Presbyterian Village - Athens
Inspection history, citations, penalties and survey trends for this long-term care facility in Athens, Georgia.
- Location
- 1400 Live Oak Ln Bldg 100, Athens, Georgia 30606
- CMS Provider Number
- 115775
- Inspections on file
- 14
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Presbyterian Village - Athens during CMS and state inspections, most recent first.
A resident with a history of sacral fracture and cognitive impairment experienced unmanaged pain during a podiatry procedure. Despite vocal expressions of pain, the podiatrist continued without assessing or administering pain relief, contrary to the care plan. The resident was not given prescribed pain medication before or after the procedure, highlighting a failure in pain management by the facility.
The facility failed to follow care plans for three residents by not properly documenting meal intake and snacks. Residents with conditions such as dementia and Alzheimer's had care plans requiring meal monitoring, but records showed missing documentation for meal intake percentages and snacks over several days. Interviews revealed that CNAs were responsible for documentation, and missing data might be due to agency CNAs unfamiliar with the electronic system.
A resident with moderate cognitive impairment experienced a lack of dignity during a podiatry procedure conducted in a common area. The resident, who has a history of various medical conditions, was in pain during the procedure, which involved toenail cutting and hematoma debridement. The DON intervened and instructed the podiatrist to move the procedure to the resident's room, highlighting a failure to adhere to the facility's policy on resident dignity.
A resident reported being handled roughly by a CNA during a bed transfer, resulting in rib soreness. Despite the facility's policy requiring a thorough investigation, only a statement from the alleged CNA was documented, with no additional witness statements or interview notes. The DON confirmed the lack of comprehensive documentation, indicating an incomplete investigation process.
A facility failed to provide a resident or their representative with written notification of the bed-hold policy upon hospital transfer. The resident, with severe cognitive impairment and multiple health issues, was transferred due to a possible stroke. Interviews revealed confusion among staff about the responsibility for communicating the policy, resulting in no signed documentation of notification.
A facility failed to follow physician orders to offer snacks between meals to a resident with Alzheimer's and other conditions, resulting in inconsistent snack provision. Despite the availability of snacks, staff interviews revealed gaps in distribution, particularly when the Activity Director was absent, and reliance on families during weekends. This led to inadequate nutritional intake and significant weight loss for the resident.
The facility was found to have a medication error rate of eight percent, exceeding the acceptable threshold. Errors included an LPN failing to check vital signs before administering Metoprolol to a resident with hypertension and not administering Polyethylene Glycol to another resident as ordered. The LPN attributed these errors to nervousness during the survey, and the DON confirmed the expectation for medications to be administered as ordered.
An LPN in an LTC facility failed to perform hand hygiene during medication administration for three residents, as observed by a surveyor. Despite claiming to use hand sanitizer, the LPN did not wash hands or use antibacterial hand rub before or after handling medications. The DON acknowledged the expectation for staff to perform hand hygiene and noted the LPN's inexperience and nervousness during the survey.
A resident at the facility was administered an incorrect dosage of lamotrigine for 13 days, leading to a grand mal seizure. The pharmacy dispensed 25 mg tablets instead of the prescribed 250 mg ER tablets. The error was not identified until after the seizure, despite internal audit tools being in place. Interviews revealed lapses in the medication dispensing process and failure to provide audit reports to the survey team.
A resident experienced a grand mal seizure due to a significant medication error at an LTC facility. The resident was prescribed lamotrigine 250 mg ER daily but received only 25 mg for 13 days due to a pharmacy dispensing error. Nursing staff failed to verify the medication against the MAR and bubble pack, leading to the error. Interviews revealed inadequate education and oversight on medication administration.
The facility failed to ensure the dietary department had a certified dietary manager or equivalent, affecting all residents receiving meals. The Dietary Manager lacked certification and had been in the role since April, with plans to enroll in a certification course. The Executive Director was aware of the situation, and the Director of Dining Services was working towards certification.
