Pruitthealth - Fort Oglethorpe
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Oglethorpe, Georgia.
- Location
- 1067 Battlefield Parkway, Fort Oglethorpe, Georgia 30742
- CMS Provider Number
- 115409
- Inspections on file
- 20
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Pruitthealth - Fort Oglethorpe during CMS and state inspections, most recent first.
A resident whose preferred language was Spanish, with documented ability to communicate and little cognitive decline, was not provided effective communication in his preferred language despite facility policies and a care plan calling for interpreter services and other supports. Staff, including a RN, CNA, and LPN, attempted to communicate primarily in English or through nonverbal cues, did not routinely use interpreter services, and had not previously used the language line. During an interview facilitated by an interpreter, the resident reported never having used the language line with staff and being unable to have meaningful conversations, only trying to understand what was occurring.
Surveyors found that PTAC units in two resident rooms were not maintained in a clean, intact condition as required by facility policy, with one unit having a broken front grill, visible residue, and a broken air filter, and another unit containing debris, rust, and a rusty, clogged main screen. The Maintenance Supervisor acknowledged the poor condition of these units despite stating that PTAC units were serviced monthly, and the Administrator confirmed that maintenance staff were responsible for routine cleaning and upkeep of PTAC units and that failure to maintain them could negatively impact cleanliness.
The facility failed to provide and document scheduled bathing and related ADLs for three dependent residents, despite a policy requiring point-of-care ADL charting and daily nursing review. One cognitively intact resident with significant mobility and medical issues was care planned for showers three times weekly but received far fewer showers or bed baths, with no refusals documented; the resident reported rarely receiving showers and never refusing them, while CNAs and an LPN acknowledged showers were not consistently provided or verified. A second cognitively intact amputee with visual impairment and need for personal care assistance was scheduled for regular showers but received only a fraction of them, with the resident observed disheveled and stating she wanted baths and that staff were lazy, and the LPN Unit Manager confirming missed and undocumented bathing. A third resident with dementia and impaired mobility, care planned for scheduled showers and ADL setup, received significantly fewer baths than scheduled, had greasy hair despite repeated family requests for hair washing, and was observed in bed with a CNA confirming that hair care is part of ADLs; the Administrator stated all residents should be receiving showers without excuses.
A facility failed to follow its own smoke-free policy and care plan for a grandfathered supervised smoker. A resident with hemiplegia, vascular dementia, lack of coordination, and moderate cognitive impairment was care planned as a supervised smoker requiring staff oversight at designated smoking times. However, review of assignment sheets on multiple days showed no staff assigned to smoke breaks, and observations found the resident waiting in the lobby at scheduled smoking times without staff arriving, then returning to his room. Staff, including an RN, an LPN, a CNA, and the staffing coordinator, confirmed that no specific person was designated to supervise smoking and that it was generally assumed the CNA on the resident’s hall would handle it, leading the resident to report that he frequently missed his smoke breaks.
The facility failed to properly label and store food, with expired items and undated frozen pizzas found in storage. Additionally, a staff member did not follow hand hygiene protocols after touching a trash can lid, continuing food preparation without washing hands. These deficiencies could increase the risk of foodborne illness for residents.
The facility failed to provide written transfer notices to residents and their responsible parties for hospitalizations. A resident with dementia, another with chronic kidney disease, and a third with cognitive impairment were transferred without written notification. The Director of Health Services acknowledged the lack of awareness and policy regarding this requirement.
The facility failed to assist residents with hand hygiene before meals, as observed in five residents who required varying levels of assistance. Staff interviews revealed inconsistencies in practice, with some staff not assisting unless hands were visibly soiled, citing lack of resources and time. The Infection Control Preventionist and Director of Health Services acknowledged the absence of a specific policy for hand hygiene before meals.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident with a history of inappropriate behavior. Despite witnessing incidents, staff failed to follow the facility's abuse prevention policy and care plan interventions, allowing the abuse to occur in front of the nursing station. The facility's investigation was inadequate, as no additional staff or residents were interviewed, and there was a delay in providing psych services to the offending resident.
