Pinewood Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Whigham, Georgia.
- Location
- 433 North Mcgriff Street, Whigham, Georgia 39897
- CMS Provider Number
- 115607
- Inspections on file
- 21
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 8 (7 serious)
Citation history
Health deficiencies cited at Pinewood Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents with complex medical histories and Foley catheters did not receive care in accordance with physician orders, and physicians were not promptly notified of significant condition changes. For one resident, an LPN inserted a Foley, irrigated it without an order when blood was noted, and later removed it without a physician order based on instructions from the former DON, despite ongoing bleeding and no urine output reported by a CNA. The resident subsequently experienced severe bleeding, altered mental status, and respiratory arrest, and later died with urethral injury among the listed causes. For the second resident, ordered UA/C&S testing was not documented as completed, there was no clear documentation of a hospital transfer noted on a lab requisition, and the Foley catheter reportedly remained in place for more than a month despite orders for routine changes. The resident was twice hospitalized with altered mental status and sepsis, ultimately dying from urosepsis and pneumonia.
Surveyors found that the facility did not follow its own comprehensive care plans for two residents. One resident on antiplatelet therapy had care plan directives for monitoring and documenting adverse reactions, but the record lacked any daily monitoring tool to track potential complications from the medication. Another resident with obstructive uropathy and an indwelling Foley catheter had a care plan requiring catheter changes as ordered, catheter care every shift, and monitoring for infection, yet the Treatment Administration Record showed multiple days and shifts with no documented catheter care, indicating that the planned interventions were not consistently carried out.
The facility failed to remove a malfunctioning Hoyer lift from service and continued to use it as the only mechanical lift to transfer multiple residents. During one transfer, a resident being moved from a wheelchair to a bed by two CNAs fell when the defective lift tilted over, later reporting pain though imaging showed no fractures. Records and staff interviews showed the maintenance director had identified the need for major replacement parts, including the motor, arm lift, and wheels, yet the lift remained in use while parts were ordered, with CNAs reporting they had to stand on the lift’s leg to prevent it from tipping.
Two residents experienced significant care issues due to failures in administrative oversight of physician orders, catheter management, and equipment safety. One resident with multiple comorbidities had a Foley catheter inserted and then irrigated by an LPN without a physician order, and later had the catheter removed on instruction from the former DON without a documented order, after staff noted bleeding and no urine output; the resident then developed bleeding and altered mental status and was sent to the hospital. Another resident with HIV, uropathy, and other conditions had physician orders for urine specimens and UA/C&S that were not carried out as written, with missing documentation of ordered urine collections and inconsistent records regarding a hospital discharge, and was later hospitalized with altered mental status, concern for sepsis, and subsequently septic shock and a complicated UTI. In addition, staff used a malfunctioning Hoyer lift that was not removed from service, resulting in a resident fall during transfer, while facility QAA data showed multiple falls over two months without evidence of other falls linked to the lift.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not support residents' highest practicable physical, mental, and psychosocial well-being.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as identified by surveyors.
Staff did not document the presence of maggots found between a resident's toes, despite multiple nurses and a wound care NP being aware of the issue. The omission occurred even though facility policy requires factual and objective documentation, and the resident had significant comorbidities and ongoing wound care needs.
The facility failed to properly date, label, and store food, with some items showing spoilage and expired use-by dates. Scoops were improperly stored in food containers, and the kitchen's oven, can opener, and exhaust hood vents were unclean. These issues posed potential health risks to all 57 residents consuming food from the facility's kitchen.
The facility failed to implement appropriate interventions for two residents with pressure ulcers, leading to potential delays in healing. One resident with diabetes and a below-the-knee amputation had a heel wound that was not properly managed, lacking documentation of elevation or pressure-relieving devices. Another resident with a stage four pressure ulcer was not adequately repositioned or encouraged to limit wheelchair time, with staff unaware of necessary interventions. These deficiencies were due to poor communication, documentation, and staff training.
A facility failed to document a resident's DNR status as specified in the POLST form, leading to a discrepancy in the resident's medical records. The resident, with cognitive impairments, was listed as Full Code in the records despite choosing DNR. The Social Services Director did not communicate the DNR preference to the nursing staff, and the care plan team failed to update the care plan. Interviews revealed that the resident's code status was not discussed during care plan meetings, and the family was unaware of the DNR preference.
The facility failed to provide written notification of transfer to two residents or their representatives, omitting appeal rights information. For one resident with mental health issues, the DON claimed the notice was in the discharge packet, but the resident did not receive it. Another resident with severe impairments was transferred without a written notice, and the DON admitted the form lacked appeal rights. The Social Service Director confirmed that necessary transfer details were not provided.
A facility failed to implement a comprehensive care plan for a resident with impaired cognition, who required assistance with meals. Despite the care plan's directive, the resident was observed eating without staff assistance, leading to food spillage and potential nutritional complications. The administrator and Regional Director confirmed the care plan's requirements were not met.
A resident with a stage four pressure ulcer did not have their care plan updated to include physician-recommended interventions such as repositioning and limiting wheelchair time. The MDS Coordinator was unaware of the 60-minute wheelchair limit, and the Kardex did not reflect these critical instructions, placing the resident at risk for unmet care needs.
A resident with cognitive impairments and an eating disorder was not provided with necessary assistance during a meal, leading to significant food spillage and potential nutritional complications. Despite facility policy requiring staff assistance, the resident was left to eat alone, using her fingers and spitting out food. Interviews confirmed the resident needed help, which was not provided during the observed meal.
