Powder Springs Center For Nursing & Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Powder Springs, Georgia.
- Location
- 3460 Powder Springs Road, Powder Springs, Georgia 30127
- CMS Provider Number
- 115538
- Inspections on file
- 21
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Powder Springs Center For Nursing & Healing during CMS and state inspections, most recent first.
Surveyors found that the facility failed to store its emergency drinking water supply in a safe and sanitary manner as required by its food storage and emergency water policies. Multiple boxes of emergency water were observed stacked outside behind the kitchen near the dumpster and grease trap, with some boxes wet, open, missing gallons, and containing debris, and a broom placed on top. Additional emergency water was stored in a cluttered, disorganized closet in the AU. The Dietary Supervisor and RD confirmed these were part of the emergency water supply for all residents, and the Administrator acknowledged the water had been placed outside due to renovations and lack of space in the designated storage area.
Facility policy required activities staff to empty ash containers into a red step-on container after smoking sessions and for maintenance to later flood and dispose of the contents, while trash-only receptacles were to contain only general refuse. During an observed smoking session, the red step-on container was empty, but a trash-only receptacle contained trash and more than 50 cigarette butts for a group of residents who smoke. An activities assistant, the administrator, the assistant administrator, the activities director, and the maintenance director all confirmed that cigarette butts had been discarded into the trash-only receptacle instead of the designated red container, contrary to the written Smoking Debris Protocol/Procedures, creating a situation the report states had the potential to cause a fire.
The facility did not ensure its binding arbitration agreement included a provision for selecting a mutually convenient venue for arbitration proceedings, as required by its own policy. Review of the arbitration agreement form showed no mention of a venue or any requirement that the venue be agreed upon and suitable to both parties. A staff member responsible for explaining arbitration to residents and families confirmed she did not provide any information about a venue and did not know where arbitration would occur. Facility leadership also confirmed that the agreement did not specify a venue or reference a mutual venue requirement.
The facility failed to consistently follow infection control protocols for PPE disposal in rooms with residents on Droplet Precautions. An Activities Director reused a KN95 mask and face shield after exiting a room, while a housekeeper improperly discarded PPE in the hallway. Staff interviews revealed inconsistencies in PPE disposal practices, highlighting a lack of adherence to facility policies.
The facility did not provide adequate treatment and services to prevent a catheter-associated urinary tract infection from worsening for a resident with multiple diagnoses, including dementia and neuromuscular dysfunction of the bladder. Despite the presence of a urinary catheter, there was no method to monitor urine output, and documentation of urine color or odor was missing. The resident's altered mental status and lethargy led to an emergency room transfer, where it was found that the catheter was not draining due to purulent sediment. This resulted in a severe urinary tract infection, shock, sepsis, and metabolic crisis, ultimately causing the resident's death. Staff interviews revealed lapses in observation and documentation, with an LPN noting but not recording cloudy urine, and a Nurse Practitioner noting altered mental status but refusing to answer questions related to the case.
A resident with increased confusion, a common sign of a urinary tract infection (UTI), was ordered urine culture sensitivity tests by a Nurse Practitioner. However, there was no documentation that the laboratory specimens were collected or acted upon. The resident was later transferred to an acute care hospital with shock, sepsis, metabolic crisis, acute kidney injury, and acute renal failure, and subsequently passed away. The facility's policy required timely laboratory services, which were not adhered to. Interviews revealed gaps in communication and execution of orders, and the Medical Director noted ongoing issues with timely completion of physician and lab orders.
The facility failed to maintain proper hygiene and food safety standards in the kitchen, including the Dietary Manager not wearing a hair net, dirty vents and fan, and improper storage of frozen food items on the freezer floor.
The facility failed to maintain a clean outside garbage disposal area. During a kitchen tour, two trash compactors were found with several bags of trash on the ground, including gloves and plastic bags. One compactor lid was open. The Dietary Manager confirmed the lids should have been closed and that cleaning was a joint effort between dietary and housekeeping staff.
The facility failed to maintain proper tracking and trending of its Infection Control Program from October 2023 through March 2024, with significant discrepancies between tracked and documented infections. Interviews revealed that the designated Infection Preventionist had not been actively involved since January 2024.
The facility failed to ensure that residents were offered and/or consented to the pneumococcal vaccination, as required by their policy. Three residents had incomplete or missing documentation regarding the offering, refusal, or administration of the vaccine, despite the facility's policy mandating such actions upon admission and every five years thereafter.
