Parkside Post Acute And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Snellville, Georgia.
- Location
- 3000 Lenora Church Drive, Snellville, Georgia 30078
- CMS Provider Number
- 115643
- Inspections on file
- 20
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Parkside Post Acute And Rehabilitation during CMS and state inspections, most recent first.
Staff failed to ensure PTAC unit filters and grills were free of debris in two resident rooms, with gray, fuzzy debris observed on filters and additional debris on a grill. The Maintenance Director confirmed responsibility for PTAC upkeep and acknowledged the deficiency, while the Administrator stated that filters should be cleaned monthly and at resident transitions.
Surveyors identified multiple lapses in infection control, including a respiratory therapist performing tracheostomy care without sterile gloves, improper storage of CPAP masks for two residents, a nurse failing to sanitize shared wound care supplies, personal items stored on clean linen carts, and an LPN entering a contact precautions room without proper PPE. Staff interviews revealed gaps in training and policy awareness regarding infection prevention procedures.
A resident with multiple sclerosis, muscle weakness, and lack of coordination experienced harm due to unreported critical urinalysis results. Despite complaints of painful urination and suspected UTI, the abnormal results indicating a severe urinary tract infection were not communicated to the physician. The resident was subsequently hospitalized for 11 days with urosepsis and acute renal failure. Facility policies required prompt notification of changes in medical condition, but there was no evidence of physician notification or treatment orders. Staff interviews revealed a lack of documentation and accountability, with the DON attributing issues to a change in laboratory providers and ongoing process improvement efforts.
A resident with multiple sclerosis and muscle weakness experienced a severe UTI that was not promptly treated despite abnormal urinalysis and culture results. The facility did not inform the physician or initiate treatment, resulting in the resident's hospitalization for UTI and acute renal failure. Communication lapses between the nursing staff and the NP were identified as contributing factors.
The facility failed to develop comprehensive care plans for three residents with specific needs, including PTSD, dementia, and smoking. Despite documented diagnoses and assessments, the care plans did not address these issues, and staff members acknowledged the oversights but could not explain why the care plans were not developed.
The facility failed to ensure the environment was free from potential accident hazards. One resident was found with an electrical power strip in her bed, despite the facility's policy prohibiting extension cords. Another resident had an unlabeled spray bottle of cleaning solution left in her room. Staff acknowledged the risks but did not report or address the issues promptly.
Failure to Maintain Clean PTAC Filters and Grills in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment by not ensuring that the Packaged Terminal Air Conditioner (PTAC) unit filters and grills were free of debris in specific resident rooms. Observations in two rooms (A9 and A8) revealed gray, fuzzy debris on the PTAC filters, and additional debris was found on the grill in one of these rooms. The facility's policy requires that PTAC filters be inspected and cleaned or replaced at least every three months, and the grill should also be cleaned during this process. However, the observed filters and grill had not been maintained according to this policy. Interviews with the Maintenance Director confirmed that he was solely responsible for the inspection, cleaning, and upkeep of all PTAC units in the facility. He acknowledged the presence of debris on the filters and grill in the affected rooms and stated that proper maintenance was essential for resident comfort, air quality, and infection control. The Administrator also confirmed that filters were to be cleaned monthly and at resident admission or discharge, and noted that unclean filters could compromise air quality, particularly for residents with respiratory issues.
Multiple Lapses in Infection Control Practices
Penalty
Summary
The facility failed to maintain appropriate infection control practices in several instances, as observed and documented by surveyors. During tracheostomy care for a resident with chronic respiratory failure and severe cognitive impairment, a respiratory therapist used non-sterile gloves instead of sterile gloves while performing suctioning, contrary to both facility policy and physician orders that required aseptic technique. The therapist acknowledged the error, and the Director of Nursing confirmed that this was an unacceptable practice. In another instance, a nurse placed a hand sanitizer bottle back into a plastic bag after wound care without sanitizing the outside of the bottle or the bag, then transported it to a wound care cart in the hallway. This action did not follow proper infection control procedures for handling shared medical supplies. Additionally, two residents' CPAP masks were found improperly stored: one inside a cluttered nightstand drawer with personal items and debris, and another on a dusty chair without protective covering, both in violation of manufacturer guidelines and facility policy for respiratory equipment storage. Further deficiencies included the storage of personal items, such as a staff cell phone, inside a clean linen cart, with staff interviews revealing a lack of awareness or training regarding linen cart contents. There was also an incident where an LPN entered a room under contact precautions for MRSA pneumonia wearing only gloves and no gown, despite signage and facility expectations requiring full PPE. Staff interviews confirmed gaps in training and policy awareness related to both linen cart use and adherence to isolation precautions.
