Pruitthealth - Brookhaven
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Georgia.
- Location
- 3535 Ashton Woods Drive Ne, Atlanta, Georgia 30319
- CMS Provider Number
- 115313
- Inspections on file
- 21
- Latest survey
- January 18, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Pruitthealth - Brookhaven during CMS and state inspections, most recent first.
The facility failed to provide quarterly financial statements to several residents and did not employ proper bookkeeping techniques for two residents, leading to discrepancies in their financial records. Interviews revealed that residents had not received statements, causing confusion about their account balances. The Financial Counselor admitted to not providing printed copies to all residents, citing the large number of residents as a reason. The Administrator acknowledged these issues and indicated that the facility had not been following basic accounting standards.
A facility failed to provide a resident with the required Notice of Medicare Non-Coverage (NOMNC) upon discharge from Medicare Part A services. The facility's policy mandates that the Advance Beneficiary Notice of Noncoverage (ABN) be delivered in advance, but records showed no evidence of this being done. Interviews with staff confirmed the oversight, with uncertainty about the discharge reason and acknowledgment of the need to follow CMS guidelines.
A resident with a history of falls and cognitive deficits was found to have loose wires hanging in her room, posing a tripping hazard. Staff, including a Maintenance Assistant, LPN, and CNA, confirmed the wires were an accident risk and should not have been present, yet they remained unsecured.
A facility failed to complete and submit a Part A PPS Discharge MDS assessment for a resident discharged from Medicare Part A services. The assessment was started but deleted, and staff interviews confirmed the oversight. The Administrator acknowledged the failure to complete the assessment in a timely manner, which could potentially impact care, services, and finances.
A resident with severe cognitive impairment and a history of Autism was admitted to the facility without a timely PASARR Level II assessment, despite being in the facility for nearly four months. The Social Services Coordinator and Administrator confirmed that the assessment should have been completed at admission, as it was necessary for the resident to receive appropriate services and treatment.
A resident admitted with a PICC line for antibiotics did not have a baseline care plan developed within 48 hours, as required by facility policy. Despite the policy's stipulation for timely care plan initiation and completion, the care plan lacked documentation for PICC line management. Interviews with staff revealed that the nursing team was responsible for initiating care plans, with oversight by the MDS team, but no care plan was created for the resident's PICC line from admission until a week later.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing specific medical needs. One resident's care plan lacked interventions for diuretic use, another's omitted G-tube care, and a third's did not include seizure precautions. Staff interviews confirmed these omissions, highlighting a lack of resident-centered planning.
A resident with cerebral infarction and right-sided hemiplegia was found with long and dirty fingernails, indicating a failure in providing necessary nail care. Despite being dependent on staff for personal hygiene, observations showed untrimmed nails on both hands, with the right hand's nails turning inward. Interviews revealed inconsistencies in staff actions and communication regarding nail care responsibilities.
The facility failed to provide culturally and linguistically appropriate activities for three non-English speaking residents, leading to dissatisfaction and lack of participation. One resident expressed boredom due to inability to understand the activities schedule and TV channels, while another with severe cognitive impairment had no recorded participation in activities. A third resident's care plan included culturally appropriate activities, but there was no evidence of participation. The Activities Director confirmed activities were not conducted in residents' primary languages.
A facility failed to properly administer and label enteral feedings for a resident with a G-tube. The resident's feeding schedule was not followed as per physician's orders, with the feeding pump found paused instead of turned off. Additionally, formula bottles and syringes were incorrectly labeled with dates and names not matching the resident. Interviews with staff revealed a lack of adherence to prescribed feeding schedules and labeling protocols.
A facility failed to follow physician orders for a resident's oxygen therapy, administering it at a lower rate than prescribed and leaving the equipment off at times. Additionally, nebulizer equipment for another resident was not changed weekly or stored properly, increasing infection risk. Staff interviews confirmed these lapses, highlighting significant deficiencies in respiratory care practices.
The facility failed to follow its food safety policy, resulting in expired and unlabeled food items in storage and an unclean ice machine. The Certified Food Manager was responsible for discarding expired items and maintaining equipment cleanliness, but deficiencies were observed during an inspection.
The facility failed to follow infection control practices for three residents involving PICC line and catheter care. One resident's PICC line dressing was not changed as per policy, while another resident experienced inadequate hand hygiene by staff during PICC line access. Additionally, a CNA improperly used double gloving during catheter care, which was not addressed in the facility's policy.
The facility failed to maintain a safe and comfortable environment due to an unpleasant odor on the South Wing. Observations confirmed the odor's presence, and the facility lacked a policy to address it. Staff interviews revealed that cleaning was performed daily, but disinfectant was only used for stains. The Housekeeping Supervisor attributed the odor to heavy wetters, and the Administrator confirmed the odor's persistence, compromising the expected homelike environment.
The facility failed to maintain infection control practices, with a significant number of UTIs not analyzed for trends and an LPN not performing hand hygiene between glove changes during wound care. The IP noted inappropriate hand washing as a contributing factor to the high UTI cases, and staff interviews confirmed the deficiency in hand hygiene practices.
The facility failed to maintain a safe, clean, and homelike environment, with observations of malodorous odors, trash, and disrepair in resident rooms and common areas. Housekeeping staff were not observed cleaning, and issues such as cracked shower mattresses and feces stains on walls were confirmed by staff. The Maintenance Director and Administrator acknowledged these environmental concerns.
The facility failed to provide a sufficient activity program for its residents, as evidenced by limited and infrequent activities, particularly on weekends. Three residents, all cognitively intact, reported a lack of engagement and opportunities to participate in activities, with minimal one-to-one interactions. The Activity Director acknowledged the challenges in meeting residents' preferences due to staffing limitations.
