Perimeter Rehabilitation Suites By Harborview
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Georgia.
- Location
- 5470 Meridian Mark Road, Bldg E, Atlanta, Georgia 30342
- CMS Provider Number
- 115270
- Inspections on file
- 25
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 39 (4 serious)
Citation history
Health deficiencies cited at Perimeter Rehabilitation Suites By Harborview during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse and to correctly identify sexual abuse. One cognitively intact resident with dementia and occasional confusion was found in bed with another resident who had moderate cognitive impairment and impaired decision-making, where a CNA observed the cognitively impaired resident kissing the other on the lips and a roommate reported hearing kissing sounds and suggestive comments with laughter. Despite a policy defining sexual abuse as any non-consensual sexual contact and a legal guardian’s statement that the cognitively impaired resident could not consent, facility leadership concluded no sexual abuse occurred because the residents did not appear distressed and were viewed as capable of making their own decisions. In a separate incident, a cognitively intact resident with multiple serious medical conditions and bilateral leg amputation reported that an RCA refused to assist him back inside after a smoke break, used profanity, and threatened to pull him from his wheelchair and stomp on him; other residents corroborated the verbal altercation, and the RCA admitted refusing assistance and cursing at the resident.
The facility failed to follow its abuse and exploitation policies after a resident with dementia and a resident with delirium and a psychological disorder were found in bed together, with one kissing the other on the lips. Although facility policy required determining capacity to consent to sexual contact, documenting that assessment, and immediately protecting residents through separation and increased supervision, there was no evidence that a qualified professional evaluated capacity or consent. The residents were not immediately separated, required 30‑minute checks were not implemented at the time of the incident, and law enforcement was not notified until days later. The Administrator later stated that both residents were capable of making their own decisions and had consented, and the report notes that a misunderstanding of the definition of resident‑to‑resident sexual abuse led to the failure to initiate capacity and protective interventions.
The facility failed to follow its abuse reporting policy by not promptly reporting an alleged resident-to-resident sexual incident to the Administrator and the SSA. A CNA observed two residents in the same bed, with one resident kissing the other on the lips, and stated she reported this to a nurse, later identified by the facility as an LPN, though this was not clearly documented. The ADON learned of the incident two days later and then informed the Administrator, who subsequently reported it to the SSA. Interviews revealed conflicting accounts about which nurse received the initial report and confirmed that the incident was not reported within the required 2-hour timeframe for alleged abuse.
The facility failed to provide written notices of transfer, bed-hold practices, and appeal rights to responsible parties for two residents who were transferred to the hospital. Facility policies required written transfer/discharge notices with the reason for transfer, effective date, destination, explanation of appeal rights, and State appeal agency contact information, as well as written bed-hold information and retention of a signed copy in the medical record. For both residents—each severely cognitively impaired, dependent for all ADLs, and transferred for acute neurologic and respiratory concerns—documentation showed only that the responsible party was notified by phone, with no written notices in the EMR. The National Director of Risk Management reported that staff routinely called responsible parties but did not send written notifications and did not retain copies of bed-hold forms, and the Administrator stated he was unaware of the requirement to provide written transfer and bed-hold information upon hospital transfer.
Surveyors found that staff failed to follow hand hygiene and enhanced barrier precautions policies during incontinence care for two residents. For a resident on enhanced barrier precautions for wounds, a CNA began care without a gown, did not perform hand hygiene during glove changes, and left the room while gowned to obtain linens from a hallway cart and dispose of soiled items without bagging them. For another resident who was always incontinent of bowel and bladder, a CNA used the same pair of gloves throughout incontinence care, including handling a urine-soiled brief, applying barrier cream, and placing a clean brief, without changing gloves or performing hand hygiene between tasks.
A resident with severe cognitive impairment and a high risk for elopement was able to exit a secured unit due to malfunctioning alarms and delayed egress mechanisms on exit doors. Staff initially focused their search inside the building despite the wander guard alarm sounding, and it was later discovered that the exit discharge door alarm had not been working for some time and was not reported for repair. The resident was eventually found outside the facility, highlighting lapses in supervision and maintenance of safety devices.
A resident with multiple medical conditions was not properly informed of her rights, financial liability, or treatment consent upon admission. Admission paperwork was sent electronically with incorrect information, preventing proper signatures. The resident did not sign any forms, and required documents regarding rights and financial expectations were incomplete or unsigned. Staff interviews confirmed the lack of documentation and that the responsible admissions staff had resigned during the admission process.
A staff member exploited a resident with a history of trauma and mental health conditions by requesting money, as confirmed by text message evidence and the facility's investigation. The staff member's personnel file lacked required background and reference checks, and the incident was reported to authorities.
A floor technician was hired without a documented criminal background check or completed reference checks, as required by facility policy. This lapse was discovered after a resident reported that the technician requested money via text messages, leading to a substantiated finding of exploitation and the technician's termination.
The facility did not conduct thorough investigations into two separate incidents: one involving a resident with intact cognition who reported missing money from her lockbox, and another involving a cognitively impaired resident who suffered an unwitnessed fall resulting in a head laceration and cervical fracture. In both cases, required interviews and documentation were incomplete or inaccurate, and the facility's own investigative procedures were not followed.
A resident who was diagnosed and treated for a multidrug-resistant E. coli UTI in the hospital did not have the infection coded on their quarterly MDS assessment upon return to the facility. Staff interviews revealed a misunderstanding of coding requirements and a lack of auditing to ensure MDS accuracy.