A resident with type 2 diabetes and dementia experienced multiple instances of abnormal blood sugar levels, which were not reported to the physician as required by facility policy. Despite having orders to notify the physician for blood sugar levels below 60 mg/dL or above 500 mg/dL, there was no documentation of such notifications or interventions. Interviews revealed that the necessary actions were not documented, and the Medical Director was not informed of the abnormalities.
A facility failed to accurately document insulin administration for a resident with diabetes, as the EMR system's check marks incorrectly indicated insulin was given when blood sugar levels were below the threshold. Interviews revealed staff confusion about the EMR coding, leading to documentation errors. The DON admitted to mistakenly using the wrong codes, and the Medical Director emphasized the need for accurate documentation according to orders.
The facility failed to include necessary information in its binding arbitration agreements for two residents, omitting that signing was not required for care and that residents could communicate with officials and the ombudsman. The Social Services Director was aware of the agreement's contents but had not received education on regulatory requirements.
The facility's arbitration agreement failed to ensure a neutral arbitrator and venue, affecting two residents. One resident, moderately cognitively impaired, signed the agreement without understanding the arbitration process. The Social Service Director, responsible for obtaining signatures, was aware of the agreement's stipulations but lacked education on regulatory requirements. This placed residents at risk of an unfair advantage in arbitration selections.
The facility failed to offer pneumococcal vaccinations to two residents as required by their policy and CDC guidelines. The Infection Preventionist did not assess the residents' vaccine status or check the state's database for vaccination history, and was unaware of the CDC's recommendations. This oversight was confirmed by the Director of Nursing, placing the residents at risk of pneumococcal infections.
A resident with severe cognitive impairment was not protected from sexual abuse by another cognitively intact resident. The incident occurred in the dining area and was observed by an LPN who reported it to the DON and Administrator. Despite existing policies on abuse prevention, the facility failed to prevent this incident.
The facility failed to report allegations of abuse and neglect in a timely manner, including an incident of inappropriate sexual behavior between two residents, a verbal abuse allegation by a resident against an RN, and unexplained bruising on a resident. Reports to the State Survey Agency were delayed or contained inaccuracies, indicating a lapse in regulatory compliance.
A facility failed to promptly investigate and protect two residents after an alleged incident of sexual abuse. Despite immediate notification to the DON and Administrator, necessary assessments and intense monitoring were delayed. The residents, one with severe cognitive impairment and the other cognitively intact, continued to reside near each other without adequate protective measures. The Administrator did not interview the witness or obtain a statement until the following day, contributing to the facility's noncompliance and risk of harm.
The facility administration failed to implement its abuse prevention system effectively, resulting in deficiencies in handling abuse allegations for several residents. The administration did not maintain an environment free from sexual abuse, failed to report abuse allegations to the state survey agency and law enforcement in a timely manner, and did not thoroughly investigate or implement corrective actions for a sexual abuse allegation. Interviews revealed inadequate training and unclear protocols for handling such situations.
The facility failed to follow wound care treatment plans for two residents, leading to incorrect treatments for pressure ulcers. One resident's heels were treated with the wrong dressing, and another resident's Stage 4 ulcer was treated with Xeroform gauze instead of the prescribed Leptospermum honey. The DON confirmed the errors after reviewing the treatment plans.
The facility did not complete annual performance reviews for 10 of 27 CNAs, hindering in-service education. The Regional Director of Operations could not find additional evaluations, and the MDS Coordinator stated the DON was responsible for these reviews, while the part-time Staff Development Coordinator scheduled them.
A resident with a history of serious medical conditions and on anticoagulation therapy developed extensive bruising, which was observed by facility staff. Despite the severity of the bruising, the physician was not notified immediately, as required by facility protocol. The DON was informed the following day, and the physician was contacted two days later, leading to the resident being sent to the emergency room for further evaluation and treatment.
A facility failed to maintain accurate clinical records by allowing an LPN to falsify a physician's signature on telephone order forms for a resident with schizophrenia and bipolar disorder. The resident's Klonopin dosage was increased based on a recommendation, but the physician's signature section contained unauthorized signatures. The Medical Director confirmed the discrepancies, raising concerns about documentation integrity.
The facility failed to implement enhanced barrier precautions (EBP) for two residents with pressure ulcers. During wound care, nurses did not wear gowns, and PPE was not available outside the residents' rooms. The Infection Prevention Nurse acknowledged the oversight, citing being pulled in many directions as a reason for not setting up EBPs.