The facility failed to ensure that five residents received education, were offered, consented to receive, and/or refused the pneumococcal vaccination. Despite policies requiring documentation of vaccination or refusal upon admission, the facility did not adhere to these protocols. The Infection Preventionist confirmed the lack of documentation for these residents, relying on verbal information and the GRITS site, which proved insufficient.
A facility failed to assess a resident's ability to self-administer medications, leaving pills at the bedside without authorization or supervision. The resident, with multiple diagnoses and a BIMS score indicating cognitive intactness, had no care plan for self-administration. An LPN left the medications unattended while fetching water, leading to a breach in protocol confirmed by the Regional Nurse Consultant.
The facility failed to accommodate the needs of three residents, including not providing a prescribed lift chair for a resident with mobility issues and failing to ensure transportation for two residents' medical appointments. These deficiencies resulted in missed medical follow-ups and potential risks to resident safety.
The facility failed to promptly resolve grievances related to missing personal items for three residents, as required by their policy. Although the grievances were filed in November and marked as resolved, the actual replacement of items did not occur until March, indicating a significant delay in addressing the residents' concerns.
The facility failed to conduct a thorough investigation of abuse allegations involving two residents. Despite the policy requiring interviews and signed statements from involved parties, no such documentation was found in the reports. The current Administrator could not locate corroborating witness statements, and attempts to contact the previous Administrator were unsuccessful.
A facility failed to complete a Significant Change MDS assessment for a resident placed on hospice services, as required by policy. Despite multiple hospice orders, only one assessment was completed, and no documentation was found to justify the lack of further assessments. Interviews confirmed the oversight, highlighting the need for evaluations with each hospice assessment.
A facility failed to accurately assess a resident's language needs on the MDS, documenting them as not requiring an interpreter despite being primarily Greek-speaking. The care plan did not address language barriers, and the MDS RN relied on interviews and records that failed to capture the resident's true language requirements.
Two residents in an LTC facility developed pressure ulcers due to the facility's failure to conduct weekly skin assessments. One resident, with severe cognitive impairment, developed multiple pressure injuries that were not identified until hospitalization. Another resident, with moderate cognitive impairment, did not receive skin assessments for eight weeks, leading to the development of a sacral pressure ulcer and a heel blister. Interviews with staff confirmed the lack of regular assessments, contributing to the worsening of the residents' conditions.
The facility failed to provide scheduled showers for three residents, who were cognitively intact and required assistance with ADLs. Despite being scheduled for showers multiple times a week, records showed inconsistencies and fewer showers than planned. Interviews revealed a lack of care planning for bathing preferences and no policy on ADL care, contributing to the deficiency.
The facility failed to perform weekly skin assessments and implement timely interventions to prevent pressure ulcers for two residents. One resident developed an unstageable sacral ulcer and other complications, while another developed a sacral pressure wound and heel blister. The facility's documentation was inconsistent, and staff interviews revealed a lack of regular skin assessments, contributing to the development and worsening of pressure ulcers.
The facility failed to provide restorative therapy services for two residents, despite being referred for such services. One resident, with osteoarthritis and cerebellar ataxia, did not receive restorative care after completing physical therapy. Another resident, with hemiplegia and muscle weakness, was care planned for restorative services but did not receive them. The facility has not had an active Restorative Care Program since the pandemic, and the newly hired Restorative Care Nurse only performs weight checks, with no other restorative care provided.
A resident experienced a significant weight loss of 7.82% due to the facility's failure to adhere to its weight monitoring policy. The resident, who had severe cognitive impairment and was dependent on staff, was not weighed during the first four weeks after admission, and timely interventions were not implemented. The resident's condition worsened, leading to hospital admission for dehydration and hypernatremia. Interviews with staff revealed lapses in communication and policy adherence, contributing to the deficiency.
A facility failed to evaluate a therapy recommendation for a DME lift chair for a resident, despite orders from two orthopedic physicians. The resident, with a history of chronic conditions and falls, was not assessed for the lift chair, which was intended to prevent falls and alleviate knee pain. The Rehabilitation Director was unaware of the orders, and the facility did not accommodate the resident's needs.
A facility failed to update its assessment to include specialized cardiac care for a resident with a wearable cardioverter defibrillator (WCD). The resident, with multiple cardiac-related diagnoses, was admitted without the facility ensuring staff education on WCD care. The Regional Nurse Consultant confirmed the oversight in updating the 2023 Facility Assessment to reflect the need for specialized care.
The facility failed to maintain a functioning call light system for several residents, resulting in their inability to call for assistance. Observations showed call lights were unplugged or out of reach, affecting residents with cognitive impairments and physical limitations. The facility lacked a policy on call light accessibility, as noted by the Administrator.
A facility failed to ensure staff were educated on the use of a wearable cardioverter defibrillator (WCD) for a resident with cardiac conditions. Despite a physician's order to change the WCD battery daily, records did not reflect this action. Interviews revealed that CNAs and LPNs lacked knowledge about the WCD, and the facility had no policy on its use, relying on vendor-provided training.