The facility failed to securely store medications and discard expired medications on two units. An LPN left medication blister packets unattended on a cart, and expired medications were found in the Secure Memory Unit's Medication Room. The DON and another LPN confirmed that medications should always be secured and checked for expiration.
The facility failed to promote dignity and independence for a resident by not providing incontinence pull-ups, which the resident could manage independently. The resident, who has cerebral palsy and no cognitive impairment, had to use briefs that he found difficult to manage, reducing his independence and requiring him to wait for staff assistance. The Administrator confirmed that the facility had stopped ordering pull-ups, leading the resident to spend his monthly allowance on purchasing them.
The facility failed to resolve a grievance related to a missing pair of glasses for a resident with severely impaired cognition. Despite the responsible party notifying an LPN, no formal grievance was filed, and the issue was not escalated to the Administrator as required by the facility's policy.
The facility failed to develop a comprehensive care plan for a resident with an indwelling catheter, despite the resident's need for substantial assistance and specific physician's orders for catheter care. This deficiency was confirmed through record reviews, observations, and staff interviews.
A resident with hypertension, cardiomyopathy, and congestive heart failure was administered blood pressure medications despite having blood pressure readings below the physician-prescribed parameters. The facility did not report these medication errors to the physician, as confirmed by the DON.
The facility failed to ensure adequate supervision and documentation for two residents who experienced falls. One resident on Plavix had no neurological checks after an unwitnessed fall, and another resident on heparin had multiple falls without incident reports or post-fall interventions.
The facility failed to maintain accurate medical records for a resident with a complex medical history. Conflicting entries in the resident's records indicated they were deceased, hospitalized, and on leave of absence at different times. Staff interviews revealed miscommunication and lack of follow-up as reasons for the errors.
A facility failed to ensure a functional nursing call system for a resident (R37) with multiple medical conditions. The resident's call light was reported non-functional by a roommate and confirmed through testing. The issue was not reported by staff, and the facility's room readiness checklist, which includes ensuring call light functionality, was not retained.
Improper Storage of Emergency Drinking Water Supply
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to store emergency drinking water in a safe and sanitary manner consistent with its policies on food receiving, storage, and emergency water supply. The facility’s policy on Food Receiving and Storage required foods to be received and stored in a manner that complies with safe food handling practices, and the Emergency Water Supply policy specified that primary emergency water storage was to be in an alternative location in the Alzheimer’s unit (AU). During observation behind the kitchen, surveyors found multiple brown boxes of emergency water stacked outside near the dumpster and grease trap, with a broom placed on top. Some boxes were moistened, some were open with gallons missing, and debris such as sticks and dirt was present in the boxes. The boxes were also located next to a non-operating freezer. The Dietary Supervisor stated that these boxes were part of the facility’s emergency water supply and explained that they were stored outside because there was not enough room in the AU closet. Further observation of the AU emergency water storage area with the Dietary Supervisor and the Registered Dietitian showed that the remaining emergency water was kept in a cluttered closet with boxes stored without order. They counted 66 boxes of emergency water on hand, which they stated was sufficient for each resident for three days, and the facility census was 195 residents. The Administrator later confirmed that the water had been placed outside due to renovations and moving items from one area to the AU, and acknowledged that there was not enough room for it inside. The Regional Registered Dietitian, the Administrator, and the Dietary Supervisor all confirmed that the water stored outside was part of the facility’s emergency water supply.
Improper Disposal of Cigarette Butts in Designated Smoking Area
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper disposal of cigarette butts in the designated outdoor smoking area, as required by its Smoking Debris Protocol/Procedures. The written policy states that activities staff are responsible for general cleanup of the smoking area, emptying individual ash containers into a red step-on container after smoking sessions, and contacting maintenance if the red container is full. The policy further specifies that after the last smoking session of the day, maintenance staff must remove the red container from the smoking area, flood it with water or sand to extinguish any embers, and then empty the contents into a trash bag for disposal. Five residents who smoke were included in the sample reviewed for compliance with this policy. During an observed smoking session, surveyors noted that the red step-on container in the smoking area was empty, while a nearby trash-only receptacle contained general trash and more than 50 cigarette butts. An activities assistant monitoring the session confirmed the presence of cigarette butts in the trash receptacle and stated she had been instructed during orientation to empty ash containers into the red step-on container and to call maintenance when it was full; she did not know who had discarded the cigarette butts into the trash receptacle and reported that this was the first smoking session she had supervised that day. The administrator, assistant administrator, activities director, and maintenance director each confirmed that cigarette butts were present in the trash-only receptacle and acknowledged that, per facility policy and their training practices, cigarette butts were to be placed only in ash containers and then into the red step-on container, not into the trash-only receptacle. The report states that this failure to follow the established protocol for cigarette butt disposal had the potential to cause a fire.