A resident with a history of hip arthroplasty and related complications experienced increased pain and was found to have a dislocated hip on X-ray. The critical result was faxed to the facility but was not communicated to the physician or addressed by nursing staff until the following day, resulting in a delay in intervention and hospital transfer. Staff interviews confirmed the delay and lack of immediate action as required by facility policy.
A resident did not receive sufficient food and fluids to maintain their health, as required. The report identifies a lapse in meeting the nutritional and hydration needs necessary for the resident's well-being.
A resident was admitted without a physician's order and was not placed under a doctor's care at the time of admission, as required. The facility did not ensure proper medical authorization and oversight during the admission process.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as identified by surveyors.
A resident with severe cognitive impairment and multiple medical conditions sustained a significant periorbital injury of unknown origin, despite recent documentation of no injuries following a witnessed fall. Staff were unable to determine how the injury occurred, and inconsistencies existed between the fall event and the resulting injury. The lack of adequate supervision and monitoring contributed to the failure to prevent or promptly identify the cause of the injury.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal, and failed to establish or implement a grievance policy or promptly resolve complaints as required.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required by regulations.
The facility did not provide a registered nurse on duty for at least eight hours a day on most days, particularly on weekends, over several months. Staffing shortages led to reliance on ADONs, with only one being an RN, and MDS RNs who do not provide direct care. Residents reported long delays in call light response and instances where medications were left unattended, reflecting the impact of inadequate RN coverage on care quality.
The facility did not consistently post daily nurse staffing data in a prominent and accessible location, as required. Observations and staff interviews revealed that staffing information was often outdated, missing, or posted at heights inaccessible to residents, affecting the ability of residents, staff, and visitors to view current staffing levels.
The facility did not complete a thorough facility-wide assessment to determine necessary resources and staffing for competent resident care during daily operations and emergencies. The assessment contained incomplete information and blanks, and the Administrator confirmed it was considered complete despite these deficiencies, potentially affecting all residents.
The facility failed to maintain an effective infection prevention and control program, with incomplete infection surveillance documentation and unsanitary conditions in both clean and dirty laundry rooms. Issues included missing infection data, improper linen storage, visibly soiled surfaces, leaking equipment, and unaddressed maintenance problems, as confirmed by staff interviews.
Handrails on three resident floors were observed to be loose and crooked in several locations, including across from nurse stations and resident rooms. Staff interviews confirmed the issue was present facility-wide, and the Maintenance Director acknowledged that repairs were pending. Facility policy required ongoing inspections and staff reporting of such deficiencies, but the handrails remained unsecured during the survey period.
Staff did not immediately inform a resident, their physician, and a family member about events such as injury, decline, or room changes that affected the resident, resulting in a deficiency for lack of timely notification.
Surveyors observed that two shower rooms were left in unsanitary and unsafe conditions, with doors propped open, soiled linens, unmarked toiletry items, used gloves, masks, and other debris scattered on the floors, as well as unflushed toilets with visible waste. Staff interviews confirmed that the rooms should have been cleaned and secured between uses, but this was not done, resulting in a failure to provide a safe and clean environment for residents receiving showers.
Medication carts were repeatedly left unlocked and unattended by nursing staff, with medications and gastrostomy supplements exposed and accessible to unauthorized individuals. Staff interviews confirmed lapses in following the facility's policy requiring all drugs and biologicals to be stored in locked compartments, and multiple observations documented carts left unsecured in hallways and near nurse stations.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency related to meal quality standards.
A resident with moderately impaired cognition and multiple medical conditions experienced repeated delays in her responsible party receiving monthly cash advances from her account, despite facility policy requiring timely processing. The responsible party reported receiving funds one to two months late, and staff interviews confirmed that delays occurred due to workload, even though the resident was able to authorize the release of funds.
Surveyors found that two medication carts were left unattended with computer screens displaying residents' personal and medical information, including names, dates of birth, allergies, advance directives, and physician orders. In both cases, LPNs failed to lock the screens before stepping away, and the Interim DON confirmed that screens should be locked when not in use.
A resident with multiple medical conditions reported being struck by another resident and informed staff, but the incident was not reported to the Administrator or authorities as required by facility policy. The resident later stated that staff did not address the incident, and the current Administrator confirmed that the previous Administrator was not informed.
The facility did not ensure that each resident received an accurate assessment, as required. Inaccurate assessments were identified, which could affect care planning and service delivery.
A resident admitted with acute respiratory failure, second-degree burns, legal blindness, and a history of homelessness did not have a care plan addressing activities of daily living (ADL) or legal blindness. The care plan only included skin issues, discharge planning, and fall risk, despite facility policy requiring comprehensive care plans. The omission was confirmed through record review and staff interview.
The facility did not update care plans for three residents after significant changes in condition or incidents, such as falls and new medical orders. For example, a resident's care plan was not revised after a fall with injury, another was not updated to reflect new oxygen use and weight loss interventions, and a third did not include a fall resulting in a black eye. Staff interviews confirmed that care plan updates were not consistently made as required by facility policy.
A resident with significant mobility impairments and dependent on staff for ADLs did not receive timely assistance with changing soiled briefs. Despite activating the call light and requesting help, the LPN who responded did not provide care and failed to ensure that a CNA was notified. As a result, the resident remained in soiled briefs for an extended period, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions was not seen by the podiatrist for eight to nine months after their appointment was missed due to COVID-19 precautions on their floor. Facility staff acknowledged a system failure in ensuring the resident was rescheduled for podiatry care, and no policy for podiatry services was provided when requested.
A CNA did not complete the required twelve hours of annual in-service training, receiving only 10.7 hours during the review period. This was confirmed by the IDON, indicating noncompliance with the facility's policy for CNA training.