Failure to Provide Financial Statements and Proper Bookkeeping
Penalty
Summary
The facility failed to provide quarterly financial statements to seven residents, which is a requirement under the facility's Resident Trust Fund Policy. This policy is in place to ensure compliance with the Omnibus Budget Reconciliation Act of 1990 (OBRA) and relevant state policies. Interviews with residents revealed that they had not received these statements, leading to confusion and concerns about their account balances. The Financial Counselor admitted to not providing printed copies of the statements to all residents, citing the large number of residents as a reason for this oversight. Additionally, the facility did not employ proper bookkeeping techniques for two residents, resulting in discrepancies in their financial records. For one resident, there were multiple instances where debits were recorded without corresponding entries on the snack sheet or cash receipts. Similarly, another resident's records showed discrepancies between the amounts debited and the amounts recorded on cash receipts. These errors in bookkeeping could potentially lead to inaccuracies in the residents' financial accounts. The Administrator acknowledged these issues and indicated that the facility had not been following basic accounting standards. The Financial Counselor was aware of the requirement to provide quarterly statements but did not consistently fulfill this obligation. The lack of proper financial management and transparency could affect the residents' trust in the facility's handling of their personal funds.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to a resident who was discharged from Medicare Part A services. The facility's policy requires that the Advance Beneficiary Notice of Noncoverage (ABN) be completed and delivered to affected beneficiaries or their representatives before providing the items or services that are the subject of the notice. The ABN must be delivered in advance to allow the beneficiary or representative time to consider options and make an informed choice. However, a review of the clinical records for the resident revealed no evidence that a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form or a NOMNC was provided. Interviews with the Social Service Coordinator and the Administrator confirmed that the resident was discharged from Part A services with days remaining, and both expressed uncertainty about the reason for the discharge. The Social Service Coordinator stated that the resident should have received both an ABN and a NOMNC at least 48 hours prior to the last covered date. The failure to provide these notices could disadvantage the resident by preventing them from filing an appeal or receiving necessary services. The Administrator acknowledged the expectation that the facility follows CMS guidelines to ensure timely issuance of ABNs and NOMNCs.
Unsafe Environment Due to Loose Wires in Resident's Room
Penalty
Summary
The facility failed to provide a safe environment for a resident, identified as R50, who was at risk for falls due to multiple medical conditions including muscle weakness, cognitive communication deficit, and dementia. Observations over several days revealed loose wires hanging from the wall in the resident's room, near her rolling walker. These wires included a cable wire, a telephone cord, and an unidentified wire with an uncovered end. The presence of these wires posed a potential hazard for tripping and falling, which was particularly concerning given the resident's history of repeated falls and altered mental status. Interviews with the resident and staff, including a Maintenance Assistant, LPN, CNA, and the Maintenance Director, confirmed the presence of the loose wires and acknowledged that they should not have been there. The Maintenance Assistant and other staff members recognized the wires as an accident hazard, with the potential for the resident to trip, fall, or even be electrocuted if the wires came into contact with water. Despite these acknowledgments, the wires remained unsecured in the resident's room, indicating a lapse in maintaining a safe environment as required by the resident's care plan.
Failure to Complete and Submit MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed and submitted for a resident reviewed for Beneficiary Notification. Specifically, the facility did not complete and submit a Part A Prospective Payment System (PPS) Discharge MDS assessment for the resident. The resident was admitted and later discharged from Medicare Part A services, but the required discharge assessment was deleted and not submitted. This oversight was confirmed through staff interviews and record reviews. The Registered Nurse Clinical Reimbursement Consultant verified that the Part A PPS Discharge Assessment was not completed for the resident's last covered day of Part A services. The assessment was started but deleted, and there was uncertainty about the necessity of completing the assessment. The facility's Administrator confirmed the deletion and non-submission of the assessment, acknowledging that it was not completed in a timely manner, which could potentially affect care, services, and finances.
Failure to Conduct PASARR Level II Assessment for Resident
Penalty
Summary
The facility failed to conduct a Pre-Admission Screening and Resident Review (PASARR) Level II assessment for a resident, identified as R119, who was admitted with a diagnosis of Autistic Disorder. Upon review of R119's electronic medical records, it was found that he had severe cognitive impairment and a history of Autism, which should have triggered a PASARR Level II assessment. However, the assessment was not completed, despite the resident being in the facility for nearly four months. Interviews with the Social Services Coordinator revealed that although residents are admitted with a PASARR Level I, a Level II referral should be made if behaviors or certain diagnoses are present, which was not done in this case. The Administrator confirmed that PASARR Level II referrals are supposed to be completed at the time of admission if triggered by the Level I assessment. The failure to conduct the PASARR Level II assessment for R119 was acknowledged by the Administrator, who noted that this oversight could potentially lead to negative outcomes for the resident. The lack of timely referral and assessment meant that R119 might not have received the necessary services and treatment appropriate to his needs, potentially affecting his quality of life.
Failure to Develop Baseline Care Plan for PICC Line
Penalty
Summary
The facility failed to develop a baseline care plan for a resident with a peripherally inserted central catheter (PICC) line within 48 hours of admission, as required by their policy. The resident, identified as R542, was admitted with a PICC line for antibiotic administration. Despite the facility's policy mandating the initiation of a baseline care plan within 24 hours and its completion within 48 hours, no care plan addressing the PICC line care and management was documented. This oversight was identified during a review of the resident's electronic medical records and care plan dated 11/6/2024, which lacked any mention of PICC line care. Interviews with facility staff, including the MDS Coordinator, Assistant Director of Health Services (ADHS), and Clinical Reimbursement Coordinator (CRC)/Consultant, revealed that the responsibility for initiating care plans lay with the nursing staff, with follow-up checks by the MDS team. The ADHS emphasized the importance of care planning for specialized care to prevent missed care and serious outcomes. However, it was confirmed that no care plan for the PICC line was developed for the resident from their admission on 10/30/2024 until 11/7/2024, highlighting a lapse in the facility's adherence to its care planning procedures.
