notifications and the inability to track wound progression. The Administrator confirmed that staff were expected to notify families of any changes in residents' conditions and document these notifications, which was not done in these cases.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by several observations and staff interviews. In three of the 17 residents' rooms, privacy curtains were found to have noticeable dirt and debris, including black and brown stains. Additionally, the bathroom ceilings in some rooms had a black substance, which was identified as being caused by condensation and moisture due to the building's age. The sink in one resident's room was not functioning, as the water was turned off to prevent flooding, and it was later discovered that the pipes were leaking and required repair. Interviews with the facility's staff revealed a lack of awareness and communication regarding the maintenance issues. The Director of Engineering was unaware of the need for repairs in the room with the non-functioning sink, and there was no established timeline for completing repairs. The process for reporting and completing maintenance tasks involved notifying the Administrative Assistant, who would then enter a work order into the system. However, the system did not indicate a timeline for completion, and the Director of Engineering only became aware of the issues during the survey. Housekeeping practices were also found to be inadequate, as the privacy curtains were supposed to be cleaned every two weeks, but the housekeeper was unsure of when they were last cleaned. The Interim Administrator confirmed the observations during walking rounds and acknowledged the need for improvement. The expectation was for resident rooms to be clean and free from debris at all times, in accordance with state laws and regulations.
Failure to Conduct PASARR Level II Evaluation for Resident with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASARR) Level II for a resident after new mental illness diagnoses were added. The resident, identified as R15, was admitted with diagnoses including anxiety disorder and depression. The resident's Annual Minimum Data Set (MDS) indicated severe cognitive impairment and active diagnoses of anxiety disorder, depression, and PTSD. Despite these diagnoses, the facility did not submit for a PASARR Level II evaluation, which is required when a resident has a qualifying mental illness diagnosis. The facility's policy mandates compliance with PASARR requirements, including screening residents prior to admission and performing a Level II evaluation if the screening is positive for serious mental illness (SMI) or intellectual and developmental disabilities (ID/DD). Interviews with the Administrator In Training and the Administrator revealed that the facility struggled to obtain accurate information from discharging facilities and that it was the responsibility of behavioral health services to apply for a Level II evaluation. However, no Level II evaluation was completed for R15, and the resident was not listed among those with Level II PASARR in the facility.
Failure to Submit Accurate PASRR Level I for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I application, which included a diagnosis of schizophrenia and depression, was submitted prior to or on admission for a resident. This oversight was identified during a review of the facility's policy and the resident's electronic health record (EHR). The resident, who was admitted with diagnoses including unspecified dementia, schizophrenia, and depression, did not have a PASRR Level I assessment that accurately reflected these conditions. The facility's policy mandates that all residents be screened for mental illness or intellectual and developmental disabilities before admission, and if the screening is positive, a Level II evaluation should be conducted. The deficiency was further highlighted by the fact that the resident's PASRR Level I assessment incorrectly marked the absence of schizophrenia, anxiety, or depressive disorder. The facility's list of residents with Level II PASRR did not include this resident, indicating a failure to follow through with the necessary evaluation process. Interviews with the Administrator In Training and the Administrator revealed that there was an expectation for PASRRs to be accurate and complete, and the failure to resubmit the PASRR with the correct diagnoses was acknowledged. The Administrator emphasized the importance of adhering to legal requirements in the PASRR process.
Inaccurate Wound Care Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of wound care for residents receiving such care. Specifically, the documentation on the weekly wound report inaccurately reflected the date wounds were identified, as the date the report was completed was used instead of the actual date the wound or injury occurred. This issue was noted in the facility's Wound and Skin Status Report for the months of March, June, and October 2024, where the same date was recorded for both the completion of the report and the identification of the wound or skin alteration. Interviews with staff revealed that the problem with wound documentation was identified three weeks prior to the surveyors' visit, but there was no documentation confirming a skin sweep conducted by the staff and the DON to ensure no other unidentified wounds existed. Additionally, the concern with wound documentation was not incorporated into the facility's QAPI plan for evaluation and monitoring. The Administrator in Training acknowledged the issue, noting the inability to determine when wounds were identified or if they were progressing or declining. The Administrator expressed an expectation for accurate documentation of resident wounds, but no specific meetings were conducted to address the issue beyond regular morning meetings discussing residents' current conditions.
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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