The facility failed to thoroughly investigate two incidents of resident-to-resident sexual abuse. Despite policy requirements, the facility did not interview additional staff, residents, or family members present in surveillance footage during incidents involving a resident groping another. The Administrator confirmed that no further interviews were conducted to ensure a comprehensive investigation.
Failure to Provide Preferred Language Communication Services
Penalty
Summary
The facility failed to honor a resident’s right to communicate in his preferred language, Spanish, despite documentation and policies indicating that language services were available. The resident’s EMR listed Spanish (Castilian) as his preferred language, and his annual MDS showed a BIMS score of 13, indicating little or no cognitive decline. His care plan identified that he did not speak the dominant language of the facility, noted that he understood some English, and outlined approaches such as using simple English phrases, encouraging gestures or assistive devices, involving family or friends who spoke his language, and providing a language interpreter line or foreign language translation device. The facility’s Notice of Nondiscrimination also stated that free language services, including qualified interpreters and information in other languages, were available for people whose primary language was not English. In practice, staff did not implement these communication supports for this resident. A RN reported attempting to understand the resident using nonverbal cues and English, noting her own primary language was Filipino and that the resident spoke Spanish. A CNA stated that although the resident’s preferred language was Spanish, she asked him to communicate in English and did not use other communication methods. An LPN reported difficulty understanding the resident due to the language barrier and acknowledged he did not speak Spanish; he stated that CNAs were only able to obtain a few phrases from the resident. During an interview with the resident and the LPN, an interpreter from a language line was brought in using a postcard with the language line information, and the LPN indicated he had never used the language line before. The resident stated he had never used the language line to communicate with staff and that he could not have a meaningful conversation, only trying to understand what was happening.
Failure to Maintain Clean and Intact PTAC Units in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain PTAC (Packaged Terminal Air Conditioner) units in a safe, clean, and intact condition as required by facility policy and resident rights to a safe, clean, comfortable, and homelike environment. The facility’s HVAC policy required staff to remove or open the PTAC access cover, inspect and clean or replace dirty air filters, reinstall the filter and access cover, clean the grill, and ensure filters were replaced or thoroughly cleaned at least every three months. Despite this policy, observations in two rooms on the 200 Hall showed PTAC units that were not properly maintained, including broken components, visible residue, debris, and rust. In one room, observations on two separate days revealed a PTAC unit with a broken front grill, visible residue inside the unit, and a broken air filter. In another room, observations on two separate days showed a PTAC unit containing debris and visible rust. During an observation and interview, the Maintenance Supervisor confirmed that the PTAC unit in the first room had a broken front grill with an approximately six-inch by four-inch piece of plastic missing, and that the PTAC unit in the second room had a main screen that was rusty and clogged. The Maintenance Supervisor stated that PTAC units were serviced monthly and acknowledged the observed units were not in good condition. In a separate interview, the Administrator stated that maintenance staff were responsible for the cleanliness and upkeep of PTAC units, that the expectation was for the units to be routinely cleaned and maintained, and that failure to maintain PTAC units could negatively impact cleanliness.