Failure to Specify Mutually Convenient Venue in Arbitration Agreements
Penalty
Summary
The facility failed to ensure its binding arbitration agreement provided for the selection of a mutually convenient venue for arbitration proceedings, as required by its own policy, for three residents reviewed for arbitration (R246, R140, and R251). The facility’s written policy on Binding Arbitration Agreements stated that the agreement must provide for selection of a venue that is convenient for both parties. However, review of the actual arbitration agreement form showed there was no mention of a venue and no provision that the venue should be agreed upon and suitable to both parties. In interviews, the Concierge II, who was responsible for informing residents and families about arbitration, confirmed that the agreement did not document a venue, that she did not inform residents or families of any venue, and that she did not know where arbitration would occur. The Administrator and Assistant Administrator each confirmed that the arbitration agreement did not specify a venue or mention a mutual venue, and the Administrator stated he could not say for sure that the agreement was required to state the venue.
Inconsistent PPE Disposal Practices in Droplet Precaution Rooms
Penalty
Summary
The facility failed to adhere to infection control protocols related to the disposal of personal protective equipment (PPE) in rooms with residents on Droplet Precautions. During an observation, the Activities Director was seen entering a room with residents on Droplet Precautions wearing a gown, gloves, face shield, and a KN95 mask. Upon exiting, she discarded the gown and gloves in the room but retained the mask and face shield, which she cleaned and reused. She continued to use the KN95 mask throughout the day, contrary to the facility's policy that mandates the disposal of single-use masks after use. Interviews with various staff members, including a Registered Nurse, Certified Nursing Assistant, and Licensed Practical Nurse, revealed inconsistencies in the understanding and implementation of PPE disposal protocols, with some staff reusing PPE and others discarding it as required. In another instance, a housekeeper was observed entering a room with residents on Droplet Precautions without wearing a face shield and failed to discard her gown and gloves inside the room. Instead, she removed them in the hallway and disposed of them in a trash bin on her cart. The Director of Nursing confirmed that this behavior was unacceptable and emphasized that PPE should be discarded in designated trash receptacles inside the room. These observations indicate a lack of consistent adherence to the facility's infection control policies, potentially compromising the safety of residents and staff.
Inadequate Monitoring and Documentation of Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a catheter-associated urinary tract infection from worsening for resident R10, who was admitted with multiple diagnoses including cerebral infarction, cerebrovascular disease, dementia, benign prostatic hypertrophy with lower urinary tract symptoms, neuromuscular dysfunction of the bladder, and cystostomy. Despite having a urinary catheter, there was no method in place to monitor if urine output was normal, and there was no documentation of urine color or odor in the medical record. The Nurse Practitioner noted R10's altered mental status and lethargy, leading to a transfer to the emergency room where it was discovered that the urinary catheter was not draining due to purulent sediment in the bladder. The facility's failure to appropriately monitor and address the urinary catheter care for R10 resulted in a severe urinary tract infection that led to shock, sepsis, and metabolic crisis, ultimately causing R10's death in the hospital. The lack of proper documentation of cloudy urine and inadequate monitoring of urine output contributed to the delayed recognition and treatment of the worsening infection. The facility's policy on Urinary Tract Infections/Bacteriuria-Clinical Protocol emphasized the importance of identifying signs and symptoms of UTIs, but these protocols were not effectively implemented in R10's case. Interviews with staff members revealed lapses in observation and documentation of R10's condition, with the Licensed Practical Nurse noting cloudy urine but failing to document it in the medical record. The Nurse Practitioner, who noted R10's altered mental status, left the facility and refused to answer questions related to R10.
