Pruitthealth - Holly Hill, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Valdosta, Georgia.
- Location
- 413 Pendleton Place, Valdosta, Georgia 31602
- CMS Provider Number
- 115562
- Inspections on file
- 22
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Pruitthealth - Holly Hill, Llc during CMS and state inspections, most recent first.
The facility did not ensure dietary staff wore beard guards as required by policy, risking food contamination. The Dietary Manager was observed preparing and serving food without a beard cover, contrary to the facility's hygiene standards. Interviews confirmed the expectation for all staff to use hair nets and beard guards, with the DM admitting to not wearing one and being unsure of the policy's application in the dining room.
The facility failed to prevent personal food items from being stored in the medication room, risking contamination of medications and supplies. Observations revealed items like hot dog buns and condiments next to medical supplies. Staff interviews confirmed that such storage is unsanitary and could lead to contamination and infection. The facility lacked a policy on this issue.
A resident with visual impairment and multiple health issues was not cleaned promptly after meals, and the call light was repeatedly found out of reach. Staff interviews confirmed that care plan interventions were not consistently followed, leading to a deficiency in maintaining the resident's dignity and rights.
Three residents in the facility were found with unauthorized medications at their bedside, posing a risk of unauthorized access and potential harm. One resident had unauthorized nasal spray and Advair Diskus, another had 23 bottles of medications without a self-administration order, and a third had nitroglycerin tablets for chest pain without proper authorization. Facility staff were unaware of these situations, highlighting a failure in monitoring and ensuring compliance with medication storage policies.
The facility failed to accommodate the needs of two residents: one morbidly obese resident was not provided with a suitable bed, causing fear of falling, and a visually impaired resident did not have a call light within reach and was not assisted with eating and cleaning. Staff interviews confirmed that care plans were not followed, leading to these deficiencies.
The facility failed to provide residents and their representatives with written information about their right to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified through interviews and record reviews, revealing that the Admission Packet lacked necessary language. Three residents were specifically noted, with varying cognitive statuses, and staff confirmed the absence of required documentation.
The facility failed to maintain a safe, clean, and homelike environment on the 100 hall. Observations revealed stained toilet bases and caulking, rusty light fixtures, and protruding wall trim in several rooms. These conditions were confirmed by the Maintenance Director, posing potential risks to residents' safety and quality of life.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. A resident assessed to self-administer medications lacked a supporting care plan. Another resident received oxygen therapy at an incorrect rate, contrary to physician orders. Additionally, a resident's care plan for nutrition was not followed, as they were not weighed weekly as required. Further discrepancies were noted in oxygen therapy management for two other residents, with incorrect flow rates administered compared to physician orders.
A resident with multiple contractures and muscle weakness did not receive the prescribed splints as ordered, which were essential for managing their condition. Despite clear medical orders and a care plan requiring daily application of orthoses, observations revealed the resident was without splints over several days. Interviews with CNAs, LPNs, and the Director of Health Services confirmed the lapse in care, highlighting a failure to adhere to the prescribed treatment plan.
The facility failed to prevent accident hazards for two residents. One resident was exposed to harmful chemicals when bleach was found in their bathroom, contrary to facility policy. Another resident had a free-standing oxygen tank in their room, which was not secured in a rack or cart as required. Staff confirmed that such practices were against policy and posed potential risks.
A resident with urinary retention and neurogenic bladder had their catheter tubing improperly positioned, coiled, and hung at bed height instead of below the bladder, contrary to care plan instructions. Observations revealed staff placed the catheter bag on a dresser knob based on the resident's preferences, and the CMA admitted to not receiving proper instructions. The DHS confirmed the improper positioning and corrected it.
The facility failed to complete timely nutrition assessments for two residents, as required by its policy. One resident, with conditions like dysphagia and acute kidney failure, and another with atrial fibrillation and end-stage renal disease, did not receive assessments until months after admission. The Registered Dietitian confirmed the oversight, and the facility's administration was unaware of the delay, potentially risking the residents' nutritional health.
A LTC facility failed to follow physician orders for oxygen administration for four residents, leading to potential respiratory complications. One resident received oxygen at an incorrect rate, confirmed by a nurse who adjusted it. Another resident received oxygen at a higher rate than prescribed, with no humidifier attached. A third resident's oxygen rate was incorrect, and equipment was not dated. A fourth resident's oxygen masks were not stored properly, posing an infection risk. Staff interviews confirmed these deficiencies.