Deficiencies in Resident Care Planning
Penalty
Summary
The facility failed to develop a resident-centered care plan for several residents, leading to deficiencies in addressing their specific medical needs. For one resident, identified as R68, the care plan did not include problems, goals, or interventions related to the use of diuretics, despite the resident's complex medical history, which included cerebral infarction, hemiplegia, dementia, and chronic heart failure. The care plan only addressed risks related to anticoagulation and psychotropic drug use, but omitted necessary considerations for diuretic use. Another resident, R101, who was admitted with a gastrostomy tube, did not have a comprehensive care plan addressing enteral feeding and G-tube care. Although the resident had orders for G-tube management and enteral nutrition, the care plan lacked specific interventions for G-tube care, focusing instead on risks of dehydration and malnutrition. The absence of detailed care planning for the G-tube and enteral nutrition was noted during staff interviews, where it was revealed that care plans are typically reviewed quarterly. Additionally, the facility did not include seizure precautions in the care plan for resident R6, who had a seizure disorder. Despite receiving anticonvulsant medication and having a significant cognitive impairment, the care plan did not mention the seizure diagnosis or necessary precautions. Interviews with staff, including the Unit Manager and MDS coordinator, confirmed the omission, although they acknowledged that seizure precautions should be included if blood work monitoring is required. The Director of Health Services indicated that medical diagnoses should trigger care planning during the MDS process.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as R101, who was dependent on staff for personal hygiene due to medical conditions including cerebral infarction, right-sided hemiplegia, and contractures. Observations on two separate days revealed that R101 had long fingernails on both hands, with the nails on the right contracted hand turning inward towards the palm and the nails on the left hand being dirty. This lack of nail care was noted despite the resident's care plan indicating a need for assistance with activities of daily living due to his medical conditions. Interviews with facility staff, including CNAs and the LPN/Unit Manager, indicated a lack of consistent action in addressing the resident's nail care needs. The CNA stated that nail care should be performed during showers or when nails are long and dirty, and the LPN/Unit Manager mentioned that if nail care could not be performed safely by the staff, podiatry or therapy should be consulted. However, the resident's nails remained untrimmed and dirty, indicating a failure to follow through with these procedures. The Director of Health Services also expressed expectations for nail care to be performed by CNAs if they felt comfortable, or otherwise to inform the nurse, but this protocol was not effectively implemented for R101.
Failure to Provide Culturally Appropriate Activities for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities based on person-centered activities for three residents whose primary language was non-English. The facility's policy on activities programming emphasized the need to reflect cultural and ethnic interests of the residents. However, the review of records showed that the facility had nine residents whose primary language was non-English, and three of these residents were not provided with activities that met their cultural and linguistic needs. One resident, who had a BIMS score indicating little to no cognitive impairment, expressed dissatisfaction with the activities offered, stating that they could not read the activities schedule or understand the TV channels. This resident reported that the facility was boring and that they only ate and slept, as they were unable to participate in activities that interested them. Another resident, with severe cognitive impairment, had no recorded participation in one-on-one activities over a three-month period, despite their care plan indicating the need for culturally appropriate activities. A third resident, also with little to no cognitive impairment, had a care plan that included the provision of culturally appropriate activities and a communication board to facilitate participation. However, there was no data showing their active participation in any one-on-one activities. The Activities Director confirmed that activities were not performed in the residents' primary languages, which contributed to the deficiency in meeting the residents' needs for culturally and linguistically appropriate activities.
Improper Administration and Labeling of Enteral Feedings
Penalty
Summary
The facility failed to ensure proper administration and labeling of enteral feedings for a resident, identified as R101, who was admitted with multiple diagnoses including cerebral infarction, dysphagia, and gastrostomy status. The physician's orders specified that the resident should receive Jevity 1.5 formula through a G-tube at a rate of 55 mL per hour for 22 hours daily, with the feeding to be turned on at 10 am and off at 8 am. However, observations revealed discrepancies in the labeling and timing of the feedings. On multiple occasions, the formula bottles and syringes were incorrectly labeled with dates and names not corresponding to R101, and the feeding pump was found paused for extended periods instead of being turned off as per the physician's orders. Interviews with the nursing staff and the Director of Health Services highlighted a lack of adherence to the prescribed feeding schedule and labeling protocols. A registered nurse admitted to pausing the feeding for two hours instead of turning it off, as required, and acknowledged the incorrect labeling of syringes. The Director of Health Services confirmed that the expectation was for the feedings to be taken down and restarted according to the orders, with all equipment properly labeled with the resident's name, date, and time. These lapses in following the physician's orders and facility policies resulted in a deficiency in the care provided to the resident.
Deficiencies in Oxygen Therapy and Nebulizer Equipment Maintenance
Penalty
Summary
The facility failed to adhere to physician orders for oxygen therapy for a resident, identified as R8, who was on continuous oxygen therapy. The resident's electronic health record indicated a prescription for oxygen at 3 liters per minute (LPM) via nasal cannula. However, observations revealed that the oxygen was administered at 2 LPM on multiple occasions, and at one point, the oxygen equipment was found to be off entirely. Interviews with staff, including a CNA and an LPN, confirmed that the oxygen levels were not checked as required, and the prescribed oxygen flow rate was not maintained, posing a risk of respiratory distress and other complications for the resident. Additionally, the facility did not follow its policy regarding the maintenance of nebulizer equipment for another resident, identified as R539. The nebulizer mask was observed to be undated, unbagged, and uncovered in the resident's bedside table drawer on several occasions. Interviews with the resident and staff, including an LPN and the Infection Preventionist, confirmed that the nebulizer equipment was not changed weekly as required, and the mask was not stored properly, increasing the risk of infection. The Director of Health Services and other staff members acknowledged the importance of following physician orders and maintaining proper equipment hygiene to prevent potential health risks. The failure to comply with these protocols for both residents highlights significant lapses in the facility's respiratory care practices, which could lead to medical complications and diminished quality of life for the residents involved.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to adhere to its policy on labeling, dating, and storage of food items, leading to deficiencies in food safety practices. During an inspection, it was observed that the dry storage area contained several cans of puree beef stew without expiration dates, and multiple cans of grape jelly and thickened juices with expired dates. Additionally, there were unlabeled and undated food items in the walk-in freezer, including a bag of meatballs and a pack of fresh toast slices. The ice machine was also found to have a dirty substance inside, indicating a lack of proper maintenance. Interviews with the Certified Food Manager (CFM) and a Registered Dietitian (RD) revealed that the CFM was responsible for removing and discarding expired food items and ensuring the cleanliness of the kitchen equipment. However, the presence of expired and improperly labeled food items, as well as the unclean ice machine, suggests a failure in executing these responsibilities. The RD confirmed that monthly inspections were conducted to ensure compliance with food safety standards, but the deficiencies observed indicate lapses in these procedures.