Failure to Protect Residents From Sexual and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual and verbal abuse, and to correctly identify and treat certain resident-to-resident contact as sexual abuse. One cognitively intact resident with dementia and occasional confusion was found in bed with another resident who had moderate cognitive impairment and impaired decision-making. A CNA witnessed the cognitively impaired resident in the other resident’s bed kissing her on the lips and reported the incident to nursing staff. The roommate of the kissed resident reported hearing smacking noises, hearing the cognitively impaired resident ask if the other resident wanted more, and hearing laughter. The facility’s investigation documented that attempts to interview both residents and law enforcement interviews were unsuccessful due to confusion, and the facility concluded that the interaction was not sexual abuse because the residents did not appear distressed and seemed to enjoy themselves. The facility’s abuse policy defined sexual abuse as non-consensual sexual contact of any type with a resident, but the Administrator and ADON stated they did not believe abuse occurred in this incident. The Administrator described sexual abuse as involving a resident who was upset, crying, and not wanting to be touched, and stated that both residents were capable of making their own decisions and that consent was determined by whether residents could make their needs known. The ADON acknowledged that one resident had fluctuating coherence and that the other resident had moderate cognitive impairment, yet still did not consider the incident to be abuse. The legal guardian for the cognitively impaired resident stated that this resident was not able to consent, was not capable of signing paperwork, and was not capable of making decisions, but this was not reflected in the facility’s determination that the event was not sexual abuse. The deficiency also includes an incident of staff-to-resident verbal abuse. A cognitively intact resident with multiple complex medical conditions, including end stage renal disease, Parkinsonism, liver cirrhosis, chronic pain, anxiety, seizures, and bilateral leg amputation, reported that during a smoke break he asked a Resident Care Assistant to roll his wheelchair back toward the door. The RCA refused, telling the resident that since he rolled himself out, he should roll himself back in, and called him an expletive. The resident and other residents reported that the RCA refused to assist and engaged in a verbal altercation, and the resident stated that the RCA threatened to pull him out of his wheelchair, stomp on him, and cussed at him. The RCA’s written statement confirmed that he refused to assist and used profanity toward the resident, and the facility substantiated the allegation of verbal abuse based on the resident’s account, witness statements, and the RCA’s admission.
Failure to Implement Abuse Policy for Resident-to-Resident Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policies related to capacity to consent to sexual activity and immediate protection measures following a resident-to-resident sexual interaction. The facility’s written policy required establishing a safe environment that supports consensual sexual relationships by identifying when, how, and by whom determinations of capacity to consent to sexual contact would be made, and where this documentation would be recorded. The policy also required written procedures to assist staff in identifying different types of abuse, including sexual abuse, and mandated immediate protective actions such as responding immediately to protect the alleged victim, examining the alleged victim for injury or psychosocial harm, increasing supervision, making room or staffing changes if necessary, and providing emotional support. Despite these requirements, there was no evidence in the records that capacity assessments were completed or that consent was evaluated by a qualified professional for the residents involved. The incident involved two residents out of a sample of 51. One resident was admitted with dementia without behavioral disturbances and had a quarterly MDS BIMS score of 15/15, indicating cognitively intact status. The other resident was admitted with delirium with a known psychological disorder and had a quarterly MDS BIMS score of 10/15, indicating moderate cognitive impairment. An incident report documented that one resident was found in the other resident’s bed and was observed kissing the other resident on the lips. The facility did not immediately separate the residents at the time of the incident, did not implement 30‑minute checks as required, and did not notify police until two days after the event. During a subsequent interview, the Administrator stated that both residents were capable of making their own decisions, believed that sexual abuse had not occurred, and stated that both residents had consented to the interaction. The report notes that the facility’s misunderstanding of the definition of resident‑to‑resident sexual abuse resulted in a failure to initiate capacity assessments and protective interventions as required by policy.
Failure to Timely Report Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse involving two residents to the Administrator and the State Survey Agency (SSA), as required by its abuse, neglect, and exploitation policy dated 07/15/2025. The policy required all alleged violations, regardless of residents' cognitive status, to be reported to the Administrator, the state agency, and all other required agencies within specified timeframes, specifically immediately but not later than two hours after the allegation is made if the events involve abuse. Resident 35 was admitted on 09/05/2024 and Resident 236 was admitted on 10/26/2023. On 01/11/2026, according to a facility incident report dated 01/13/2026, Resident 236 was found in Resident 35's bed and was observed kissing Resident 35 on the lips. A document titled Abuse-Resident to Resident, dated 01/20/2026, indicated that CNA 9 wrote a statement on 01/11/2026 stating she witnessed Resident 236 in Resident 35's bed and kissing Resident 35 when she directed Resident 236 to get out of the bed, and that she reported the incident to a nurse, later identified by the facility as LPN 1, although no nurse's name was documented in the investigation. The Administrator stated in an interview on 03/17/2026 that he was notified of the sexual incident on 01/13/2026 by the Assistant Director of Nursing (ADON 1), and that he reported the resident-to-resident incident to the SSA at that time. He also stated that CNA 9 reported the sexual encounter to LPN 1 and that the incident between the two residents was not considered sexual abuse, and that he reported it to the SSA out of an abundance of caution. In a separate interview on 03/18/2026, ADON 1 confirmed he learned about the sexual encounter two days after it occurred and that the staff involved were CNA 9 and LPN 1; he also confirmed he notified the Administrator two days after the incident and was unable to identify how he initially obtained the information. In another interview on 03/18/2026, LPN 1 stated she was not the nurse to whom CNA 9 reported the resident-to-resident incident. The record review and interviews showed a delay between the date of the incident and the date the Administrator and SSA were notified, and a lack of clear documentation and identification of the nurse who received the initial report, resulting in noncompliance with the facility’s abuse reporting policy and required reporting timeframes.