The facility failed to develop comprehensive care plans for several residents, including those with cognitive impairments and complex medical needs, due to issues with transitioning to a new EMR system. This resulted in missing care plans for critical areas such as pressure ulcer risk, psychotropic drug use, and hospice care, leaving staff without access to essential resident information.
The facility did not comply with its Abuse/Neglect Prevention Program by hiring a Dietary Manager before completing a required criminal background check. The program requires thorough investigation histories and criminal background checks prior to hiring. The Dietary Manager was hired before the Georgia Criminal History Check System (GCHEXS) background screening was received. The Director of Human Resources acknowledged that some employees were hired based on local background screenings before receiving the GCHEXS results.
The facility failed to provide a resident or their representative with written notice of the bed-hold policy upon hospital transfer. The resident, with multiple health conditions, was transferred without receiving information about the bed-hold process. The Social Services Director was unsure of the responsibility for issuing the Bed Hold Letter, and no system was in place to ensure compliance.
Two residents in an LTC facility did not receive necessary assistance with ADL care, specifically facial hair removal. One resident, who was cognitively intact, expressed a desire for help with shaving but was not assisted by staff. Another resident with severe cognitive impairment was observed with facial hair, and staff failed to inquire about or provide assistance with its removal. The DON confirmed that both residents should have received this care on their designated shower days.
Failure in Pain Management During Podiatry Procedure
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R4, during a podiatry procedure. R4, who has a history of a non-displaced fracture of the sacrum, hypertension, mild dementia, anxiety, and depression, was observed yelling in pain while Podiatrist GG performed care in a common area. Despite R4's vocal expressions of pain, the podiatrist continued the procedure without stopping to assess the resident's pain level or administering any pain relief. The care plan for R4 included administering analgesia before treatments when possible, but there was no evidence that pain medication was given before or after the procedure. Interviews with staff revealed that R4 was not provided with pain medication before or after the podiatry care, despite having a physician's order for hydrocodone-acetaminophen for pain management. The Director of Nursing (DON) stated that staff should assess and provide medication for pain if there is an order, and if not, they should contact the physician for an order. The deficiency was identified as actual harm, as the resident experienced unmanaged pain during the procedure, and the facility did not adhere to the care plan or professional standards of practice.
Failure to Document Meal Intake and Snacks for Residents
Penalty
Summary
The facility failed to follow the care plans for three residents regarding the monitoring and recording of meal intake. Resident 1, who was admitted with diagnoses including dementia and major depressive disorder, had a care plan that required monitoring and recording meal intake and providing snacks between meals. However, there were gaps in documentation for meal intake percentages and snacks given over several days in August and September 2024. Resident 2, diagnosed with Alzheimer's disease and severe cognitive impairment, also had a care plan that required monitoring meal intake and providing snacks. Similar to Resident 1, there were missing records for meal intake percentages and snacks given on multiple days in August and September 2024. The care plan for Resident 3, who had a history of cerebral vascular accident and Alzheimer's disease, required similar monitoring and documentation, but there were also missing records for meal intake and snacks on various days. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that Certified Nursing Assistants (CNAs) were responsible for documenting meal intake percentages. The ADON suggested that missing data might be due to agency CNAs not knowing how to use the electronic system. The DON confirmed that CNAs were expected to document meal intake after each meal, and it was her expectation that all staff follow each resident's care plan.