Infection Control Deficiencies in PICC and Catheter Care
Penalty
Summary
The facility failed to adhere to infection control practices for three residents, specifically in the management of peripherally inserted central catheters (PICC) and catheter care. For one resident, R549, the facility did not change the PICC line dressing as per the physician's orders and facility policy, which required a change every seven days. The dressing was observed to be overdue for a change, indicating non-compliance with the established protocol. Interviews with the Assistant Director of Health Services and the Infection Preventionist confirmed the expectation for weekly dressing changes, which was not met. Another resident, R543, was observed to have been subjected to inadequate hand hygiene practices by the Assistant Director of Health Services. The staff member entered the resident's room without sanitizing hands or donning a gown, despite the resident being on Enhanced Barrier Precautions due to the PICC line. The staff member also failed to sanitize hands before and after glove use and after performing a blood draw from the PICC line. This lapse in hand hygiene was acknowledged by the staff member and the Director of Health Services, who confirmed the importance of hand hygiene in preventing infections. For resident R16, the facility did not follow proper catheter care procedures. A Certified Nursing Assistant was observed double gloving during catheter care, which is not addressed in the facility's policy. The CNA did not remove both pairs of gloves after providing care, potentially allowing for cross-contamination. The Infection Preventionist and the Director of Health Services confirmed that double gloving is not encouraged and that both pairs of gloves should be removed to prevent the spread of germs or bacteria.
Unpleasant Odor in South Wing
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for residents, staff, and the public, as evidenced by an unpleasant odor on the South Wing of the facility. Observations during the survey from November 3 to November 7, 2024, confirmed the presence of this odor. The facility lacked a policy regarding maintaining an environment free from unpleasant odors. Interviews with staff revealed that the Floor Technician cleaned the hallways daily and applied liquid disinfectant only when there was a stain. The Housekeeping Supervisor acknowledged the odor, attributing it to the area having heavy wetters. The Administrator, who had been at the facility for about two months, confirmed the persistent odor and expressed that it compromised the homelike environment expected for residents, staff, and visitors.
Infection Control Deficiency Due to Inadequate Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection control practices, leading to a potential risk of infections and cross-contamination. The Infection Preventionist (IP) confirmed that infection control data for August 2023 was not analyzed for trends in urinary tract infections (UTIs), particularly noting that eight out of nine UTI cases occurred in residents on the 300 East Hall. The IP attributed the high number of UTIs to inappropriate hand washing practices among staff, indicating a need for continued education on hand hygiene, urinary catheter care, and perineal care. Additionally, during a wound care procedure for a resident with multiple diagnoses including spastic hemiplegia and unstageable pressure ulcers, an LPN failed to perform hand hygiene between glove changes. The LPN washed her hands before the procedure and after removing soiled gloves but did not sanitize her hands between removing soiled gloves and donning new ones. This was contrary to the facility's policy and the RN/LPN Annual Skills Fair guidelines, which require hand hygiene between dirty and clean tasks. Interviews with staff confirmed the deficiency in hand hygiene practices during wound care.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and interviews. During the survey, strong malodorous odors were detected upon entering the building, and various halls and resident rooms were found with trash on the floors, scuffed walls, broken blinds, and rusted furniture. Housekeeping staff were not observed performing cleaning duties during multiple visits, and family members reported persistent cleanliness issues, including sightings of bugs. The shower rooms were also in disrepair, with cracked shower bed cushions and unclean equipment, which were confirmed by the Maintenance Director and Infection Prevention staff. Interviews with facility staff revealed that the issues had been ongoing, with paint spots on floors remaining unaddressed for years and cracked shower mattresses not being replaced. The Housekeeping Director acknowledged the presence of feces stains on walls and confirmed that daily cleaning tasks were not being completed as per policy. The Maintenance Director and Administrator confirmed the environmental concerns identified during the survey, indicating a systemic failure to uphold the residents' right to a safe and clean living environment.
Inadequate Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the preferences and needs of its residents, as evidenced by the lack of person-centered activities for three residents. The activity calendars for several months showed limited activities, particularly on weekends, with some months having no activities listed for Sundays. The facility's policy required daily structured recreational activities that accommodate residents' needs, but this was not consistently implemented. Resident 8, who was cognitively intact and had a strong preference for choosing his activities, reported spending all his time in bed without being offered activities or one-to-one visits. Similarly, Resident 35, also cognitively intact, expressed that he was not aware of any activities beyond bingo and church services and had not been offered one-to-one activities or other engagement options. Both residents' activity notes indicated minimal participation in activities, with only one recorded instance for each. Resident 19, who had a preference for group activities and going outside, was observed to be mostly confined to bed, with limited opportunities to engage in activities or leave his room. Interviews with staff, including the Activity Director, revealed that the facility struggled to provide adequate one-to-one activities due to staffing limitations, and the activities offered were not sufficiently diverse or frequent to meet the residents' documented preferences and needs.