Failure to Provide and Document Scheduled Bathing and ADL Care for Three Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document scheduled bathing and related ADLs for three dependent residents, despite a policy requiring CNAs and nurses to document ADL care at the point of care and for nurses to review ADL documentation daily. The facility’s policy states that ADLs must be tracked daily in the EHR or CNA ADL flow sheet and that nurses should not accept illegible documentation. For one resident with hemiplegia, morbid obesity, CHF, diabetes, muscle weakness, difficulty walking, and abnormal posture, the MDS showed the resident was cognitively intact and required substantial to maximal assistance with bathing and other ADLs, and the care plan called for showers or baths on scheduled days and as needed, with daily hygiene care. However, review of bathing sheets over several weeks showed only eight documented showers or bed baths, fewer than the three scheduled showers per week, with no documentation of refusals in either the bathing records or progress notes. Interviews with this resident revealed she understood she was supposed to receive showers three times per week and reported she had not received a shower that week and generally only received one shower per week. She stated she had never refused showers and wanted showers or bed baths three times per week as scheduled. CNAs interviewed stated residents typically receive showers three times per week, that refusals should be documented after multiple attempts, and that this resident did not refuse showers. An LPN confirmed the resident’s shower schedule, acknowledged that she did not consistently receive showers or bed baths, and, after reviewing the shower sheets, stated it appeared the resident had not been consistently asked to shower. The LPN and the LPN Unit Manager both stated that if care or refusals were not documented, it meant it was not done, and the Unit Manager acknowledged she had not been verifying showers daily, citing being busy. For a second resident with peripheral vascular disease, gait abnormalities, a left below-knee amputation, phantom limb pain, legal blindness, and a need for assistance with personal care, the MDS showed the resident was cognitively intact, and the care plan included providing showers or baths on scheduled days and as needed. Review of bathing sheets over about a month showed bathing documented on 14 dates, but only six baths were actually received, fewer than the three scheduled showers per week, with only one documented refusal due to cold water. The LPN Unit Manager confirmed, based on the point-of-care history, that the resident did not receive scheduled bathing and reiterated that if it was not charted, it was not done. During observation and interview, this resident, found lying in bed disheveled, stated she was not refusing to bathe and that staff were simply lazy, and confirmed she wanted the baths. For a third resident with unspecified dementia, white matter disease, gait abnormalities, need for assistance with personal care, and bilateral artificial hip joints, the MDS indicated severe cognitive impairment. The care plan identified risk for ADL decline related to impaired mobility and dementia, with goals that ADL needs be met and interventions including providing showers per schedule and setting up the resident for ADLs. Review of bathing sheets over a similar period showed bathing documented on 14 dates, but only five baths were received, again fewer than the three scheduled showers per week, with only one documented refusal. A family representative reported having requested staff three or four times over two weeks to wash the resident’s hair during bathing. A CNA described ADLs as including washing hair, shaving, bathing the body, and cutting nails, and, on observation, confirmed the resident’s hair appeared greasy while the resident was lying in bed. The Administrator confirmed that everyone should be receiving showers and that there were no excuses for not doing so.
Failure to Provide Assigned Supervision for Grandfathered Supervised Smoker
Penalty
Summary
The deficiency involves the facility’s failure to follow its Smoke Free Policy and care plan requirements for a grandfathered supervised smoker, resulting in a lack of assigned staff supervision during designated smoking times. The facility’s policy states that when a grandfathered resident is identified as needing supervision, a partner must be physically present in the designated smoking area for all supervised smokers. The resident’s EHR documented diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, unspecified lack of coordination, hypertension, vascular dementia, and bilateral age-related nuclear cataracts. The resident was identified as a current every day smoker, with a quarterly MDS showing a BIMS score of 12 (moderate cognitive impairment), and the care plan documented that he was a supervised smoker at risk for smoking-related injury, requiring staff supervision during smoking at designated times. Despite these documented needs and the facility’s policy, review of CNA assignment sheets for multiple dates showed no medical staff assigned to supervise smoke breaks. Interviews with nursing staff and the staffing coordinator confirmed that no specific individual was designated for the resident’s smoke breaks and that it was generally assumed the CNA on the 100 hall would manage this responsibility. Observations on two separate days showed the resident waiting in the lobby at scheduled smoking times without staff arriving to supervise, leading him to return to his room and report that he frequently missed his smoke breaks. Staff interviews further revealed confusion and inconsistency about who was responsible for supervising smoking, including reference to a prior assignment book that may no longer be in use, demonstrating that the facility did not implement its own procedures for supervised smoking for this resident.