Failure to Provide Written Transfer, Bed-Hold, and Appeal Notices for Hospitalized Residents
Penalty
Summary
Surveyors identified that the facility failed to provide required written notices of transfer, bed-hold practices, and appeal rights to residents’ responsible parties for two residents who were transferred to the hospital. Facility policy on Transfer and Discharge required that, once admitted, residents and their representatives receive a written transfer/discharge notice in a language and manner they can understand, including the specific reason for transfer, effective date, transfer location, explanation of the right to appeal, and the name, address, and telephone number of the State entity that receives appeal requests, as well as information on how to obtain an appeal form. The facility’s Bed Hold Notice policy required that, at the time of transfer to the hospital, written information be provided to the resident and/or representative specifying the reserve bed payment policy and facility bed-hold policies, and that a signed and dated copy of this notice be kept in the resident’s record. Record review showed that one resident with severe cognitive impairment, dependent for all tasks and diagnosed with non-traumatic intracerebral hemorrhage, cerebral edema, pneumonia, osteoarthritis, right-sided hemiplegia/hemiparesis, aphasia, and seizures was transferred to the hospital after the daughter requested transfer due to worsening condition and breathing concerns; the progress note documented that the responsible party was notified, but there was no written transfer or bed-hold notice in the EMR. Another resident, also severely cognitively impaired and dependent for all tasks, with diagnoses including non-traumatic subacute subdural hemorrhage, seizures, cerebral infarction, atrial fibrillation, unspecified dementia, malnutrition, and type II diabetes, was transferred to the hospital after family reported cyanosis of the fingernail beds and the physician ordered oxygen and transfer for further diagnosis and treatment; again, the record only reflected that the responsible party was notified, with no written transfer or bed-hold documentation retained. In interviews, the National Director of Risk Management stated that staff always called the responsible party when a resident was discharged but did not send written notification, and that while a bed-hold notification form was sent with the resident to the hospital, a copy was not kept in the EMR. The Administrator reported he was not aware that the responsible party needed to receive written notice of transfer and bed-hold information upon any hospital transfer.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies, including hand hygiene, glove use, and enhanced barrier precautions (EBP), during incontinence care for two residents. Facility policies required perineal care to promote cleanliness, comfort, and infection prevention, and specified that hand hygiene must be performed before moving from a contaminated to a clean body site and after contact with bodily fluids. The EBP policy required gown and glove use for high-contact care activities such as changing linens, changing briefs, providing hygiene, and wound care, and the hand hygiene policy stated that glove use does not replace hand hygiene and that hand hygiene must be performed before donning and immediately after removing gloves. One resident, admitted with hemiplegia and hemiparesis following cerebral infarction and needing assistance with personal care, had a BIMS score indicating moderate cognitive impairment and was on EBP for potential infection related to wounds. An EBP sign on the resident’s door directed staff to wear gloves and a gown for high-contact care activities. During observed incontinence care, a CNA performed hand hygiene and donned gloves but did not initially wear a gown, only putting one on after being instructed by the Regional Risk Consultant. The CNA did not perform hand hygiene during glove changes and exited the room while still wearing the gown to obtain a clean sheet from a linen cart in the hallway, then disposed of soiled linens and a brief in hallway receptacles without bagging them. In interviews, the CNA acknowledged not sanitizing hands between glove changes and not wearing a gown at the beginning of care, while the ADON and DON stated that staff are expected to wear gowns and gloves for EBP residents, perform hand hygiene with each glove change, have supplies in the room, and not go in and out of rooms while gowned or handle hallway linen carts while wearing gowns. For another resident with diagnoses including cerebrovascular insufficiency, hemiplegia, vascular dementia, and major depressive disorder, and who was always incontinent of bowel and bladder per the MDS, a separate incontinence care observation showed additional failures in infection control. A CNA donned gloves before entering the room and then provided the entire episode of incontinence care using the same pair of gloves. The CNA wrapped a urine-soiled brief, applied barrier cream to the perineal area, and placed a new brief on the resident without changing the contaminated gloves or performing hand hygiene between tasks. In a subsequent interview, the CNA confirmed that gloves were not changed during the care episode and that handwashing and glove application occurred only before entering the room.
Failure to Maintain Secure Exit Doors and Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident identified as being at high risk for elopement. The resident had a history of severe cognitive impairment, vascular dementia, and other medical conditions, and was assessed as a high elopement risk with a care plan that included the use of a wander guard device and regular checks. Despite these interventions, the resident was able to exit the secured unit through a second-floor door, as the alarms and delayed egress mechanisms on the exit doors were not functioning properly. The wander guard alarm did sound, but the search for the resident was initially focused inside the building, delaying the discovery that the resident had left the premises. Observations and interviews revealed that the exit discharge door's alarm had not been working for an extended period, and this malfunction was not reported or addressed through the facility's maintenance system. Staff interviews indicated that the door alarm was frequently triggered by the resident, and staff would reset the alarm without ensuring the underlying issue was resolved. Additionally, a contractor had previously unlocked the exit discharge door and failed to relock it, further compromising the security of the unit. The lack of proper signage indicating the delay time on the doors and the absence of a functioning alarm on the exit discharge door contributed to the resident's ability to elope undetected. Documentation showed that the resident was found outside the facility in a parking garage after an internal search and a delayed external search. The facility's policy required immediate action and notification of authorities in the event of a missing resident, but the initial response focused on searching inside the building. The failure to maintain functioning safety devices and to promptly identify and address the malfunctioning alarm system directly led to the resident's elopement.