Resident Dignity Compromised During Podiatry Procedure
Penalty
Summary
The facility failed to ensure that a podiatrist provided care in a dignified manner for a resident during a foot care procedure. The incident involved a resident with a history of non-displaced sacrum fracture, hypertension, mild dementia, anxiety, and depression, who had a moderate cognitive impairment as indicated by a BIMS score of 11 out of 15. The podiatrist performed the procedure, which included cutting toenails and debriding a subungual hematoma, in a common area where other residents were present. During the procedure, the resident was observed yelling out in pain, and the podiatrist continued despite the resident's distress. The Director of Nursing (DON) intervened after noticing the resident's discomfort and instructed the podiatrist to move the procedure to the resident's room. The DON later stated that the podiatrist typically sees residents in a clinic or their rooms, and she was unsure why the procedure was conducted in the common area. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, which was not upheld in this instance. Attempts to contact the podiatrist for further clarification were unsuccessful.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an abuse allegation involving a resident, identified as R13, who reported being handled roughly by a Certified Nursing Assistant (CNA) during a transfer to bed. The resident, who had a BIMS score indicating no cognitive impairment, reported soreness in her ribs following the incident and expressed a desire not to be assisted by the same CNA again. The facility's policy requires immediate initiation of an investigation upon receipt of any report of abuse, which should include determining the nature, cause, and extent of the reported abuse, as well as an assessment of the resident's current condition and needed actions. However, the investigation conducted by the facility was incomplete, as evidenced by the lack of written statements or interview notes from other staff members or residents involved in the incident, except for a statement from the alleged perpetrator, CNA EE. The Director of Nursing (DON) confirmed the absence of these documents, indicating that the investigation did not fully comply with the facility's policy. This deficiency highlights a failure in the facility's process to adequately address and document allegations of abuse, potentially compromising resident safety and trust.
Failure to Notify Resident of Bed-Hold Policy
Penalty
Summary
The facility failed to provide evidence that notice of the bed-hold policy and return was given to a resident or the resident's representative upon transfer to the hospital. This deficiency was identified for one of the three sampled residents, who was transferred to the hospital following an emergent medical situation. The resident, who had a history of hemiplegia, hemiparesis, mixed receptive-expressive language disorders, hypertension, dementia, and depression, exhibited symptoms of a possible stroke, prompting the transfer. Despite the transfer, there was no documentation in the electronic medical record indicating that the resident or their representative received written notification of the facility's bed-hold policy. Interviews with facility staff revealed a lack of clarity and responsibility regarding the communication of the bed-hold policy. The Social Services Director admitted that the bed-hold notification process was new and that the Bed-Hold Letter was included in the hospital transfer packet but not necessarily communicated directly to the resident or their representative. Furthermore, the Director of Nursing confirmed that it was the Social Services Director's responsibility to ensure the completion and signing of the Bed-Hold Letters, which was not done in this case. The absence of signed Bed-Hold Letters indicated a failure in the facility's process to ensure residents or their representatives were informed of the bed-hold policy upon hospital transfer.
Failure to Provide Snacks as Ordered
Penalty
Summary
The facility failed to adhere to the physician's orders to offer snacks between meals to a resident diagnosed with Alzheimer's disease, dementia, major depressive disorder, GERD, and chronic pain syndrome. The resident, who was unable to complete a mental status assessment, had an active order from late August 2024 to receive snacks between meals. Despite this order, documentation revealed inconsistent snack offerings, with several days showing no record of snacks being provided. The resident's nutritional intake was poor, with only 25-50% of meals consumed, leading to a 12% weight loss over 180 days. Interviews with facility staff highlighted a lack of consistent snack distribution. The Dietary Manager confirmed the availability of various snacks, but the Assistant Director of Nursing noted that the Activity Director, responsible for afternoon snacks, was absent on certain days, resulting in no snacks being offered. Additionally, on weekends, the responsibility for providing snacks fell to families. Certified Nursing Assistants stated they offered snacks when the Activity Director was unavailable, but many residents declined them, having received snacks from their families. This inconsistency in snack provision contributed to the facility's failure to meet the resident's nutritional needs as per the physician's orders.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of eight percent. This deficiency was identified through observations, record reviews, and staff interviews. Specifically, two medication errors were noted among six residents. For one resident, the LPN administered Metoprolol without checking the resident's blood pressure and pulse as required by the physician's order. The resident had a history of hypertension, and the failure to check vital signs before administering the medication was acknowledged by the LPN, who attributed the oversight to nervousness during the survey. Another error involved a resident with chronic diastolic heart failure and hypertension, where the LPN failed to administer Polyethylene Glycol as ordered. The LPN did not retrieve the medication from the cart, measure the prescribed dosage, or mix it with water as required. The LPN admitted to noticing the absence of the medication in the cart and intended to administer it later, but this was not communicated to the surveyor. The Director of Nursing confirmed that the expectation is for medications to be administered as ordered by the physician, noting that the LPN was new and nervous during the survey.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration, as observed with one of two nurses. The Licensed Practical Nurse (LPN) did not perform hand hygiene before or after administering medications to three residents. During the morning medication pass, the LPN was observed preparing and administering medications without washing hands or using antibacterial hand rub (ABHR) for each resident. This was noted for three residents, where the LPN handled medication Kardex, prepared medications, and entered and exited residents' rooms without performing hand hygiene. The LPN was questioned about her hand hygiene practices and claimed to use hand sanitizer after each medication administration, although this was not observed by the surveyor. The Director of Nursing (DON) confirmed that staff are expected to perform hand hygiene before and after resident care. The DON noted that the LPN was new and nervous during the survey, which may have contributed to the oversight in infection control practices.