Failure to Document Pneumococcal Vaccination for Residents
Penalty
Summary
The facility failed to ensure that five residents received education, were offered, consented to receive, and/or refused the pneumococcal vaccination. The review of facility policies revealed that residents should be offered the influenza vaccine during the flu season and the pneumococcal vaccine upon admission, with consent or refusal documented. However, the facility did not adhere to these policies for the residents in question. Resident 8, who was cognitively intact, was admitted with multiple diagnoses including rhabdomyolysis and type 2 diabetes mellitus, but there was no documentation of receiving or refusing the pneumococcal vaccine. Similarly, Resident 15, with moderate cognitive impairment and a history of chronic systolic heart failure, also lacked documentation of pneumococcal vaccination. Resident 16, cognitively intact and with a history of paroxysmal atrial fibrillation, was not documented as having received or refused the vaccine. Resident 40, who was cognitively intact, had a history of type 2 diabetes mellitus and cerebral infarction, and Resident 45, with moderate cognitive impairment and a history of hyperlipidemia and respiratory failure, both lacked documentation of receiving the pneumococcal vaccine. The Infection Preventionist confirmed the absence of vaccination documentation and relied on verbal information and the GRITS site to determine vaccination history, which was insufficient in these cases.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess and determine if it was appropriate for a resident to self-administer medications left at the bedside, which placed the resident at risk for inappropriate and unsafe medication use. The facility's policy requires that residents are only allowed to self-administer medications when specifically authorized by the attending physician, and there was no evidence that such an assessment or authorization was completed for the resident in question. The resident, who was admitted with diagnoses including anxiety disorder, muscle weakness, lack of coordination, pain, diabetes, and mild vascular dementia, had a BIMS score indicating cognitive intactness. However, there was no care plan addressing the resident's ability to self-administer medications. An observation revealed that the resident had a small cup containing eight pills on her bedside table without any staff present. The Unit Manager/LPN confirmed that she had left the medications at the bedside and acknowledged that she should have stayed to watch the resident take them. The LPN left to get tap water for the resident, who complained about the cold drinking water, but was delayed by assisting another resident. The Regional Nurse Consultant confirmed the incident and noted that it would result in an automatic write-up, indicating a breach in the facility's medication administration protocol.
Failure to Accommodate Resident Needs and Ensure Transportation
Penalty
Summary
The facility failed to accommodate the needs of three residents, resulting in deficiencies in care. Resident 15, who had a history of osteoarthritis, muscle weakness, and falls, was prescribed a durable medical equipment (DME) lift chair by her orthopedic physician to assist with mobility and reduce pain. Despite the prescription and the resident's history of using a lift chair prior to admission, the facility did not provide the lift chair, and the Rehabilitation Director was unaware of the physician's orders. This lack of accommodation potentially contributed to the resident's continued risk of falls. Residents 39 and 42 experienced issues with transportation arrangements for their medical appointments. Resident 39, who had a left toe amputation and required follow-up surgical appointments, missed two appointments due to transportation failures. The transportation provider either did not show up or arrived late, necessitating rescheduling. Similarly, Resident 42 missed an appointment due to the transportation provider not showing up, as documented in a grievance form. These transportation issues resulted in delays in necessary medical follow-ups for both residents. The facility's policies on therapy evaluations and specialty services, including transportation, were not effectively implemented, leading to these deficiencies. The failure to provide the prescribed lift chair for Resident 15 and the inadequate transportation arrangements for Residents 39 and 42 highlight the facility's inability to meet the residents' needs and preferences as required by their policies.
Delayed Resolution of Grievances for Missing Items
Penalty
Summary
The facility failed to ensure prompt resolution of residents' grievances regarding missing personal items, as required by their grievance policy. The policy mandates that grievances should be resolved within three business days. However, grievances filed in November 2023 by three residents for missing items were not resolved until March 2024. The grievances involved missing clothing items, and although the facility's Social Services department initially documented that the grievances were resolved in November 2023, the actual replacement of the items did not occur until March 2024. Interviews with the Social Service Director (SSD) confirmed that the grievances were marked as resolved in November 2023, but the items were not replaced until March 2024. The SSD could not explain why the grievances were considered resolved in November when the items had not been replaced. This delay in resolving the grievances indicates a failure to adhere to the facility's policy of resolving grievances promptly, as the replacement of the missing items took four months instead of the stipulated three business days.
Incomplete Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of allegations of abuse involving two residents. According to the facility's policy on the prevention of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, interviews should be conducted with all individuals who have relevant information, and written signed statements should be obtained from involved parties. However, during the review of the Facility Reported Incidents (FRIs) for the two residents, it was found that while witness statements and interviews were noted to have been conducted, no signed written statements or interview notes from any involved parties were included in the reports. The deficiency was further highlighted during an interview with the current Administrator, who revealed an inability to locate any witness statements that would corroborate the investigation documented by the previous Administrator. An attempt to contact the previous Administrator for clarification was made, but there was no return call. The lack of documentation and follow-through in obtaining necessary statements and interviews as per the facility's policy resulted in an incomplete investigation of the alleged abuse incidents.
Failure to Complete Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who was placed on hospice services. According to the facility's policy, a Significant Change in Status Assessment must be completed no later than the 14th calendar day after a significant change is determined. The resident, identified as R8, had hospice orders on multiple occasions, but the facility only completed one Significant Change MDS on 6/30/2023. There was no subsequent Significant Change MDS assessment completed for the resident's admission to hospice services on 9/8/2023. Interviews with the Regional Nurse Consultant and the Corporate MDS Coordinator confirmed the lack of a change of condition MDS for the resident. The Corporate MDS Coordinator acknowledged that a significant change MDS should have been completed each time a hospice assessment was conducted. The coordinator also confirmed that there was no documentation of assessments or evaluations to determine the need for a Significant Change MDS, despite the resident receiving hospice services and speech therapy for communication and dysphagia issues.