Removal Plan
- Management-level staff oversight of the facility.
- Monitoring the physical building for functioning egress doors.
- Assessing and monitoring residents with elopement risk.
Failure to Inform Resident of Rights and Obtain Signed Admission Documents
Penalty
Summary
The facility failed to ensure that a resident was informed of her rights regarding treatment, financial liability, and resident rights upon admission. Record review showed that the resident, who was cognitively intact but had unclear speech and some communication difficulties, was admitted with diagnoses including amyotrophic lateral sclerosis, hemiplegia, dysphagia, and slurred speech. The facility's policy required that residents be informed of their rights both orally and in writing, in a language they understand, prior to or upon admission. However, the resident's admission agreement, which included consent to treat, was signed electronically by a representative whose information was incorrect, and the resident herself did not sign any documents. The Resident Rights form was not signed, and the financial expectations and insurance forms were either incomplete or blank. Interviews with the resident's family member revealed that the admission paperwork was received electronically but could not be signed due to incorrect information, and the resident never signed any forms herself. The Director of Hospitality/Interim Admissions Staff could not confirm when the paperwork was sent, and the Administrator stated that the consent to treat should have been signed upon admission but was not present in the physical chart. The Vice President of Operations confirmed that the admission packet was not signed at admission and that there was no documentation showing the resident or representative was informed of rights, benefits, or costs. The admissions staff responsible had resigned at the time of admission, contributing to the lack of proper documentation.
Failure to Protect Resident from Exploitation by Staff Member
Penalty
Summary
A deficiency occurred when a staff member, identified as a floor technician, exploited a resident by requesting money from her. The resident, who had diagnoses including Parkinson's disease, bipolar disorder, anxiety, depression, and a history of physical and sexual abuse, reported the incident to facility staff and provided screenshots of text messages as evidence. The resident was cognitively intact at the time, as indicated by a BIMS score of 13 out of 15, and had a care plan that included approaches to support her emotional well-being and involvement in her care. The facility's policy prohibits exploitation, defined as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. The facility's investigation confirmed that the staff member had requested money from the resident, substantiating the allegation of exploitation. It was also found that the staff member's personnel file lacked evidence of a criminal background check or reference checks prior to employment. The incident was reported to the state agency, and the staff member was suspended pending investigation. No additional residents were found to be affected by this staff member.
Failure to Complete Background Checks Prior to Employment
Penalty
Summary
The facility failed to ensure that a floor technician (FT1) completed and documented a criminal background history, including checks for abuse, neglect, or exploitation, prior to employment. According to the facility's Abuse, Neglect and Exploitation policy, all potential employees are required to undergo background, reference, and credentials checks, with documentation maintained as proof. However, a review of FT1's personnel file revealed no evidence of a completed criminal background check or reference checks before employment. The file only indicated that two reference checks were attempted but not completed. This deficiency was identified following an investigation into a substantiated allegation of exploitation involving a resident (R6), who reported that FT1 sent text messages requesting money. The investigation included screenshots confirming the requests, and FT1 was subsequently terminated. During an interview, the Administrator, who also served as the Abuse Prevention Coordinator, confirmed the absence of a background check and incomplete reference checks for FT1.
Failure to Thoroughly Investigate Allegations of Misappropriation and Injury
Penalty
Summary
The facility failed to ensure that allegations of misappropriation of resident property and incidents resulting in injury were thoroughly investigated, as required by their own policies. In the case of one resident with intact cognition, the resident reported $173 missing from her lockbox, with the key found out of place after she returned from a shower. Although the incident was reported to the administrator and the police were notified, the facility's investigation was incomplete. Only one staff statement was documented, and there was no evidence of interviews with the resident's roommate or other potentially knowledgeable staff. The administrator admitted that not all interviews were documented and confirmed that the roommate was not interviewed, contrary to policy requirements for a thorough investigation. In another case, a resident with severe cognitive impairment experienced an unwitnessed fall in the dining room, resulting in a laceration to the back of the head and subsequent diagnosis of a cervical fracture after hospital transfer. Staff interviews revealed that the event was unwitnessed, and the resident was found on the floor with signs of seizure activity. However, the facility's incident report to the state agency inaccurately documented the event as a witnessed fall on a different date. The administrator acknowledged the discrepancy between the resident's record and the report submitted to the state agency and stated that a more thorough investigation would have been conducted if the event had been recognized as unwitnessed. In both cases, the facility did not follow its written procedures for investigations, which require identifying and interviewing all involved persons, focusing the investigation on determining the extent and cause of the incident, and providing complete documentation. The lack of thorough investigation and documentation had the potential to contribute to further misappropriation of property and inadequate response to incidents resulting in injury.
Failure to Accurately Code UTI on MDS Assessment
Penalty
Summary
The facility failed to accurately code a urinary tract infection (UTI) on the quarterly Minimum Data Set (MDS) assessment for one resident. The resident was admitted to the facility with a diagnosis of cerebral infarction and was later transferred to the hospital due to unresponsiveness. Hospital records indicated that the resident was diagnosed with a multidrug-resistant E. coli UTI and treated with antibiotics. Upon return to the facility, the quarterly MDS assessment did not reflect the UTI diagnosis, as the infection item was not marked. Interviews with facility staff revealed that the MDS Coordinator did not code the UTI, believing it should only be coded if the infection occurred while the resident was in the facility. The Resident Assessment Director and the Vice President of Clinical Reimbursement both confirmed that the UTI should have been coded according to the RAI Manual, as the diagnosis and treatment occurred within the required 30-day look-back period. The MDS Director acknowledged that there was no audit process in place to ensure the accuracy of MDS assessments, and regional audits had not yet focused on UTI coding errors.