Failure to Follow Foley Catheter Orders and Notify Physician of Changes Resulting in Harm to Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services in accordance with physician orders and to notify the physician promptly of significant changes in condition for two residents with Foley catheters. Facility policies required protection from abuse, neglect, and exploitation, prompt notification of changes to physicians and resident representatives, and obtaining a physician or nurse practitioner order prior to Foley catheter irrigation. Despite these policies, staff actions and omissions related to Foley catheter insertion, irrigation, removal, and follow-up care did not comply with physician orders or notification requirements. For the first resident, who had diagnoses including hypertension, GERD, type 2 diabetes mellitus, an orthopedic implant in the left leg, and morbid obesity, the physician had ordered aspirin and Foley catheter care every shift due to wounds. On the day of the incident, an LPN inserted a Foley catheter at the end of the day shift and noted urine return with a small trace of blood. The resident became panicked upon seeing blood in the Foley tubing, and the LPN irrigated the Foley catheter with sterile water without obtaining a physician order, stating that Foley irrigation was basic nursing. Later, during the evening shift, a CNA observed that there was no urine output and blood in the Foley drainage bag and reported this to the assigned LPN. The LPN did not notify the physician about the blood in the Foley drainage bag. Instead of obtaining a physician order, the LPN removed the Foley catheter based on instructions relayed from the former DON, despite having no physician order to discontinue the catheter. After removal, the resident began bleeding from the penis and rectum and developed altered mental status and loss of consciousness. EMS was called and documented that the resident had been bleeding from Foley catheter removal and was experiencing shortness of breath, later becoming unresponsive and going into respiratory arrest. Hospital records indicated that the resident had a Foley catheter placed earlier that day with a large amount of blood expressed and that the onset of shortness of breath coincided with the Foley procedure. The resident was transferred to a second hospital in critical condition, where a urologist placed a Foley catheter with cystoscopy, and bleeding continued from multiple sites. The death certificate listed acute cardiac and respiratory failure, disseminated intravascular coagulation, and urethral injury as the immediate cause of death. For the second resident, who had diagnoses including HIV, morbid obesity, obstructive and reflux uropathy, anemia, chronic pain, hypertensive heart disease, cerebral infarction affecting the left dominant side, uropathy, and an indwelling Foley catheter, the physician ordered a urine sample for urinalysis and culture and removal of the Foley catheter. After admission, the Foley catheter was discontinued, but due to urinary retention concerns it was reinserted, and an order was obtained for UA/C&S and a urology consult because the urine was cloudy with a foul odor. The resident also had orders for a routine monthly catheter change with an 18 Fr 10 cc balloon and to irrigate the catheter with 60 cc normal saline or sterile water as needed for leakage or blockage every eight hours as needed for urinary retention. A laboratory requisition for urinalysis with microscopic sample was dated, but there was no evidence that the urine sample was collected as ordered. Further review of the second resident’s records showed a handwritten lab requisition noting that the resident was discharged to the hospital on a certain date, but there was no documentation in the medical record that the resident was sent to the hospital, and the census did not reflect a leave of absence. There was no indication that the ordered urine specimen was obtained, although a urology appointment was scheduled and later rescheduled. Hospital records documented that the resident was admitted from the nursing home with altered mental status and concern for sepsis, with a chronic indwelling Foley catheter and a history of complicated UTIs. The urinalysis showed extremely turbid urine with high leukocyte esterase and elevated WBCs. The resident was discharged back to the facility with a Foley catheter changed in the emergency department and no antibiotics ordered. Later, facility progress notes documented altered mental status and transfer to the hospital via EMS, where hospital records indicated hypotension and septic shock likely from a UTI or infected decubitus ulcer/osteomyelitis, and that the Foley catheter had reportedly been in place for more than a month. The death certificate listed urosepsis and pneumonia as the immediate cause of death. Staff interviews confirmed the deviations from policy and physician orders. The LPN who inserted the Foley for the first resident acknowledged irrigating the catheter without an order. The CNA on the evening shift reported observing no urine output and significant bleeding from the resident’s penis and rectum and expressed concern that the assigned LPN was not doing enough, prompting her to ask another LPN to call the former DON. The assigned LPN for the first resident confirmed that she removed the Foley catheter without a physician order, following the former DON’s instructions, and that she only texted the physician after deciding to send the resident to the hospital. Another LPN reported that the former DON, overhearing the situation by phone, first instructed that the Foley be flushed and then instructed that it be removed, with the plan to obtain a discontinuation order afterward. For the second resident, an RN stated that she had not changed the Foley catheter on the date the resident was sent to the hospital, and that she noted low oxygen saturation, reported it to the charge nurse, and called the physician, who ordered transfer to the ER.
Failure to Implement Care Plan Interventions for Antiplatelet Therapy and Foley Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to implement comprehensive care plan interventions for two residents as required by its policy on person-centered care planning. For one resident with diagnoses including hypertension, GERD, type 2 diabetes mellitus, an orthopedic implant with joint prosthesis or bone plate in the left leg, and morbid obesity, the care plan identified that the resident was receiving antiplatelet medication therapy. The care plan interventions included administering the antiplatelet medication as ordered, monitoring the skin for bruising and notifying the physician of new bruising or discoloration, and monitoring and documenting adverse reactions such as blood-tinged or bloody urine, black tarry stools, sudden severe headaches, nausea, vomiting, lethargy, or sudden changes in mental status. The medical record showed an order for Ecotrin (aspirin) 325 mg by mouth twice daily related to a tibia or fibula fracture following insertion of an orthopedic implant, but there was no evidence of a daily monitoring tool in place to track adverse risks associated with the antiplatelet therapy. The deficiency also includes failure to implement care plan interventions for another resident with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, morbid obesity, obstructive and reflux uropathy, and hypertension. This resident’s care plan documented the presence of an indwelling Foley catheter related to obstructive uropathy and wounds to the buttocks, with interventions directing staff to change the Foley catheter as ordered and as needed, provide Foley catheter care per facility protocol by cleaning every shift and as needed, and observe for and report signs and symptoms of infection such as elevated temperature, cloudy urine, foul-smelling urine, lower abdominal pain, or changes in cognition. Review of the Treatment Administration Record for a specified month showed multiple days and shifts where there was no documented evidence that daily catheter care was provided as care planned, indicating that the ordered catheter care interventions were not consistently implemented.