Deficiencies in Food Storage and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in the kitchen, as well as adequate hand hygiene by staff, which could potentially lead to the spread of foodborne illness and infection among residents. During an inspection, it was observed that six unopened containers of poultry seasoning were stored past their expiration date, and frozen pizzas were found without any received, open, or expiration dates in the walk-in freezer. Additionally, opened cases of sliced ham and beef roast in the walk-in cooler were not labeled with open dates, only received dates. The Dietary Manager (DM) and Cook1 acknowledged these oversights, with Cook1 admitting that the expired poultry seasoning should have been discarded earlier. Furthermore, the facility's staff failed to adhere to hand hygiene protocols. Cook1 was observed preparing food without washing hands after touching the trash can lid, which is against the facility's hand washing policy. The DM confirmed that dietary staff are required to wash their hands after handling unclean items, such as trash, to prevent the spread of bacteria. These lapses in food safety and hygiene practices were identified as deficiencies during the survey, posing a risk to the health of 108 out of 109 residents receiving meals from the kitchen.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of hospital transfers to residents and their responsible parties (RPs) for three residents, which is a requirement. Resident 80, who was admitted with a diagnosis of dementia, was transferred to the hospital due to an elevated temperature and a painful, swollen elbow. Although the family was notified by phone, there was no written notice provided. The Director of Health Services (DHS) admitted to not being aware of the requirement for written notices and confirmed that the facility lacked a policy addressing this requirement. Resident 32, with chronic kidney disease and a femur fracture, was transferred to the hospital following a fall and head laceration. The resident was sent with a packet of papers, but no written notice of transfer was provided to the resident or RP. Similarly, Resident 73, who was cognitively impaired, was transferred to the hospital due to seizure-like activities without a written notice being provided. The facility was unable to produce any documentation of written notices for these transfers, indicating a systemic issue in their notification process.
Failure to Provide Hand Hygiene Before Meals
Penalty
Summary
The facility failed to offer hand hygiene to residents prior to meals, as observed in five residents out of a sample of 32. These residents, who had varying degrees of cognitive impairment and required assistance with hygiene, were not assisted with hand washing before meals. For instance, one resident with moderately impaired cognition and dependent on staff for hygiene was not helped with hand washing before meals, despite expressing a desire to do so. Another resident, who was bed-bound and required moderate assistance with hygiene, also reported not being offered help with hand washing before meals. Interviews with staff revealed inconsistencies in the practice of assisting residents with hand hygiene. A Licensed Practical Nurse admitted to not assisting a resident with hand washing before setting up their meal tray. Certified Nurse Aides also reported not assisting residents with hand sanitation unless their hands were visibly soiled, citing a lack of hand wipes and time constraints. The Infection Control Preventionist acknowledged that while hand wipes were used in the dining room, they were not used for residents on the units, and the Director of Health Services confirmed that there was no specific policy for hand hygiene before meals, although it was expected to be done to prevent infections.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R62, from sexual abuse by another resident, R50. R62, who was admitted with dementia and Alzheimer's, was not cognitively intact, as indicated by a BIMS score of 5 out of 15. R50, who had a history of dementia, psychotic disturbance, and high-risk heterosexual behavior, was involved in inappropriate sexual behavior towards female residents, including R62. The facility's policy on preventing abuse was not followed, as evidenced by incidents on 06/10/24 and 07/01/24 where R50 was seen groping R62 in front of the nursing station. Staff members witnessed these incidents but failed to separate the residents or follow the care plan interventions. The facility's investigation revealed that no additional staff or residents were interviewed after the incidents, and there was a lack of documentation regarding R50's receipt of psych services until several weeks later. Surveillance footage confirmed the inappropriate contact between R50 and R62, and staff did not adequately intervene to ensure the safety of the residents. The Administrator acknowledged that staff did not adhere to the abuse policy or the care plan, which required separating the residents to prevent further incidents. Despite these failures, there have been no further incidents reported between R50 and R62 or with other residents.
Inadequate Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into two incidents of resident-to-resident sexual abuse involving Resident 62 and Resident 50. The facility's policy on the prevention of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property requires a comprehensive investigation, including obtaining signed statements from pertinent parties and assessing the cognitive status of victims and witnesses. However, during the incidents on June 10 and July 1, the facility did not interview additional staff, residents, or family members present in the surveillance footage to gather further witness statements or ensure that no other individuals were affected. The first incident was reported by an LPN on June 10, when Resident 50 was observed groping Resident 62. The facility's investigation did not include interviews with other residents or staff members following a review of surveillance cameras. In the second incident, reported on July 1 by a CNA who witnessed Resident 50 grabbing Resident 62's breast, additional staff members were interviewed, but there was no evidence that residents or Resident 50's family were interviewed. The Administrator confirmed that no further interviews were conducted to ensure a comprehensive investigation.
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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