Failure to Provide Timely Laboratory Services for Resident with Suspected UTI
Penalty
Summary
The facility failed to provide critical laboratory tests for a resident (R10) who was ordered urine culture sensitivity tests by the Nurse Practitioner to rule out a urinary tract infection. Despite the orders being placed, there was no documentation that the laboratory specimens were collected or acted upon by the staff. Subsequently, R10 was sent to an acute care hospital with a diagnosis of shock, sepsis, and metabolic crisis, including acute kidney injury and acute renal failure, and unfortunately passed away in the hospital. The facility's policy on Laboratory Services and Reporting required them to provide or obtain timely laboratory services as ordered by healthcare providers, which was not adhered to in this case. The Nurse Practitioner noted R10's chief complaint of increased confusion, a common sign of a urinary tract infection, and ordered the necessary tests. However, there was a lack of documentation in the medical record regarding the collection of the laboratory specimens or any actions taken on the orders. The Medical Director acknowledged ongoing issues with timely completion of physician and lab orders at the facility, emphasizing the expectation that laboratory orders be acted upon within 24 hours of being ordered. The failure to provide the necessary laboratory tests in a timely manner led to R10's deteriorating condition and subsequent transfer to the hospital. Interviews with healthcare providers involved in R10's care revealed gaps in communication and execution of orders. The Nurse Practitioner who ordered the tests refused to answer questions related to R10, while the former Medical Director expressed that better catheter care and infection prevention could have potentially altered the outcome for R10. The facility's lack of a policy for laboratory collections and the failure to ensure timely completion of lab orders were key factors contributing to the deficiency identified during the survey.
Failure to Maintain Kitchen Hygiene and Food Storage Standards
Penalty
Summary
The facility failed to maintain proper hygiene and food safety standards in the kitchen. During an observation, the Dietary Manager was seen not wearing a hair net while in the kitchen, which was confirmed by the manager herself. Additionally, three vents over the steam table and a fan by the kitchen sink were found to be filled with dirt and debris. The morning cook admitted that the fan is used when the kitchen gets hot but was unsure of the last time it was cleaned. The Dietary Manager stated that the maintenance department is responsible for cleaning the vents, but the kitchen staff needed to notify the receptionist to put in a work order for cleaning, which had not been done in this case. Furthermore, during an observation of the freezer, a box of frozen shrimp and two boxes of frozen bacon were found on the freezer floor, which is against the facility's policy for food storage. The Dietary Manager confirmed the improper storage of these items. These deficiencies indicate a failure to adhere to the facility's policy titled 'Food Receiving and Storage,' which mandates that refrigerated foods be stored to promote adequate air circulation and that refrigerators and walk-ins should not be overcrowded.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the outside garbage disposal area was free from trash and debris. During a kitchen tour with the Dietary Manager, two trash compactors were observed outside with several bags of trash on the ground, including gloves and several plastic bags of trash. One of the trash compactor lids was open. The Dietary Manager confirmed that the lids should have been closed and stated that the cleaning of the garbage dumpster was a joint effort between the dietary staff and housekeeping staff. The Dietary Manager also stated that the outside garbage area should have been kept clean and that staff was informed to place all trash in the bin and pick up anything that is dropped.
Failure to Maintain Proper Infection Control Tracking
Penalty
Summary
The facility failed to maintain proper tracking and trending of its Infection Control Program from October 2023 through March 2024. The review of the program revealed significant discrepancies between the number of infections tracked and those documented. For instance, in October 2023, only one Upper Respiratory Infection (URI) was tracked, but nine were documented. Similarly, no Urinary Tract Infections (UTIs) were tracked, but thirteen were documented. This pattern of underreporting continued in subsequent months, with notable differences in the number of tracked versus documented infections for URIs, UTIs, Gastrointestinal Infections (GIs), and skin conditions. By March 2024, there was no documentation for the month of March or April, indicating a complete lapse in the tracking process. Interviews with the Director of Nursing (DON) and the Administrator revealed that the designated Infection Preventionist (IP) had not been actively involved in the program since January 2024. The DON confirmed that other staff members had been dedicating 16 to 20 hours per week to the program, but the designated IP had not contributed to the infection control efforts for several weeks. The Administrator also confirmed that the IP works on an as-needed basis, which contributed to the lack of consistent oversight and documentation in the Infection Control Program.