The facility failed to lock a medication cart, remove expired medications, and label open dates on medications, posing risks of unauthorized access and ineffective treatment. An LPN confirmed the cart couldn't be locked, and expired medications were found on various carts. The DHS emphasized the importance of locking carts and labeling medications to prevent harm.
Failure to Use Beard Guards by Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff adhered to the policy requiring the use of hair nets and beard guards during food preparation and service. Observations revealed that the Dietary Manager (DM) was preparing and serving food trays without wearing a beard cover, which is a violation of the facility's policy titled 'Dietary Partner Hygiene and Dress Code' dated 11/10/2020. This policy mandates that all dietary partners must cover their hair and facial hair with appropriate coverings to prevent contamination. Interviews with the DM, Director of Health Services (DHS), and Infection Preventionist (IP) confirmed the expectation that all staff, including the DM, should wear hair nets and beard guards while handling food. The DM admitted to not wearing a beard guard and expressed uncertainty about the policy's application in the dining room. Both the DHS and IP emphasized the risk of food contamination if facial hair is not covered, highlighting the potential impact on 80 out of 83 residents receiving an oral diet.
Inappropriate Storage of Personal Food Items in Medication Room
Penalty
Summary
The facility failed to ensure that personal food items were not stored in the medication storage room, which could lead to contamination of medications and supplies. During an observation, personal food items such as hot dog buns, mustard, and ketchup were found on a shelf in a cupboard next to medical supplies in the medication room. The Director of Health Services (DHS) was present during this observation and confirmed the presence of these items, acknowledging that the medication room should only contain residents' medications and supplies to prevent contamination. Interviews with staff, including the DHS and a Licensed Practical Nurse (LPN), confirmed that food items should not be stored in the medication room as it is unsanitary and could lead to contamination and possible infection to residents. The Infection Preventionist (IP) also stated that food items could cause bacterial growth, further contaminating the medications. The facility lacked a policy regarding the storage of personal food items in the medication room, as no such policy was provided upon request.
Failure to Maintain Resident Dignity and Rights
Penalty
Summary
The facility failed to maintain or enhance the rights, dignity, and respect of its residents, specifically in the case of a resident identified as R70. R70 was admitted with multiple diagnoses, including head injury, aneurysm of the heart, muscle weakness, and visual impairment. Observations revealed that the resident was not cleaned promptly after eating, and the call light was not within reach, which are essential aspects of care for someone with R70's conditions. On two separate occasions, the call light was found on the floor, out of reach, and the resident had food on his face and clothes for an extended period after breakfast. Interviews with staff, including a CNA, MDS Coordinator, LPN, and the Director of Health Services, confirmed that the facility's staff did not follow the care plan interventions for residents with visual impairments. The care plan specified that the call light should be within reach and that residents should be assisted with eating and cleaned afterward. The staff acknowledged the need for regular checks to ensure these interventions were followed, but these actions were not consistently implemented, leading to the deficiency in care for R70.
Unauthorized Bedside Medication Storage
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Summary
The facility failed to ensure unauthorized medications were not stored at the bedside for three residents, leading to potential unauthorized access to medications. Resident 58, who was authorized to self-administer only albuterol and eye drops, was found with unauthorized medications, including nasal spray and Advair Diskus, in their room. The Director of Health Services and Unit Manager were unaware of these unauthorized medications, which posed a risk of other residents coming into contact with them. Resident 19, with no physician's orders or self-assessment for self-administration, had 23 bottles of medications on their bedside table. The resident admitted to taking their own vitamins and medications without any formal authorization or monitoring by the facility staff. The Director of Health Services confirmed that Resident 19 was not supposed to have medications at the bedside and emphasized the need for a self-assessment and physician's order for self-administration. Resident 67, who had a diagnosis of chest pain, was found with a bottle of nitroglycerin tablets at their bedside, which they took as needed for chest pain. There were no physician's orders for self-administration, and the resident admitted to taking the medication due to delays in nurse response. The Licensed Practical Nurse confirmed the absence of a self-administration order and acknowledged that the resident should not have had the medication at their bedside. The facility's staff expressed concerns about the potential for overdose and adverse reactions due to unsupervised medication use.