Failure to Notify Physician of Critical Lab Results Leads to Resident Hospitalization
Penalty
Summary
The facility failed to notify the physician and responsible party for a change in condition for resident R660, who experienced harm due to critical urinalysis lab results not being reported. R660 was admitted with diagnoses including multiple sclerosis, muscle weakness, and lack of coordination. Despite R660 complaining of painful urination and suspected UTI, abnormal urinalysis results indicating a severe urinary tract infection were not communicated to the physician. Subsequently, R660 was hospitalized for 11 days with urosepsis and acute renal failure. The facility's policies required prompt notification of changes in a resident's medical condition to the attending physician and responsible party. However, there was no evidence that R660's physician was informed of the critical lab results or that orders were received for treatment. Interviews with staff revealed a lack of documentation and accountability regarding notifying the physician of abnormal lab results. The Director of Nursing acknowledged the failure to locate documentation related to physician notification and orders, attributing issues to a change in laboratory providers and ongoing process improvement efforts.
Delayed UTI Treatment Leads to Hospitalization
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident (R660) with a severe urinary tract infection (UTI). Despite abnormal urinalysis and culture results indicating a UTI, the facility did not seek medication for treatment. This led to R660 being admitted to the hospital for 11 days with a UTI and acute renal failure. The resident had multiple sclerosis, muscle weakness, and lack of coordination upon admission to the facility. Documentation revealed that R660 complained of painful urination on 12/9/2023, prompting a plan for urinalysis with culture and sensitivity if indicated. However, there was a delay in obtaining and acting upon the abnormal UA and C/S results, which showed significant bacterial presence. The facility did not inform the physician of the laboratory results or initiate treatment for the UTI promptly. R660's condition deteriorated with increasing body temperature, culminating in her transfer to the hospital due to a change in condition related to elevated temperature on 12/16/2023. Interviews with the Director of Nursing (DON) and Nurse Practitioner (NP) GG confirmed the lapses in communication and action regarding R660's abnormal UA & C/S results. NP GG expressed that if informed promptly, she would have provided orders for treatment to prevent any delay in addressing the UTI.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents with specific needs. Resident 108, who was admitted with diagnoses including anxiety disorder, schizoaffective disorder, and PTSD, did not have a care plan addressing PTSD despite displaying symptoms such as agitation, irritability, and hypervigilance. The mental health note documented the resident's traumatic experiences, but the care plan did not reflect these needs. The Assistant MDS Coordinator and Social Worker both acknowledged the absence of a PTSD care plan but could not explain why it was not developed. Resident 116, admitted with dementia and adjustment anxiety disorder, also lacked a comprehensive care plan for dementia. The resident's MDS assessment indicated moderate cognitive impairment and feelings of depression, yet these were not addressed in the care plan. The Assistant MDS Coordinator and Social Worker confirmed the oversight but could not provide a reason for the missing care plan. Resident 126, who had a smoking assessment and signed a smoking contract, did not have a care plan for smoking. The MDS Coordinator and Activities Director both confirmed that the activities department was responsible for developing smoking care plans but acknowledged that this was overlooked. The Director of Nursing expected a smoking care plan to be developed and noted that there was no specific staff member to ensure all necessary areas were addressed in the resident care plans.
Failure to Ensure Environment Free from Accident Hazards
Penalty
Summary
The facility failed to ensure the environment was free from potential accident hazards, specifically involving two residents. One resident, diagnosed with multiple sclerosis, hypertension, muscle weakness, pulmonary embolism, and chronic pain, was observed with an electrical power strip lying in her bed. Despite the facility's policy prohibiting extension cords, the power strip was used to power multiple devices. The resident and a CNA were aware of the potential fire risk, but the issue was not reported to a supervisor, and no work order was found in the electronic maintenance system. The Assistant Director of Nursing and the Director of Nursing confirmed that the power strip should not have been in the bed and should have been removed immediately. Another resident, diagnosed with Parkinson's disease, chronic systolic congestive heart failure, chronic obstructive pulmonary disease, dementia with behavioral disturbances, and generalized anxiety disorder, was found with an unlabeled spray bottle of cleaning solution in her room. The cleaning solution, identified as Rapid Multi-Surface Disinfectant Cleaner, was left unattended by a housekeeper who was rushing to clean the floor. The CNA and the Licensed Practical Nurse Unit Manager acknowledged that the cleaning solution should not have been left in the room. The Director of Environmental Services and the Administrator confirmed that cleaning chemicals should never be left in a resident's room unattended. The facility's failure to adhere to its policies regarding the use of electrical power strips and the proper storage of cleaning chemicals resulted in potential accident hazards. The staff's inaction in reporting and addressing these issues promptly contributed to the deficiencies observed. The facility did not have a specific policy related to electrical power strips or a comprehensive policy addressing accidents and hazards, relying instead on a newsletter to communicate the prohibition of extension cords.
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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