Use of Defective Hoyer Lift for Resident Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its only Hoyer lift, used to transfer 13 residents, was functional and free of defective parts, and to remove it from service when it malfunctioned. Facility policy required staff to use the Risk Management portal to report and investigate incidents and accidents, including equipment malfunctions. On one occasion, a resident was being transferred from a wheelchair to a bed by two CNAs using a defective Hoyer lift when the lift tilted over, causing the resident to fall to the floor. The resident reported pain the following day, but an x-ray showed no fracture, dislocation, or bony destructive lesions. Staff interviews confirmed knowledge of the fall and that the Hoyer lift was defective. Record review showed that the maintenance director assessed the malfunctioning Hoyer lift on multiple dates and determined that it needed parts, including a motor, arm lift, and wheels, which were ordered from an online vendor. Despite this, the facility continued to use the defective lift while awaiting parts, and CNAs reported having to stand on the leg of the lift to keep it from tilting over. Staff also reported that there was only one Hoyer lift available in the building, and the maintenance director confirmed that the lift remained in use until it was refurbished. A new 600-pound capacity lift was ordered later, and a new Hoyer lift was eventually received, but during the period in question the defective lift continued to be used for resident transfers. The current administrator stated he was recently hired and was not aware of the malfunctioning lift.
Failure of Administrative Oversight for Physician Orders, Catheter Care, and Equipment Safety
Penalty
Summary
The deficiency involves a failure of administrative oversight by the former Administrator and Director of Nursing to ensure physician orders were obtained and implemented as written, and to adequately supervise the quality of care. The Administrator’s job description required leading and directing operations in accordance with regulations and facility policies to provide appropriate care, and the Director of Nursing’s job description required directing nursing services in line with standards and physician direction. Despite these responsibilities, the facility did not ensure that nursing staff followed proper procedures for obtaining and carrying out physician orders, nor did it ensure that equipment used for resident care was safe and removed from service when malfunctioning. For one resident with diagnoses including hypertension, GERD, type 2 diabetes mellitus, an orthopedic implant, and morbid obesity, an LPN inserted a Foley catheter and, after noting bleeding in the tubing, irrigated the catheter with sterile water without a physician order. Later that day, a CNA reported to another LPN that the resident had no urine output and blood in the Foley drainage bag. The LPN did not notify the physician of these findings and removed the Foley catheter based on instruction from the former DON, without any physician order or documentation of such an order. After removal, the resident began bleeding from the penis and rectum, experienced altered mental status and loss of consciousness, and was subsequently sent to a hospital. For another resident with diagnoses including HIV, morbid obesity, obstructive and reflux uropathy, anemia, chronic pain, hypertensive heart disease, cerebral infarction affecting the left dominant side, and an indwelling Foley catheter, physician orders to obtain urine samples for urinalysis and culture were not carried out as written. The Foley catheter was removed per order, but the ordered urine sample was not collected. A subsequent order to reinsert a Foley catheter due to retention concerns, obtain a UA/C&S, and arrange a urology consult for cloudy, foul-smelling urine was also not fully implemented, as there was no evidence the urine specimen was obtained. Documentation was inconsistent regarding a noted discharge to the hospital, with no supporting record or census entry. Later, this resident was admitted to a hospital with altered mental status and concern for sepsis, had a Foley catheter replaced in the ER, and was again sent to the hospital with labored breathing and admitted with septic shock and a complicated UTI. Additionally, the facility allowed continued staff use of a malfunctioning Hoyer lift, which resulted in another incident where a resident fell when the lift tilted during transfer, followed by complaints of pain and negative x-rays the next day. The facility’s Quality Assessment and Assurance process documented multiple falls in consecutive months, but there was no evidence that other residents fell due to the malfunctioning Hoyer lift. The current Administrator, hired later, stated an expectation that all residents receive excellent care and reported being unaware of these incidents. The former Administrator and former DON were unavailable for interviews, leaving the documented record and staff accounts as the primary evidence of the failures in obtaining and implementing physician orders, monitoring resident condition changes, and removing malfunctioning equipment from use.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest practicable physical, mental, and psychosocial well-being of residents as required.