Inaccurate Assessment of Resident's Language Needs
Penalty
Summary
The facility failed to ensure that a resident's ethnicity and language needs were accurately assessed on the Minimum Data Set (MDS). The resident, who was primarily Greek-speaking, was incorrectly documented as White and assessed as not requiring an interpreter for communication with healthcare staff. This discrepancy was identified during a review of the resident's admission MDS and subsequent assessments, which did not reflect the resident's actual language needs. The care plan for the resident did not address language or communication barriers, despite the resident's history and physical indicating a primary language of Greek. Interviews with the MDS Registered Nurse (RN) revealed that the social worker and nursing staff are responsible for assessing language needs, but the system in place failed to capture the resident's true language requirements. The MDS RN relied on interviews, assessments, hospital records, and input from the social worker to code language barriers, but this process did not accurately reflect the resident's needs.
Failure to Conduct Weekly Skin Assessments Leads to Pressure Ulcers
Penalty
Summary
The facility failed to ensure that services were provided in accordance with professional standards of quality, specifically in conducting weekly skin assessments to prevent pressure ulcers. For one resident, R26, who was admitted with severe cognitive impairment and at high risk for pressure ulcers, the facility did not perform adequate skin assessments. Despite being identified as high risk, R26 developed multiple pressure injuries, including an unstageable sacral decubitus and deep tissue pressure injuries on the heels, which were not identified until hospitalization. The Director of Nursing acknowledged that the wounds were likely acquired at the facility and could have been prevented with proper assessments. Another resident, R20, also experienced a deficiency in care related to skin assessments. R20, who had moderate cognitive impairment and was at risk for pressure ulcers, did not receive weekly skin assessments for eight weeks. This lack of monitoring led to the development of a sacral pressure ulcer and a heel blister, which were only discovered when the wound management company conducted an assessment. The facility's failure to perform regular skin assessments resulted in the progression of R20's wounds to an unstageable state, with significant necrotic tissue present. Interviews with facility staff, including LPNs and RNs, confirmed the lack of regular skin assessments for both residents. The wound care nurse indicated that initial assessments were conducted, but ongoing weekly assessments were the responsibility of floor nurses, which were not completed. The facility's inaction in conducting these assessments contributed to the development and worsening of pressure ulcers in both residents, highlighting a significant lapse in adhering to professional standards of care.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for three residents, R8, R35, and R27, as part of their activities of daily living (ADL) care. R8, who was cognitively intact with a BIMS score of 15, was not care planned for bathing preferences and received showers inconsistently, despite a grievance filed by a family member regarding inadequate bathing and oral care. R8's shower records showed irregularities in the frequency of showers received, and the resident was unaware of the option to receive showers more frequently. R35, also cognitively intact with a BIMS score of 15, was not care planned for shower preferences and had missing shower records for several months. The Director of Nursing confirmed the absence of shower sheets for December 2023, January 2024, and February 2024, and stated that the expectation was for residents to receive three showers per week. However, R35's records indicated fewer showers than scheduled, highlighting a failure to adhere to the facility's shower schedule. R27, with a BIMS score of 15, required assistance with ADLs and was scheduled for showers three times a week. However, records showed that R27 received significantly fewer showers than scheduled in February and March 2024. Interviews with staff revealed inconsistencies in documentation and a lack of a policy on ADL care, contributing to the deficiency. The Director of Health Services confirmed the discrepancy in the number of showers R27 should have received, indicating a systemic issue in providing scheduled ADL care.
Failure to Prevent and Document Pressure Ulcers
Penalty
Summary
The facility failed to perform weekly skin assessments and implement timely interventions to prevent pressure ulcers for two residents, R26 and R20. R26 was admitted with multiple diagnoses, including sepsis and dysphagia, and was noted to have a fair appetite. Despite being at risk for skin breakdown, the facility's documentation indicated that R26 was not at risk for pressure injuries, and there were gaps in weekly skin assessments. Eventually, R26 developed redness and discoloration on the heels and sacral area, which were not documented until later. Upon transfer to the hospital, R26 was found to have an unstageable sacral ulcer and other complications, leading to a diagnosis of severe sepsis and dehydration. R20 was admitted with conditions such as diabetes and hypertension and was assessed to have moderate cognitive impairment. Initially, R20 was not considered at risk for pressure ulcers, but later developed a sacral pressure wound and a heel blister. The facility failed to conduct weekly skin assessments for R20 over an eight-week period, and the pressure ulcer was only identified during a wound management visit. The wound progressed to an unstageable stage with necrotic tissue, and there was a lack of documentation and timely intervention to prevent the deterioration of the wound. Interviews with facility staff revealed inconsistencies in performing and documenting skin assessments. The Director of Nursing and Regional Nurse Consultant acknowledged that the wounds were acquired at the facility and were preventable. The facility's failure to conduct regular skin assessments and implement preventive measures contributed to the development and worsening of pressure ulcers in both residents.
Failure to Provide Restorative Therapy Services
Penalty
Summary
The facility failed to provide restorative therapy services to maintain or improve the range of motion and mobility for two residents, R19 and R27, who were referred for such services. The facility's policy mandates that restorative nursing services be provided by qualified staff to maintain optimal physical, mental, and psychological functioning. However, the facility has not had an active Restorative Care Program since the COVID pandemic, and the newly hired Restorative Care Nurse only performs weight checks for the dietician, with no other restorative care provided. Resident R19, admitted with conditions including osteoarthritis and cerebellar ataxia, completed physical therapy services and was supposed to transition to a restorative exercise program. However, there is no evidence that R19 received these services. Interviews with the PT and OT revealed that R19 could benefit from a restorative care program, but the facility's lack of an active program prevented this transition. The DON and RNC were unaware of the absence of restorative services and the lack of an active program. Resident R27, with diagnoses including hemiplegia and muscle weakness, was also not provided with restorative care services despite being care planned for such. The resident's care plan included restorative services for range of motion and safe transfers, but there was no documentation of these services being provided. The Rehab Director was unaware of the care plan and confirmed that no recommendations for restorative care were made for R27's contracture, further highlighting the facility's failure to implement its restorative care policy.