Delay in Physician Notification and Intervention for Dislocated Hip Arthroplasty
Penalty
Summary
The facility failed to ensure timely notification and intervention for a resident who experienced a significant change in condition. The resident, who had a history of left hip arthroplasty, septic arthritis, and femur necrosis, was observed by therapy staff to have increased pain, an apparent shortening of the left leg, and inability to participate in therapy. An X-ray was ordered and performed, revealing a dislocated left hip arthroplasty. The facility's policy required that diagnostic test results, especially those requiring immediate attention, be communicated to the physician upon receipt and documented in the clinical record. Despite the X-ray result indicating a dislocation being faxed to the facility in the evening, there was no evidence that the result was reported to the physician or addressed by nursing staff until the following afternoon. Interviews with staff revealed that the night shift nurse did not retrieve or act on the faxed results, and the Assistant Director of Nursing only notified the physician the next day. The Director of Nursing confirmed the delay in physician notification and subsequent transfer of the resident to the hospital, and there was no documentation of an incident report or investigation into the delay.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific actions or omissions by staff that led to this deficiency are not detailed in the report, nor are there observations about the resident's medical history or condition at the time of the incident.
Failure to Obtain Physician Order and Oversight at Admission
Penalty
Summary
A deficiency was identified when a resident was admitted without obtaining a doctor's order for admission and without ensuring the resident was under a physician's care. The facility failed to secure the necessary medical authorization and oversight from a physician at the time of admission, as required by regulations. This lapse was observed and documented by surveyors during their review of the admission process.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Failure to Prevent and Identify Injury of Unknown Origin in Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents for a resident with severe cognitive impairment and multiple complex medical diagnoses, including traumatic brain injury, Parkinson's disease, and a history of falls. The resident was involved in a witnessed fall from her wheelchair to her knees during a smoke break, after which multiple progress notes documented no visible injuries or skin issues for several days. However, the resident was later found with significant swelling and ecchymosis around the right periorbital area, and increased confusion, which led to her being sent to the emergency room. Hospital records confirmed the presence of a black eye and intracranial hemorrhage, with the injury's origin remaining unknown. Staff interviews revealed that the cause of the resident's injury could not be determined, and there was inconsistency between the observed fall and the resulting injury, as the fall was not witnessed to involve the resident's head. The police investigation and staff statements further indicated uncertainty about how the injury occurred, with no staff able to provide an explanation. The lack of adequate supervision and monitoring, especially given the resident's history of wandering, agitation, and severe cognitive impairment, contributed to the failure to prevent or promptly identify the cause of the injury.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. The facility did not establish or implement a grievance policy and did not make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address resident complaints in a timely and non-retaliatory manner.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and the lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Provide Required RN Coverage and Resulting Care Delays
Penalty
Summary
The facility failed to provide a registered nurse (RN) on duty for at least eight hours a day during weekends, as required. Staffing record reviews for March, April, and May 2025 revealed that on the majority of days, there was no RN coverage for the required hours, with 27 out of 31 days in March, 25 out of 30 days in April, and 23 out of 29 days in May lacking the necessary RN presence. Interviews with staff, including the Scheduler Coordinator and Interim Director of Nurses (DON), confirmed ongoing nurse staffing shortages and reliance on assistant directors of nursing (ADONs), only one of whom is an RN, to attempt to fill coverage gaps. The facility's MDS staff, who are RNs, do not provide direct care and are not consistently included in the staffing numbers reported. Resident council minutes and interviews indicated that residents experienced significant delays in call light response, sometimes waiting up to three hours, and reported that care assistants would turn off call lights without resolving issues. Additionally, there were observations of nurses leaving medications on tray tables without ensuring residents took them. These findings were corroborated by both staff and resident council feedback, highlighting the direct impact of insufficient RN coverage on resident care and medication administration.
Failure to Post Daily Nurse Staffing Information in Accessible Locations
Penalty
Summary
The facility failed to post nurse staffing data daily at the beginning of each shift in a prominent and accessible location, as required. Observations revealed that on multiple occasions, the posted staffing data was outdated, with one instance showing data from two days prior still displayed by the front door. Interviews with the Interim Director of Nursing (IDON) confirmed that the correct staffing sheet was not posted daily, and the process for ensuring daily updates was not consistently followed. The absence of current staffing information was attributed to a receptionist leaving early due to an emergency, resulting in no updated sheets being left for the weekend staff to post. Further observations and interviews indicated that nurse staffing data was not posted in various areas throughout the facility, including the front desk, hallways, elevators, and multiple floors. The Resident Council President and other staff members confirmed the lack of posted staffing information in these locations. When staffing data was posted, it was sometimes placed above wheelchair height and not easily visible to residents. The Administrator acknowledged that the only posting was at the front door, at a height that may not be accessible to all residents.
Incomplete Facility Assessment for Resource and Staffing Needs
Penalty
Summary
The facility failed to complete a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Record reviews revealed that the facility assessment, dated 10/25/2024 and reviewed by the QAA Committee, contained incomplete sentences and blanks, particularly in sections addressing staffing patterns and goals. The assessment did not fully articulate how staffing levels and assignments were determined or maintained, and some statements were left unfinished, such as the goal for actual PPD (per patient day) staffing. The documentation also lacked specific details on how specialized rehabilitation and behavioral health services staffing were evaluated and ensured to be adequate. During a staff interview, the Administrator acknowledged that the facility assessment was considered complete despite the presence of incomplete information and missing data. This deficient practice was identified as having the potential to affect all 214 residents in the facility, as the assessment is a critical tool for ensuring that staffing and resources are sufficient to meet residents' needs at all times, including nights, weekends, and emergencies.