Medication Dosage Error Leads to Seizure
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the correct dosage of medication was dispensed to a resident, identified as R77, who was prescribed lamotrigine for seizures. The error occurred when the pharmacy dispensed 25 mg tablets instead of the prescribed 250 mg extended-release tablets. This incorrect dosage was administered for 13 days before the error was recognized, leading to a grand mal seizure experienced by the resident on 7/15/2024. The facility's policy, titled Pharmacy Policy & Procedure Guide for Care Centers, outlines the joint responsibility of the nursing center and the pharmacy to ensure accurate medication administration. However, the checks and balances intended to prevent such errors were not followed. The Pharmacy Director admitted that the previous Pharmacy Director was responsible for inputting, filling, and packaging the medication orders, which contributed to the oversight. The error was not identified until after the resident experienced a seizure, despite the presence of internal audit tools like medication cart audits and medication pass observations. Interviews with facility staff, including the Director of Nursing and the Director of Health Services, confirmed the medication error and the subsequent seizure. The Pharmacy Director and the previous Pharmacy Director both acknowledged the lapse in the medication dispensing process. Despite the availability of internal audit tools, the facility did not provide the survey team with the medication cart audit, resident medication audit, or medication pass observation reports, which could have potentially highlighted the error earlier.
Medication Error Leads to Resident Seizure
Penalty
Summary
The facility failed to ensure that a resident, identified as R77, was free from significant medication errors, resulting in actual harm. R77 was prescribed lamotrigine 250 mg extended release daily to manage seizures. However, due to a pharmacy dispensing error, the resident was administered only 25 mg per day for 13 days. This subtherapeutic dose led to R77 experiencing a grand mal seizure, which was documented in a Nursing Alert Note. The error was discovered after the seizure occurred, when the Director of Nursing and other staff members reviewed the hospital discharge orders and the resident's electronic medical record, confirming the correct prescription was for 250 mg. The pharmacy had dispensed the incorrect dosage, and the nursing staff failed to verify the medication against the Medication Administration Record (MAR) and the bubble pack, as per the facility's policy. Interviews with staff, including the Director of Nursing and Registered Nurse DD, revealed that the five rights of medication administration were not followed, contributing to the error. Further interviews with nursing staff indicated a lack of consistent education and oversight regarding medication administration. Licensed Practical Nurse FF stated she had not received any education on medication administration, and no one had observed her medication pass. Similarly, LPN EE admitted to not checking the bubble pack with the MAR when administering medications to R77. The facility's policy on medication management was not adequately implemented, as evidenced by the lack of adherence to established procedures and guidelines.