Failure to Accommodate Resident Needs
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Summary
The facility failed to accommodate the needs of a morbidly obese resident, R66, by not providing a bed that was suitable for her size. R66, who had a history of obesity class 3, vascular dementia, and cerebral vascular accidents with left side paralysis, was observed lying in a bed with a mattress that was too narrow, causing her fear of falling during care activities. Despite expressing her concerns to the staff, the issue persisted, and it was confirmed by the Therapy Director that the bed was inadequate for R66's body size, putting her at risk of falling. Another deficiency was identified with resident R70, who was visually impaired and had multiple diagnoses including unspecified head injury, aneurysm of the heart, and muscle weakness. The facility failed to ensure that R70 had a call light within reach, as it was observed on the floor and out of reach on multiple occasions. Additionally, R70 was found with food on his face and clothes after breakfast, indicating a lack of assistance with eating and cleaning, which was necessary due to his vision impairment. Interviews with staff confirmed that the care plan required the call light to be accessible and assistance with eating and cleaning to be provided. The Director of Health Services and other staff acknowledged the deficiencies, noting that interventions in the care plan were not being followed, particularly for residents with visual impairments. The lack of adherence to the care plan and failure to provide necessary accommodations for residents' needs led to these deficiencies being identified during the survey.
Failure to Provide Written Information on Medical Rights
Penalty
Summary
The facility failed to provide residents and their representatives with written information regarding their right to accept or refuse medical or surgical treatment, as well as to formulate an advance directive. This deficiency was identified through resident and staff interviews, record reviews, and examination of the facility's Admission Packet and Advance Directive policy. The policy, dated November 6, 2017, required that residents or their responsible parties be asked about the existence of any advance directives prior to or upon admission, and that an Advance Directive Checklist be completed. However, the Admission Packet lacked language pertaining to the provision of written information about these rights. Three residents were specifically noted in the findings. One resident, admitted with Alzheimer's Disease and other conditions, had an undetermined cognition status. Another resident, with chronic kidney disease and cerebral infarction, had a BIMS score indicating little to no cognitive impairment and had signed an Advance Directive form, but there was no documentation of a discussion about their right to accept or refuse treatment. A third resident, with multiple diagnoses including viral pneumonia and diabetes, also had a BIMS score indicating little to no cognitive impairment. Interviews with facility staff confirmed that there was no evidence of residents being provided with the necessary written information regarding their rights upon admission.
Facility Fails to Maintain Safe and Homelike Environment
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Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on one of its halls, specifically the 100 hall. Observations revealed that the toilet base and caulking in a shared bathroom between rooms 102, 104, and other rooms were stained dark brown. Additionally, in one of the rooms, the light fixtures above the residents' beds were observed to be rusty brown colored, and the wall trim was sticking out toward the residents' bed. These conditions were noted during multiple observations over several days. The Maintenance Director confirmed the observations, acknowledging the stained toilet bases and caulking, rust-covered light fixtures, and the wall trim issue. The deficient practice resulted in an unsafe and unsanitary environment, potentially placing residents at risk for avoidable injury or illness and diminishing their quality of life.
Deficiencies in Care Plan Implementation and Oxygen Therapy Management
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. Resident R58, who had chronic kidney disease and other conditions, was assessed to self-administer medications such as albuterol and eyedrops. However, there was no care plan in place to support this assessment and authorization, indicating a lack of proper documentation and planning for the resident's medication management. Resident R77, with chronic respiratory failure and moderate cognitive impairment, was prescribed oxygen therapy at 2 liters per minute via nasal cannula. Observations revealed that the resident was receiving oxygen at 3 liters per minute without a humidifier, contrary to the physician's order. Additionally, the care plan for R47, who required oxygen therapy and had a risk of nutrition and hydration issues, was not followed as the resident was not weighed weekly as required. This lack of adherence to care plans and physician orders was confirmed by staff interviews, highlighting a systemic issue in care plan implementation. Further deficiencies were noted with residents R29 and R338, both of whom were receiving oxygen therapy at incorrect flow rates compared to their physician orders. R29 was observed receiving oxygen at 3 liters per minute instead of the prescribed 2 liters, while R338 was receiving 2.5 liters per minute instead of the ordered 3 liters. These discrepancies were verified by nursing staff, who acknowledged the responsibility to ensure care plans and physician orders were followed. The lack of updated care plans for oxygen use and the failure to administer oxygen at the correct rates were significant deficiencies in the facility's care delivery.