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 documented 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 Document Presence of Maggots in Resident's Medical Record
Penalty
Summary
Staff failed to ensure complete and accurate documentation in the medical record for a resident with multiple diagnoses, including type 2 diabetes mellitus, unspecified dementia, peripheral vascular disease, and severe morbid obesity. The resident was receiving ongoing wound care for a left medial leg wound, with changes in treatment orders documented over time. On one occasion, staff observed maggots between the resident's left great toe and second toe, but this finding was not documented in the medical record. Interviews revealed that a registered nurse saw approximately 10 maggots between the toes for two to three days but did not document this because she was instructed not to write 'maggots' in her documentation. The wound care nurse practitioner also confirmed the presence of maggots but did not document it, stating her focus was on wounds, not the area between the toes. Other staff members, including another RN and an LPN, were aware of the maggots either through direct observation or conversation but did not document the finding. The facility's policy on documentation requires that records be factual, objective, and resident-centered, but this was not followed in this instance. The lack of documentation regarding the presence of maggots between the resident's toes represents a failure to maintain complete and accurate medical records in accordance with accepted professional standards.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its food storage and sanitation policies, leading to potential health risks for all 57 residents consuming food from the kitchen. Observations revealed that food items in the walk-in refrigerator were not properly dated, labeled, or covered, with some items showing expired use-by dates or signs of spoilage. Additionally, scoops were improperly stored inside containers of sugar, flour, and cornmeal, violating the facility's policy. The Dietary Manager confirmed these issues, acknowledging that bread products should be dated when thawed and discarded if not used within 14 days. Further inspection of the kitchen revealed significant cleanliness issues, including a heavily soiled oven, a manual can opener with dried and sticky substances, and greasy, dusty metal exhaust hood vents. The Dietary Manager admitted uncertainty about the last cleaning of the exhaust hood vents, which had not been cleaned since her employment began. These lapses in sanitation and food handling practices created an environment conducive to food-borne illnesses, potentially affecting all residents reliant on the facility's kitchen for meals.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement appropriate interventions for the healing of pressure ulcers for two residents, leading to potential delays in their healing process. For one resident, who had a history of diabetes and a below-the-knee amputation, a red area was noticed on the right heel, which was not initially identified as a pressure ulcer by the Director of Nursing (DON) due to the resident's diabetic condition. Despite the presence of a wound, there was no documentation of efforts to encourage the resident to elevate the foot or use pressure-relieving devices while in a wheelchair. Observations revealed that the resident's foot was improperly positioned, causing pressure on the heel, and there was a lack of necessary equipment like extra pillows or heel protector boots in the resident's room. Another resident, who was cognitively intact but had mobility impairments and a stage four pressure ulcer, was not adequately repositioned or encouraged to limit time in a wheelchair as recommended by the wound physician. The care plan did not address repositioning or limiting wheelchair time, and staff interviews revealed a lack of awareness of these interventions. The resident was observed to be non-compliant with repositioning and wound care, and there was no consistent documentation of efforts to encourage compliance or adherence to the physician's recommendations. The facility's failure to adhere to its own policies and the recommendations of medical professionals contributed to the inadequate care of these residents. The lack of communication and documentation regarding necessary interventions, as well as the absence of proper equipment and staff awareness, were significant factors in the deficiency. These oversights potentially delayed the healing of the residents' pressure ulcers and highlighted a need for improved care planning and staff training.
Failure to Document Resident's DNR Status
Penalty
Summary
The facility failed to ensure that a resident's Do Not Resuscitate (DNR) code status, as specified in the resident's Physician Orders For Life-Sustaining Treatment (POLST), was accurately documented in the resident's medical record. The resident, who was admitted with diagnoses including dementia, schizophrenia, major depression, and bipolar disorder, had a POLST form indicating a preference for Allow Natural Death (AND) - Do Not Attempt Resuscitation. However, the resident's medical records, including the admission record, electronic medical record (EMR) dashboard, and care plan, incorrectly listed the resident as Full Code, which would have led to resuscitation efforts in the event of a health emergency. The discrepancy arose because the Social Services Director (SSD) failed to communicate the resident's DNR preference to the nursing staff, resulting in the resident's code status not being updated from Full Code to DNR. The Director of Nursing (DON) confirmed the inconsistency between the POLST form and the resident's medical records. The SSD acknowledged the failure to communicate the change in code status and confirmed that the care plan team did not update the resident's care plan to reflect the DNR status during quarterly care plan meetings. Interviews with staff and the resident's family member revealed that the resident's code status was not discussed during care plan meetings, and the family member was unaware of the resident's DNR preference. The resident, who had moderate cognitive impairment at the time of admission, expressed uncertainty about her resuscitation preferences during an interview. The MDS Coordinator admitted that the care plan inaccurately reflected the resident's code status as Full Code, acknowledging that the error had persisted since the resident's admission.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of a facility-initiated transfer to the resident or their responsible party for two residents reviewed for hospitalization. This deficiency was identified during a review of the facility's policy on transfer or discharge, which mandates that residents and their representatives be notified in writing about their rights to appeal the transfer or discharge. The policy also requires the inclusion of contact information for the entity that handles appeal requests and the Office of the State Long-term Care Ombudsman. For Resident R7, who was cognitively intact with diagnoses of anxiety, depression, and schizophrenia, the facility did not provide a written notice of transfer when she was sent to a behavioral health center. Although the Director of Nursing (DON) stated that the notice was included in the discharge packet given to the hospital, there was no confirmation that the resident or her representative received it. The resident confirmed that she did not receive any paperwork regarding her transfer. Similarly, for Resident R41, who was severely impaired with diagnoses of cancer, Down syndrome, and anxiety, the facility did not provide a written notice of transfer when the resident was sent to the hospital for evaluation. The DON acknowledged that the transfer form in the electronic medical record did not include appeal rights and that the notice was given to the hospital staff without confirmation of receipt by the resident's representative. The Social Service Director also confirmed that a written transfer form with necessary details was not provided to residents or their representatives during hospital transfers.
Failure to Implement Comprehensive Care Plan for Resident's Nutritional Needs
Penalty
Summary
The facility failed to implement the comprehensive plan of care for a resident identified as R29, who was at risk for weight loss and nutritional complications. R29 was admitted with diagnoses including psychosis, Alzheimer's disease, an eating disorder, and anxiety disorder. The resident's care plan, dated 11/30/24, indicated that R29 required assistance with activities of daily living due to impaired cognition and specified that staff should set up the meal tray and assist the resident as needed. However, during an observation on 02/16/25, R29 was seen eating lunch without any staff assistance, despite the care plan's directive. During the observation, R29 was noted to use her fingers to eat, placing food in her mouth, chewing it, and then spitting it out onto her plate, the table, or the floor. No staff member offered assistance to R29 during the meal, even though a staff member was present in the dining room assisting another resident. The administrator confirmed the food spillage and acknowledged that R29 preferred eating with her fingers. The Regional Director later confirmed that R29's care plan required staff assistance during meals, which was not provided, leading to the deficiency.