Infection Control and Laundry Sanitation Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by incomplete infection surveillance documentation and unsanitary conditions in the laundry areas. Review of the Monthly Infection Control Logs for April 2025 showed that critical information such as cultures, dates obtained, organism types, and antibiotic resistance status was missing for 35 of 37 infections. The Infection Control Preventionist acknowledged that the log was not fully completed and confirmed that all sections should have been accurately filled out. Observations of the Clean and Dirty Laundry Rooms revealed multiple sanitation and maintenance issues. Clean linens were improperly stored on top of a linen cart instead of inside it, and wet towels used to clean up a leaking washer were placed on a clean storage rack. The clean storage shelf was soiled and dusty, with employee gowns placed on top of clean towels. The floor was dirty, sticky, and littered with tissues and paper towels. The washer was leaking a white fluid and had visible rust and buildup, while the wall base was cracked and missing sections. In the Dirty Laundry Room, the sink was soiled with residue, a pipe above the sink was leaking water down the wall, and the wall had holes and broken sections. Staff interviews confirmed awareness of these issues and that they had been reported to supervisors, but the problems persisted.
Loose and Crooked Handrails on Multiple Floors
Penalty
Summary
Handrails on the second, third, and fourth floors were found to be loose and crooked throughout the facility, as observed during multiple walkthroughs. Specific locations included areas across from the nurse station and various resident rooms, where handrails were not firmly secured or properly affixed to the corridor walls. Staff interviews confirmed that the handrails were loose on all floors, and the Maintenance Director acknowledged the issue. The facility's policy, as outlined in the Director of Maintenance job description, required ongoing inspections to identify and address needed repairs, but the loose handrails persisted across multiple days of observation. Staff were expected to report such issues through the TELS maintenance tracking system, with maintenance responsible for repairs.
Failure to Promptly Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the failure to provide prompt notification to all required parties when significant events impacting the resident occurred, as required by regulation.
Failure to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in two of its three shower rooms, as evidenced by multiple observations of unsanitary and unsafe conditions. On several occasions, surveyors found shower room doors propped open with no staff or residents present. The rooms contained soiled linens, wet washcloths and towels, used and unmarked bars of soap, gloves, masks, and other debris scattered on the floors. Toilets were found unflushed with visible feces and urine, and there were strong odors of feces. Unsecured cabinets contained unmarked toiletry items and a medicine cup with an unidentified green fluid. Equipment such as shower chairs had visible brown substances, and personal protective equipment was improperly discarded throughout the rooms. Interviews with staff, including LPNs, a CNA, and the Regional Nurse Consultant, confirmed that the shower room doors should not be left open and that the rooms should be cleaned and secured between uses. Staff acknowledged the poor condition of the shower rooms and indicated that cleaning should occur after each resident's shower. The Interim Director of Nursing also confirmed that shower rooms should always be closed and locked, and that CNAs are responsible for cleaning between residents. These observations and staff interviews demonstrate a failure to provide a safe, clean, and homelike environment for residents receiving showers.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Multiple instances were observed where medication carts were left unlocked and unattended by nursing staff, contrary to the facility's policy requiring all drugs and biologicals to be stored in locked compartments and only accessible to authorized personnel. During medication administration, an LPN left the cart unlocked while entering a resident's room, admitting to forgetting to secure it. On another occasion, a medication cart was found unlocked and unattended on the third floor, with gastrostomy supplements left exposed on top of the cart. Staff interviews revealed a lack of awareness regarding the ownership of the cart and failure to follow proper storage procedures. Additional observations on the fourth floor and near the nurse station documented medication carts left unlocked and unattended for several minutes, with no nurses present and residents in proximity to the unsecured carts. Further interviews with staff indicated that some nurses left medication carts unlocked due to distractions or leaving the facility in a hurry, with one LPN admitting to forgetting to lock the cart multiple times. The Interim Director of Nursing confirmed that the facility's policy mandates medication carts be locked when unattended and that only authorized personnel should have access. The repeated failure to secure medication carts as required by policy was confirmed through direct observation and staff interviews, demonstrating noncompliance with established medication storage protocols.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the meals did not consistently meet standards for taste, appearance, or temperature at the time of service.
Delayed Access to Resident Funds for Responsible Party
Penalty
Summary
The facility failed to ensure that a resident's responsible party (RP) had immediate access to the resident's funds, as required by facility policy. According to the Resident Funds Management Policy and Procedure, if a resident requests a check from their account, the facility is to process the request within 24 hours. However, record review showed that the resident's Social Security Administration (SSA) direct deposits were made monthly, but the corresponding cash advances to the RP were often delayed by one to two months. The RP confirmed receiving the funds late, with the May funds only received in June, despite checks being scheduled for mailing on the 10th of each month. Interviews with the Business Office Manager (BOM) revealed that the process required resident confirmation before releasing funds to the RP, and delays were attributed to staff being busy. The BOM acknowledged that the resident had no cognitive issues preventing her from authorizing the release of funds and that this resident was the only one with a consistent arrangement for monthly cash advances to her RP. The resident confirmed that her RP had access to her funds, but the facility did not consistently provide timely access as outlined in their policy.