Failure to Monitor and Address Resident's Nutritional Needs
Penalty
Summary
The facility failed to provide adequate care and services to maintain the nutritional status of a resident, identified as R26, resulting in a significant weight loss of 7.82%. The facility's policy required new admissions to be weighed weekly for four weeks or until weight stability was achieved, with specific thresholds for significant weight changes. However, R26 was not weighed during the first four weeks after admission, contrary to the facility's policy. The resident, who had severe cognitive impairment and was dependent on staff for all care, experienced a decline in nutritional intake, as noted by the Registered Dietician and nursing staff. Despite being at risk for pressure injuries and having a fair appetite reported, the resident was not placed on the weight monitoring program, and interventions were not implemented in a timely manner. The resident's condition deteriorated, leading to a hospital admission where dehydration and hypernatremia were diagnosed due to poor intake. Interviews with facility staff, including the Assistant Director of Nursing and the Regional Nurse Consultant, revealed lapses in communication and adherence to the weight monitoring policy. The resident's weight loss was not discussed in weekly meetings, and the staff failed to notify the physician or implement interventions when the weight loss exceeded 7%. The Director of Nursing confirmed that the necessary communication and interventions were not executed as per the facility's protocol, contributing to the resident's significant weight loss and subsequent health issues.
Failure to Evaluate Therapy Recommendation for Lift Chair
Penalty
Summary
The facility failed to evaluate a therapy recommendation for a Durable Medical Equipment (DME) lift chair for a resident, R15, as ordered by two different physicians. The policy titled Therapy Evaluations requires that all physician's orders for therapy evaluations be addressed in a timely manner by the appropriate therapy discipline. However, the facility did not assess R15 for the lift chair, despite orders from Orthopedic Physicians MMMM and NNNN, who prescribed the lift chair due to R15's arm and leg weakness, arthritis, and risk of falls. The resident's medical history includes chronic systolic heart failure, osteoarthritis, cognitive communication deficit, muscle weakness, falls, type 2 diabetes, and bipolar disorder, with a BIMS score indicating moderate cognitive impairment. The resident's electronic medical record showed multiple falls and a history of using a lift chair prior to admission to the facility. Interviews with the resident's responsible party and the orthopedic physicians confirmed the necessity of the lift chair to prevent falls and alleviate knee pain. Despite this, the Rehabilitation Director stated that the facility does not assess for DME lift chairs and was unaware of the physician orders. Consequently, R15 was not evaluated for the lift chair, and the facility did not accommodate her needs as per the physician's orders.
Failure to Update Facility Assessment for Specialized Cardiac Care
Penalty
Summary
The facility failed to adequately assess its capacity and capability to provide necessary care for a resident who required specialized cardiac services. Specifically, the facility's assessment documents did not include a section addressing cardiac services, which was crucial for the care of a resident admitted with a wearable cardioverter defibrillator (WCD). The resident, who had a history of cerebral infarction, dysphagia, anemia, acute myocardial infarction, atherosclerotic heart disease, chronic atrial fibrillation, atrial flutter, ischemic cardiomyopathy, end-stage renal disease, and hemiparesis, was admitted with a physician's order for a WCD. However, the facility did not update its 2023 Facility Assessment to reflect the need for specialized care related to the WCD. Interviews with the Regional Nurse Consultant (RNC) confirmed that the facility had the capability to update the facility assessment at any time but failed to do so upon the resident's admission. The RNC acknowledged that the facility should have updated the 2023 Facility Assessment to include the specialized care required for the WCD. This oversight indicates that the facility did not ensure its staff was educated on how to care for a resident with an external defibrillator, leading to a deficiency in providing competent care for the resident.
Deficiency in Call Light System Accessibility
Penalty
Summary
The facility failed to ensure that the call light communication system was functioning adequately for five residents, leading to deficiencies in providing necessary assistance. Observations revealed that the call lights for several residents were either unplugged or out of reach, preventing them from calling for help. For instance, one resident's call light was found unplugged, and another resident reported that despite pressing the call light, no assistance was provided for days. Additionally, some residents had their call lights placed on the floor or hanging from the side rail, making them inaccessible. The residents involved had various medical conditions, including cognitive impairments, muscle weakness, and incontinence, necessitating maximum or moderate assistance with activities of daily living. Despite these needs, the facility did not have a policy in place regarding the call light communication system, as confirmed by the Administrator. The Director of Nursing acknowledged the importance of having functioning call lights within residents' reach to ensure their needs are met, highlighting a gap in the facility's operational procedures.
Lack of Staff Training on Wearable Cardioverter Defibrillator
Penalty
Summary
The facility failed to ensure that clinical staff were adequately educated on the use of a wearable cardioverter defibrillator (WCD) for a resident with significant cardiac conditions. The resident, who was admitted with a WCD, had a history of cerebral infarction, acute myocardial infarction, atherosclerotic heart disease, chronic atrial fibrillation, atrial flutter, ischemic cardiomyopathy, and end-stage renal disease. Despite a physician's order to change the WCD battery daily, the July 2023 Medication Administration Record did not reflect this action, indicating a lapse in care. Interviews with various staff members, including CNAs and LPNs, revealed a lack of knowledge and training regarding the WCD. Several CNAs were unfamiliar with the device and its care requirements, while one LPN mentioned that training was provided by an outside vendor but did not seem to have comprehensive knowledge of the device's operation. The Regional Nurse Consultant confirmed the absence of a facility policy on WCD use, relying instead on vendor-provided in-service training. This lack of consistent and thorough training placed the resident at risk of not receiving necessary care and monitoring for cardiac instability.
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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