Failure to Ensure Pneumococcal Vaccination Offered and Documented
Penalty
Summary
The facility failed to ensure that residents were offered and/or consented to the pneumococcal vaccination for three of six residents reviewed for immunizations. The facility's policy, reviewed and revised in December 2023, mandates that each resident be assessed for pneumococcal immunization upon admission, with documentation of either the immunization, refusal, or medical contraindication in the clinical record. However, this policy was not followed for residents R25, R44, and R46, leading to a deficiency in immunization practices. Resident R25, who was admitted with multiple diagnoses including peripheral vascular disease and heart failure, had a documented pneumococcal vaccination date of 11/2/2018 but no further documentation of the vaccine being offered or refused. Similarly, resident R44, with diagnoses including chronic systolic heart failure and hypertension, had a family representative sign a consent form for the pneumococcal vaccination on 10/23/2023, but there was no documentation of the vaccine being administered. Additionally, resident R46, admitted with conditions such as cerebral infarction and hyperlipidemia, had a family refusal documented on 6/7/2018, but no further documentation of the vaccine being offered or refused after that date. The Director of Nursing (DON) stated that the primary care doctor or the DON/Infection Preventionist (IPC) is responsible for ensuring vaccinations are offered and/or provided, and that influenza and pneumococcal vaccinations are offered every five years. However, the clinical records, Medication Administration Records (MAR), and progress notes for the three residents did not reflect adherence to this policy, resulting in the identified deficiency.
Medication Storage and Expiration Issues
Penalty
Summary
The facility failed to ensure medications were securely stored and expired medications were appropriately discarded on two of three units. On the East Unit, an LPN was observed administering medication to a resident and left medication blister packets on top of the medication cart while entering the resident's room. The LPN stated there had not been any problem with leaving the medication packets on top of the cart, contrary to the facility's policy. Another LPN confirmed that medication packets should never be left unattended and should always be secured in the medication cart. The Director of Nursing (DON) also confirmed that all medications are required to be secured under lock and key and that it had never been the facility's practice to leave medication blister packets on top of the cart. In the Secure Memory Unit's Medication Room, the DON confirmed that certain medications were expired, including Vitamin D 10 mg and Aspirin 325 mg. An LPN stated that the medications had been checked for expiration dates, but the expired medications must have been overlooked. The facility policies on Medication Administration and Medication Storage were reviewed, revealing that medications should be administered by licensed nurses and stored according to the manufacturer's recommendations, ensuring proper security and sanitation.
Failure to Provide Incontinence Pull-Ups Reduces Resident's Independence
Penalty
Summary
The facility failed to promote dignity and independence for a resident (R20) by not providing incontinence pull-ups, which the resident could manage independently. The facility's policy on Activities of Daily Living (ADLs) states that residents' abilities in ADLs should not deteriorate unless unavoidable. R20, who has cerebral palsy and no cognitive impairment, required limited assistance for toileting and could change himself if provided with pull-ups. However, the facility stopped supplying pull-ups a few months prior, forcing R20 to use briefs, which he found difficult to manage, thereby reducing his independence and requiring him to wait for staff assistance. This situation led R20 to spend his monthly allowance on purchasing pull-ups, as the facility did not provide them, and family members of other residents had to supply them if preferred. During an interview, the Administrator confirmed that the facility had stopped ordering pull-ups before her tenure and that she had to inform residents that the facility does not provide them, despite the Ombudsman stating otherwise. The Administrator acknowledged that residents who previously managed their own pull-ups now had to wait for staff assistance, potentially being left wet or soiled. This deficiency highlights the facility's failure to adhere to its policy and ensure the resident's dignity and independence in managing their incontinence needs.
Failure to Resolve Grievance for Missing Glasses
Penalty
Summary
The facility failed to resolve a grievance related to a missing pair of glasses for a resident (R17) with severely impaired cognition, as indicated by a BIMS score of three. The facility's policy requires prompt efforts to resolve grievances, including recording the specifics on a designated grievance form. However, a review of the facility's filed grievances for August 2023 revealed no grievances were filed on behalf of R17 to locate the missing glasses. Despite the responsible party notifying the Licensed Practical Nurse (LPN) KK about the missing glasses, no formal grievance was filed, and the issue was not escalated to the Administrator as required by the facility's policy. During an interview, LPN KK confirmed that they were aware of the missing glasses and had documented the notification from R17's responsible party. However, LPN KK did not remember being told about the missing glasses and did not follow the procedure to file a grievance or report the issue to the Administrator. The LPN acknowledged that a lot was happening with R17 the night they were sent to the hospital, which may have contributed to the oversight. This failure to follow the grievance policy resulted in the unresolved issue of the missing glasses for R17.