Deficiency in Dietary Department Staffing
Penalty
Summary
The facility failed to ensure that the dietary department had a designated staff member as the director of food and nutrition services who was a certified dietary or food service manager, or had a similar food service management degree. This deficiency was identified through a review of records, the Certifying Board of Dietary Managers, and interviews. The review of the employee file for the Dietary Manager (DM) revealed that the individual was hired on January 29, 2021, but did not possess any certification or educational degree in culinary arts or food service management. This lack of certification or qualification had the potential to affect all 25 residents who received meals at the facility. During an interview conducted on July 22, 2024, the DM admitted to not having the required certification but mentioned plans to enroll in a course to become certified. The DM had been in the position since April 2024, and the Registered Dietitian was only present at the facility once a week. The Executive Director acknowledged awareness of the DM's lack of certification and stated that the DM was not required to be certified at that time according to the Certified Board for Dietary Managers. Additionally, the Director of Dining Services was in the process of obtaining the CDM certification but had not yet completed the coursework.
Incomplete Care Plans Due to EMR Transition
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for five residents, leading to unmet care needs. Resident 5, who was admitted with multiple diagnoses including neuropathic bladder and depression, did not have a care plan addressing pressure ulcer risk, psychotropic drug use, functional abilities, or urinary incontinence. Despite being on medication for depression, these critical areas were not included in the care plan, indicating a significant oversight in addressing the resident's comprehensive needs. Resident 15, with severe cognitive impairment and multiple health issues such as COPD and heart failure, also lacked a care plan for cognitive loss, communication, functional abilities, urinary incontinence, and pressure ulcer risk. This omission highlights a failure to address the resident's complex medical and cognitive conditions adequately. Similarly, Resident 19, who was on multiple medications and receiving hospice care, did not have a care plan covering anticoagulant use, pain management, psychotropic drug use, or hospice care, among other needs. The transition to a new electronic medical record (EMR) system contributed to these deficiencies, as care plans were not properly migrated, leaving staff without access to essential resident information. Interviews with staff, including the MDS Coordinator and the Assistant Director of Nursing, revealed confusion and lack of access to previous care plans, further exacerbating the issue. Resident 20 and Resident 12 also suffered from incomplete care plans, with missing focus areas on psychotropic drug use, functional abilities, and cognitive conditions, underscoring systemic issues in care plan management during the EMR transition.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its Abuse/Neglect Prevention Program by not ensuring that a criminal background check was completed prior to hiring a Dietary Manager. The program, dated 9/29/2023, mandates an aggressive abuse prevention strategy, including thorough investigation histories and criminal background checks for potential hires. However, the Dietary Manager was hired on 1/28/2021, but the Georgia Criminal History Check System (GCHEXS) background screening was not received until 5/18/2021. During an interview, the Director of Human Resources confirmed that some employees were hired before receiving their GCHEXS background screening, relying instead on a local background screening.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident or the resident's representative upon transfer to the hospital. This deficiency was identified during a review of records and interviews, where it was found that the facility did not ensure that the resident or their representative was informed about the bed-hold process. Specifically, for one resident who was transferred to the hospital, there was no evidence in the medical record that the resident or their representative received information regarding the facility's bed-hold policy. The resident in question had been admitted to the facility with multiple diagnoses, including intracranial hemorrhage, hypertension, Alzheimer's disease, metabolic encephalopathy, and stage 3 chronic kidney disease. The resident was transferred to the hospital with an anticipated return, yet the facility did not provide the necessary bed-hold information. Interviews revealed that the Social Services Director was unsure who was responsible for preparing and sending the Bed Hold Letter, and there was no log or system in place to ensure compliance with this requirement.
Failure to Assist Residents with ADL Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, R5 and R15, who were dependent on staff for care. R5, who was cognitively intact, expressed a desire to have facial hair removed but was not assisted by staff despite multiple observations over several days. The Certified Nursing Assistant (CNA) responsible for R5's care did not notice the facial hair and stated that shaving was typically done on shower days. The Director of Nursing (DON) confirmed that R5's facial hair should have been trimmed on her designated shower day. Similarly, R15, who had severe cognitive impairment, was observed with facial hair and expressed a need for it to be removed. The CNA assigned to R15 initially stated she had not tended to the resident and later claimed she had checked on her but did not inquire about facial hair removal. The DON confirmed that R15's facial hair should have been addressed on her shower days. These observations and interviews indicate a failure to provide necessary ADL care for these residents.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