Failure to Safeguard Resident Medical Information on Unattended Medication Carts
Penalty
Summary
Surveyors identified that the facility failed to maintain the confidentiality of residents' personal and medical records as required by its policy. On two separate occasions, medication carts with computers displaying residents' sensitive medical information were left unattended in hallways. In the first instance, a medication cart on the fourth floor was observed unattended with the computer screen open, displaying a resident's name, date of birth, allergies, advance directives, and current physician orders. The responsible LPN stated they had stepped away after hearing someone coughing and did not lock the computer screen. In a second incident, another medication cart was found unattended beside the nurse station on the third floor, with the computer screen open and visible, displaying another resident's current physician orders. The LPN involved acknowledged forgetting to lock the computer screen before leaving the cart. The Interim Director of Nursing confirmed that all medication cart computer screens are expected to be locked when not in use by nursing staff.
Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident, as required by its policy on Abuse, Neglect, and Exploitation. The policy mandates reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes. In this case, a resident with diagnoses including type 2 diabetes mellitus, muscle weakness, difficulty walking, and depression, who was care planned for behaviors such as false accusations, reported to staff that another resident had hit him on the head. The incident was documented by an LPN, who noted that the resident was loud and verbally abusive, demanding that police be called, but no staff witnessed the alleged altercation and the accused resident denied the incident. Despite the resident's report and the facility's policy, staff did not inform the Administrator of the incident, and there is no evidence that the required authorities were notified. The resident later stated that he had to call the police himself because staff did not address the incident. The current Administrator confirmed that staff failed to inform the previous Administrator about the allegation, resulting in a lack of timely reporting and investigation as required by facility policy.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which could impact the care planning process and the delivery of appropriate services to residents. Specific details about the residents involved or the nature of the inaccuracies in the assessments are not provided in the report.
Failure to Develop Comprehensive Care Plan for Resident with Legal Blindness
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed all of a resident's needs, specifically omitting care plans for activities of daily living (ADL) and legal blindness. The resident in question was admitted with multiple diagnoses, including acute respiratory failure with hypoxia, second-degree burns, legal blindness, and a history of homelessness. Despite being assessed as alert and oriented with a BIMS score of 15 out of 15, the resident's care plan only included interventions for skin issues, discharge planning, and fall risk, with no mention of ADL support or accommodations for legal blindness. Review of the facility's policy indicated that care plans should describe services to help residents attain or maintain their highest practicable well-being. However, documentation in the electronic medical record and interviews with the MDS Coordinator confirmed that the required care plans for ADL and legal blindness were not developed or entered. The MDS Coordinator acknowledged the omission and stated that staff were responsible for completing care plans, but could not explain why the comprehensive care plan was incomplete.
Failure to Update Care Plans After Significant Changes and Incidents
Penalty
Summary
The facility failed to ensure that care plans were updated and revised in accordance with their own policies for three residents. For one resident with multiple diagnoses including rhabdomyolysis, orthostatic hypotension, and muscle weakness, the care plan was not updated after the resident experienced an unwitnessed fall that resulted in a head injury and required evaluation at the emergency department. The care plan, dated prior to the fall, did not reflect the incident or any new fall prevention interventions, and the electronic medical record did not document any updates related to fall prevention. Another resident with diagnoses such as congestive heart failure, COPD, hypertension, and diabetes was not care planned for new oxygen use or for weight loss interventions after a supplement was ordered. Additionally, a third resident with a history of traumatic brain injury, Parkinson's disease, and other complex conditions experienced a fall resulting in a black eye, but the incident was not included in the care plan. Staff interviews confirmed that care plan updates were the responsibility of clinical managers, nursing staff, DON, and MDS staff, but these updates were not consistently made following significant changes in condition or incidents.
Failure to Provide Timely ADL Assistance for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact but dependent on staff for activities of daily living (ADLs) such as toilet transfers and bed mobility, did not receive timely assistance with personal hygiene. The resident, admitted with multiple injuries and significant mobility impairments, reported that her briefs had not been changed since the previous night and requested assistance by activating her call light. An LPN responded to the call light, turned it off, and left the room without providing care, stating later that she notified a CNA to assist the resident. However, subsequent interviews revealed that the CNA was not informed of the resident's need, and the call light was not left on to indicate ongoing need for assistance. Further investigation showed that neither of the CNAs on duty were aware of the resident's request for help, resulting in the resident remaining in soiled briefs for an extended period. The resident later confirmed that she had a bowel movement and expressed distress about being left in that condition. The facility's policy required staff to provide necessary ADL care based on the resident's needs and assessments, but this was not followed, leading to a failure to maintain the resident's hygiene and comfort.
Failure to Provide Timely Podiatry Services
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical diagnoses, including severe cognitive impairment, was not provided with timely podiatry services. The resident's electronic medical record indicated that they were not seen by the podiatrist due to the presence of COVID-19 positive residents on their floor, and a note was made to reschedule the appointment. However, there was a significant delay, as the resident was not seen by the podiatrist for eight to nine months. Interviews with facility staff revealed that the expectation was for nursing to notify social services to ensure residents were placed on the podiatry list, and that the in-house podiatrist returned every 62 days to follow up with missed residents. Despite these procedures, the system failed, resulting in the resident missing necessary podiatry care for an extended period. The facility did not provide a policy for podiatry care when requested.
Failure to Meet Annual CNA Training Requirements
Penalty
Summary
The facility failed to ensure that each Certified Nursing Assistant (CNA) received the required minimum of twelve hours of annual in-service training, as specified in the facility's Nurse Aide Training Program policy. Record review showed that one CNA had only completed 10.7 hours of training between April 2024 and April 2025, falling short of the mandated requirement. This deficiency was confirmed during an interview with the Interim Director of Nursing, who acknowledged that the CNA did not meet the annual training hours.
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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