Failure to Update Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as R48, who was at risk for worsening of a pressure ulcer. The resident's care plan did not reflect the physician's order to reposition and limit the resident's time in her wheelchair. R48's annual Minimum Data Set (MDS) indicated that the resident was cognitively intact, had impairments in both lower extremities, required assistance for mobility, and had a stage four pressure ulcer. Despite these conditions, the care plan did not include necessary interventions such as repositioning or limiting wheelchair time, which were recommended by the wound physician. The MDS Coordinator, responsible for updating the care plan, was unaware of the physician's recommendation to limit the resident's wheelchair time to 60 minutes. The Kardex, which organizes resident care information, also failed to include these critical instructions. This oversight was discovered during an interview with the MDS Coordinator, who stated that the Kardex was automatically generated and did not know why it lacked the necessary updates. This deficiency placed the resident at risk for unmet care needs and potential worsening of the pressure ulcer.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to provide necessary eating assistance to a resident, identified as R29, who was reviewed for nutrition. R29, who has diagnoses including psychosis, Alzheimer's Disease, and an eating disorder, was observed during a lunch meal without staff assistance. Despite having severely impaired cognitive skills and requiring setup or cleanup assistance with eating, R29 was left to eat alone. Observations showed R29 using her fingers to eat, chewing food, and then spitting it out onto her plate, table, or the floor. No staff member offered assistance during this time, leading to a significant amount of food spillage. The facility's policy requires staff to assist residents who need help with meals, but this was not followed for R29 during the observed meal. Interviews with the Administrator and the Director of Nursing confirmed that R29 needed assistance and redirection during meals, which she did not receive on the observed date. This lack of assistance had the potential to cause weight loss and nutritional complications for R29, as she was unable to effectively consume her meal without help.
Failure to Report Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to report abnormal blood sugar levels to the physician for a resident, identified as R32, who was reviewed for laboratory services. R32 had a history of type 2 diabetes mellitus with complications and dementia, and was receiving insulin. The facility's policy required prompt reporting of abnormal blood sugar levels to the attending physician, but this was not adhered to. R32's blood sugar levels were recorded as significantly low on multiple occasions and extremely high on another, yet there was no documentation of physician notification or intervention. The resident's care plan indicated a risk for alterations in blood sugar due to diabetes, with interventions including blood sugar checks and notifying the physician as needed. Despite this, the facility's records showed that on several dates, R32's blood sugar levels were either below 60 mg/dL or above 500 mg/dL, which should have triggered physician notification and intervention. However, there was no documentation in the progress notes or medication administration records that the physician was notified or that glucagon was administered as ordered. Interviews with the Director of Nursing (DON) and an LPN revealed that the physician was not notified of the abnormal blood sugar levels, and the necessary interventions were not documented. The DON confirmed the lack of documentation and acknowledged that the glucagon should have been administered and documented. The LPN admitted to not documenting the interventions and stated that food and beverage were given instead of glucagon, but this was also not documented. The Medical Director expected to be notified of such abnormalities, but there was no evidence of this occurring.
Inaccurate Insulin Documentation Due to EMR Confusion
Penalty
Summary
The facility failed to accurately document the administration of insulin for a resident with type 2 diabetes mellitus and dementia. The resident's medical records indicated that insulin was administered even when blood sugar levels were 250 ml/dl or less, contrary to the physician's order to hold insulin in such cases. This discrepancy was observed in the Medication Administration Record (MAR) for January and February 2025, where check marks indicated insulin was given despite blood sugar readings below the threshold. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) revealed confusion regarding the documentation process in the Electronic Medical Record (EMR) system. The LPN was unsure about the meaning of the check marks on the MAR, and the DON acknowledged that the check marks were mistakenly used to indicate insulin administration. The DON admitted to documenting the wrong code, which suggested insulin was administered when it was not. Further investigation showed that the staff was unclear about the EMR system's coding, leading to incorrect documentation. The Medical Director, who had recently assumed the role, stated that insulin administration should be documented according to the order. The lack of clarity and understanding among the staff regarding the EMR system contributed to the inaccurate documentation of insulin administration, potentially impacting the resident's care.
Failure to Include Required Information in Arbitration Agreements
Penalty
Summary
The facility failed to include necessary information in its binding arbitration agreements for two residents, which is a requirement under regulatory standards. Specifically, the agreements did not state that signing the arbitration agreement was not a condition for receiving care at the facility. Additionally, the agreements failed to inform residents and their representatives of their right to communicate with federal, state, local officials, and the ombudsman. This omission was identified during a review of the facility's arbitration agreements, which were undated, and provided by the facility. For Resident 32, the arbitration agreement was signed on 08/09/22, and for Resident 42, it was signed on 09/07/22. Both agreements lacked the required statements. During an interview, the Social Services Director (SSD) acknowledged awareness of the agreement's contents but admitted to not having received education regarding the regulatory requirements for arbitration agreements. This lack of compliance placed residents at risk of unknowingly relinquishing their constitutional rights.