Failure to Develop Comprehensive Care Plan for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident (R42) who was admitted with diagnoses including neuromuscular dysfunction of the bladder and an unstageable pressure ulcer of the sacral region. Despite the facility's policy requiring a comprehensive, person-centered care plan to be developed within seven days of the completion of the required comprehensive assessment, the care plan for R42 did not address the management of the resident's indwelling catheter. This omission was identified through a review of the resident's electronic medical record and confirmed by multiple staff interviews, including those with an LPN and the Director of Nursing, who acknowledged that the indwelling catheter should have been included in the care plan. Observations and interviews further revealed that R42 required substantial maximal staff assistance for personal hygiene and toileting and was always incontinent of bowel with an indwelling catheter. The physician's orders specified the care required for the indwelling catheter, including cleaning and replacement protocols. However, these interventions were not documented in the resident's care plan. The deficiency was confirmed through direct observation of the resident and corroborated by staff interviews, indicating a failure to adhere to the facility's policy on comprehensive, person-centered care planning.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for administering medications to a resident (R41) with diagnoses including hypertension, cardiomyopathy, and congestive heart failure. The resident's Medication Administration Record (MAR) revealed multiple instances where blood pressure medications, carvedilol and lisinopril, were administered despite the resident's blood pressure being below the physician-prescribed parameters of 110/60. Specific instances were documented in December 2023, February 2024, and March 2024, where Licensed Practical Nurses (LPNs) administered these medications even though the resident's blood pressure readings were below the threshold. The facility's policy on Medication Administration, which mandates holding medications if vital signs are outside prescribed parameters, was not adhered to in these cases. Additionally, the clinical records indicated that the facility did not report these medication errors to the physician. During an interview, the Director of Nursing (DON) confirmed that nurses are expected to administer blood pressure medications according to the physician's orders. The failure to follow these orders and the lack of communication with the physician about the medication errors constitute the identified deficiency in the facility's care practices.
Failure to Document and Supervise Fall Incidents
Penalty
Summary
The facility failed to ensure that residents were adequately supervised, fall incidents were properly documented, and neurological checks were completed for unwitnessed falls. For Resident 4, who had a history of cerebral infarction and was on Plavix, there was no documentation of neurological checks after an unwitnessed fall. The Director of Nursing confirmed that no neuro checks were done because the resident was able to explain how he got on the floor, despite the facility's policy requiring such checks for unwitnessed falls. For Resident 17, who had severe cognitive impairment and was on heparin, there were multiple falls documented without corresponding incident reports or post-fall interventions. The Director of Nursing confirmed the absence of required documentation and assessments, including neurological checks for unwitnessed falls. The Licensed Practical Nurse admitted to being unaware of the proper procedures due to being new at the facility, highlighting a gap in staff training and adherence to protocols.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for one resident (R17). R17 had a complex medical history, including malignant neoplasm of the brain, hydrocephalus, dysphagia, hypo-osmolality and hypernatremia, gastroesophageal reflux disease without esophagitis, and anemia. The resident's medical records contained multiple conflicting entries regarding their status, including notes that R17 was deceased on several occasions, hospitalized, and on leave of absence. These discrepancies were not corrected, leading to confusion about the resident's actual status. Interviews with staff revealed that the errors were not rectified due to miscommunication and lack of follow-up. The Administrator confirmed that R17 was not deceased until a later date and had been hospitalized until then. The Director of Nursing (DON) also noted the conflicting entries and acknowledged that the staff did not follow up to correct the errors. The LPNs involved admitted to receiving incorrect information and failing to correct the documentation errors. This lack of accurate record-keeping compromised the integrity of the resident's medical records and highlighted a significant deficiency in the facility's documentation practices.
Non-Functional Nursing Call System
Penalty
Summary
The facility failed to ensure that the nursing call system was functional for one of the sampled residents (R37). R37, who was cognitively intact with a BIMS score of 15, had multiple medical conditions including multiple fractures of ribs, end stage renal disease, and muscle weakness. During an interview, R30, a roommate of R37, reported that R37's call light was not working since moving into the room in March 2024. Testing confirmed that R37's call light was non-functional, while R30's call light was working properly. CNA GGGG, who was present during the testing, confirmed the malfunction but stated she did not usually work on that side of the unit. The Administrator revealed that room readiness steps, including ensuring the call light is functional, are the responsibility of the Maintenance Department, but the completed checklists are not retained. Further observations and interviews confirmed the deficiency. The Director of Nursing (DON) tested and confirmed the non-functionality of R37's call light. The Maintenance Assistant did not recall any issues with the call light during the room readiness checklist. LPN LL confirmed that CNA GGGG did not report the malfunction, but she overheard the conversation and notified Maintenance. The DON stated that staff are expected to notify someone or put in a work order if a call light is not functional, and interim measures such as using bells are available until the call light is fixed.
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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