Arbitration Agreement Lacks Neutrality and Fairness
Penalty
Summary
The facility failed to ensure that the arbitration agreement provided for the selection of a neutral arbitrator and a venue without stipulations, affecting two residents out of a sample of 21. The arbitration agreement required that the arbitrator be a retired judge or a member of the state bar with at least 20 years of experience, and that the arbitration be conducted within 70 miles of the facility. This agreement was signed by two residents, one of whom was moderately cognitively impaired with a BIMS score of nine, indicating a lack of understanding of the arbitration process. The Social Service Director (SSD) confirmed the resident's cognitive impairment and stated that the resident would not remember or know how to utilize the arbitration process. The SSD was responsible for having residents sign the arbitration agreement, which was included in the admission packet. The SSD explained the arbitration process to residents, stating that it was voluntary and bypassed the court system. However, all residents signed the agreement. The SSD was aware of the stipulations regarding the arbitration location and arbitrator qualifications but had not received education on regulatory requirements related to arbitration agreements. One resident, who was cognitively intact, expressed no complaints about signing the agreement. The facility's failure to provide a neutral arbitration process placed residents at risk of an unfair advantage in the selection of venues and arbitrators.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal vaccinations to two residents, R1 and R45, as part of their immunization protocol. According to the facility's policy, all residents should be assessed for eligibility and offered the pneumococcal vaccine within thirty days of admission unless medically contraindicated or previously vaccinated. However, the electronic medical records for R1 and R45 showed no documentation of pneumococcal vaccinations, and notes indicated they were not eligible without providing reasons. The Infection Preventionist admitted to not assessing the vaccine status for these residents and was unaware of the CDC's pneumococcal vaccination recommendations. During interviews, the Infection Preventionist and the Director of Nursing confirmed that the residents had not been offered the pneumococcal vaccination as required by the facility's policy and CDC guidelines. The Infection Preventionist also acknowledged not checking the state's database for the residents' vaccination history and not being aware of the residents' risk factors, as both were under 65 at the time of admission. This oversight placed the residents at risk of acquiring pneumonia or pneumococcal infections.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R4, from sexual abuse by another resident, R5. R4, who was admitted with diagnoses including Alzheimer's Disease and severe cognitive impairment, was involved in an incident where R5, who was cognitively intact, engaged in inappropriate sexual behavior with her. The incident was observed by a Licensed Practical Nurse (LPN) who intervened and reported the behavior to the Director of Nursing (DON) and the Administrator. R4's clinical records indicated severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 0 out of 15, suggesting she was unable to consent to any sexual activity. R5, on the other hand, had a BIMS score of 14 out of 15, indicating he was cognitively intact. Despite this, R5 was observed engaging in inappropriate sexual behavior with R4 in the dining area, which was reported by LPN BB who witnessed the incident. The facility had existing policies on abuse prevention and identifying sexual abuse, which defined sexual abuse and the capacity to consent. However, these policies were not effectively implemented to prevent the incident. The failure to protect R4 from sexual abuse by R5 was identified as a deficiency, with the potential to cause serious harm to residents.
Failure to Timely Report Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the State Survey Agency in a timely manner for four residents. Specifically, an incident involving inappropriate sexual behavior between two residents was not reported immediately, and the initial report contained inaccurate information. The Director of Nursing (DON) and the Administrator were aware of the incident on the day it occurred, but the report to the state agency was delayed until the following day. Additionally, the report inaccurately stated that the DON and Administrator were informed of the incident a day later than they actually were. Another deficiency involved a resident who alleged verbal abuse by a Registered Nurse (RN), which was reported to the Administrator by an Ombudsman. However, there was no evidence that this allegation was reported to the State Survey Agency. The resident claimed that the RN threatened to give him an injection and restricted his movement, but the facility did not follow through with the required reporting procedures. Furthermore, the facility failed to report a case of unexplained bruising on a resident in a timely manner. The bruising was observed by a Licensed Practical Nurse (LPN) and reported to the DON a day later, but the State Survey Agency was not notified until two days after the bruising was first noted. These failures to report incidents promptly and accurately demonstrate a significant lapse in the facility's adherence to regulatory requirements for reporting abuse and neglect.
Failure to Timely Investigate and Protect Residents After Alleged Abuse
Penalty
Summary
The facility failed to conduct a timely investigation and implement protective measures following an allegation of resident-to-resident sexual abuse involving two residents. On the day of the incident, a Licensed Practical Nurse (LPN) observed inappropriate sexual behavior between the two residents in the dining area. Despite the immediate notification to the Director of Nursing (DON) and the Administrator, the facility did not initiate a timely investigation or conduct necessary assessments, such as skin assessments, until several days later. The clinical records of the involved residents revealed significant cognitive and behavioral differences. One resident had severe cognitive impairment and required assistance with activities of daily living, while the other was cognitively intact and independent with ambulation. Despite these differences, both residents were on behavior monitoring due to psychotropic medication use. However, there was no evidence of intense monitoring following the incident until much later, and the residents continued to reside in close proximity to each other for several weeks. Interviews with staff indicated that the Administrator was aware of the incident on the day it occurred but failed to interview the witness or obtain a written statement until the following day. Additionally, the facility did not separate the residents or implement frequent monitoring until weeks after the incident. The lack of immediate protective measures and delayed investigation contributed to the facility's noncompliance with requirements of participation, posing a risk of serious harm to the residents.
Deficiencies in Abuse Prevention and Reporting
Penalty
Summary
The facility administration failed to implement all components of its abuse prevention system in a thorough and timely manner, leading to deficiencies in handling allegations of abuse or injury of unknown origin for four residents. The administration did not maintain an environment free from sexual abuse, as one resident was sexually abused by another resident. Additionally, the administration failed to report abuse allegations or injuries of unknown origin to the state survey agency in a timely manner for four residents. The administration also did not ensure that an allegation of sexual abuse involving two residents was reported to law enforcement promptly. Furthermore, the initial and follow-up reports to the state survey agency regarding the sexual abuse allegation were incomplete and inaccurate. The administration did not thoroughly investigate the allegation of sexual abuse, nor did they implement corrective actions, including the protection of the residents involved, in a timely manner. Interviews revealed that the Director of Nursing (DON) was inadequately trained and unaware of her role in handling such situations. The facility's Administrator, who was also the Abuse Coordinator, was unclear about the protocol for handling abuse allegations. The in-service information provided to staff did not include the Administrator's role in the protocol, contributing to the facility's failure to address the allegations effectively.
Failure to Follow Wound Care Treatment Plans
Penalty
Summary
The facility failed to provide pressure ulcer treatments according to the wound physician's dressing treatment plans for two residents. One resident, admitted with multiple diagnoses including cerebrovascular disease and diabetes, had an unstageable full thickness pressure ulcer on both heels. The wound physician's plan was to treat the left heel with skin prep and a gauze island dressing, and the right heel with Leptospermum honey and gauze island dressing. However, staff incorrectly treated the right heel with skin prep instead of the prescribed treatment until March 5, 2024. Additionally, the left heel was treated with Leptospermum honey before the physician officially changed the treatment plan on March 19, 2024. Another resident, with diagnoses including schizophrenia and dementia, developed a deep tissue injury that progressed to a Stage 4 pressure ulcer. The wound physician applied a skin substitute graft and instructed not to disturb the wound bed, with a secondary dressing change once daily. Despite this, the resident's left heel was treated with Xeroform gauze instead of the prescribed Leptospermum honey from May through July 2024. An LPN was observed applying the incorrect treatment, and the Director of Nursing later confirmed the error after reviewing the treatment plan.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for 10 out of 27 Certified Nurse Assistants (CNAs) reviewed, which is necessary to enable in-service education based on the outcome of these reviews. A review of the Certified Nursing Assistant Skills Competency Checklist forms revealed that these 10 CNAs had not undergone a skills competency review annually. There was no evidence of any additional CNA performance reviews being conducted. During an interview, the Regional Director of Operations stated that they were unable to locate any additional CNA performance evaluations, despite contacting the former Director of Nursing (DON) for their whereabouts. The Minimum Data Set (MDS) Coordinator indicated that the DON was responsible for completing the annual CNA performance evaluations, while the Staff Development Coordinator, who was only part-time at the facility, was responsible for scheduling the skills competency evaluations.
Failure to Timely Notify Physician of Extensive Bruising
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding extensive bruising observed on a resident who was on anticoagulation therapy. The resident, who had a history of hemiplegia, hemiparesis, aphasia, chronic pain, adult failure to thrive, and Parkinson's disease, was found with significant bruising on her right side by a CNA. Despite the observation of extensive bruising by both an LPN and an RN, the physician was not notified immediately as the resident's vital signs were normal, and there were no complaints of pain. The facility's protocol required that the physician be contacted based on the urgency of the situation, but this was not adhered to in this case. The DON was informed of the bruising the following day, and subsequently, the physician was contacted, who then ordered lab work and monitoring. However, it was not until two days later that the physician was notified again and ordered the resident to be sent to the emergency room for further evaluation. The hospital admission revealed significant bruising and required a blood transfusion due to low hemoglobin and hematocrit levels. Interviews with the staff indicated a lack of urgency in notifying the physician, despite the severity of the bruising, which was beyond what the RN had ever seen. The physician confirmed that he should have been notified earlier, as the bruising warranted immediate intervention.
Falsification of Physician's Signature on Medication Orders
Penalty
Summary
The facility failed to maintain a clinical record in accordance with accepted professional standards by allowing licensed nursing staff to falsify a physician's signature on telephone order forms. This deficiency was identified during a review of the facility's policies and procedures, staff interviews, and record reviews. The facility's Charting and Documentation policy, revised in July 2017, mandates that documentation must be objective, complete, and accurate. Additionally, the Telephone Orders policy, revised in February 2014, requires that verbal telephone orders be received only by licensed personnel, documented accurately, and countersigned by the physician during their next visit. However, it was found that a Licensed Practical Nurse (LPN) had signed the physician's name on two separate occasions for a resident's medication orders. The resident involved, who had diagnoses including schizophrenia and bipolar disorder, was receiving Klonopin as part of their treatment. On July 19, 2024, the resident's Klonopin dosage was increased based on a recommendation from a behavioral health Nurse Practitioner. The order was documented by the LPN, but the physician's signature section contained two different signatures, one of which was not the physician's. A similar issue was found with a previous order dated July 15, 2024. The Medical Director confirmed that one of the signatures on the July 19 order was his, but the other was not, and that the signature on the July 15 order was not his. This discrepancy raised concerns about the integrity of the documentation process and adherence to the facility's policies.
Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents with pressure ulcers, as observed during wound care treatments. For one resident, a Licensed Practical Nurse provided wound care to a pressure ulcer on the left heel without wearing a gown, and there was no personal protective equipment (PPE) available outside the resident's room. The Infection Prevention Nurse acknowledged that the facility had been informed of the new EBP requirements earlier in the year but admitted that no residents were currently on EBPs due to being pulled in many directions. Similarly, another resident received wound care for a pressure ulcer on the right ankle and a non-pressure ulcer on the right lateral calf from a Registered Nurse, who also did not wear a gown. Again, there was no PPE available outside the resident's room. The Infection Preventionist Nurse confirmed that this resident would likely qualify for enhanced barrier precautions due to the presence of wounds. The lack of implementation of EBPs was attributed to the Infection Prevention Nurse and the Director of Nursing being occupied with other responsibilities.
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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