Failure to Apply Splints as Ordered for Resident with Contractures
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Summary
The facility failed to apply splints as ordered for a resident, identified as R56, who was receiving splints to manage contractures. R56 was admitted with multiple contractures and muscle weakness, requiring specific orthotic devices to be applied daily to prevent further deterioration. The care plan and medical orders specified the application of various orthoses for four-to-five-hour wear tolerance daily, with skin inspections following removal. However, during multiple observations over several days, R56 was found without the prescribed splints, indicating a lapse in care. Interviews with facility staff, including CNAs, LPNs, and the Director of Health Services, confirmed that the splints were not applied as ordered. The CNAs were responsible for applying the splints and documenting their application, but they failed to do so. The Director of Health Services and therapy staff emphasized the importance of following the orders to prevent worsening contractures. Despite the education provided to CNAs on the application of splints, the deficiency persisted, as evidenced by the absence of splints on R56 during the survey period.
Facility Fails to Prevent Accident Hazards for Residents
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Summary
The facility failed to ensure that two residents were free from accident hazards, as observed during a survey. Resident 59 was exposed to harmful chemicals when a bottle of bleach was found above the bathroom sink in their room. This was confirmed by a Registered Nurse, who acknowledged that bleach should not be stored in a resident's bathroom. The Director of Health Services also confirmed that it was against the facility's policy for residents to have bleach or any hazardous chemicals in their rooms. Resident 82 was exposed to a free-standing oxygen tank in their room, which was not secured in a rack or cart as required by the facility's policy on oxygen administration. The resident confirmed that the tank had been in the corner of the room for several weeks. The Director of Health Services and several staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, confirmed that oxygen tanks should be secured in a cradle or carrier to prevent them from falling and potentially causing harm.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, identified as R39, who was admitted with diagnoses including urinary retention and neurogenic bladder. The resident's care plan included instructions to keep the drainage bag below the level of the bladder. However, observations revealed that the catheter tubing was coiled and hung on a dresser knob, positioning the catheter at the height of the bed instead of below the bladder. This improper positioning was confirmed during an interview with the resident, who stated that staff placed the bag there. Further observations with a Certified Med Tech (CMA) and the Wound Nurse showed the catheter drainage bag was hung on the resident's bedside drawer handle, again resulting in the bag being at waist height. The CMA reported that the placement was based on the resident's preferences and admitted to not receiving instructions on how to hang the catheter bag. The Director of Health Services and the Unit Manager confirmed the improper positioning of the catheter bag and acknowledged that it was too high, subsequently repositioning it below the bladder.
Delayed Nutrition Assessments for Two Residents
Penalty
Summary
The facility failed to provide evidence that nutrition assessments were completed by the Registered Dietitian (RD) for two residents, R47 and R77, as per the facility's policy. The policy mandates that each resident receive an initial nutritional screening and comprehensive nutritional assessment within 14 days of admission. However, for R47, who was admitted with conditions including dysphagia, hypertension, and acute kidney failure, the nutrition assessment was not completed until several months after admission. Similarly, R77, admitted with diagnoses such as atrial fibrillation and end-stage renal disease, did not have a nutrition assessment completed until months after admission. Interviews with the RD confirmed the delay in completing the nutrition assessments for both residents. The RD acknowledged the oversight and mentioned having a system in place to track assessments, which failed in these instances. The facility's Administrator and Director of Health Services were unaware of the delay in completing the assessments, despite the facility's policy requiring timely completion. This deficiency had the potential to place the residents at risk of nutrition problems and weight loss.
Oxygen Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to physician orders for oxygen administration for four residents, leading to potential respiratory complications and infections. Resident R338, who had a BIMS score indicating little to no cognitive impairment, was observed receiving oxygen therapy at an incorrect rate of 2.5 LPM instead of the prescribed 3 LPM. This discrepancy was confirmed by a registered nurse, who adjusted the rate accordingly. The Director of Health Services (DHS) expected nursing staff to check oxygen concentrators every shift to ensure compliance with physician orders. Resident R77, with moderate cognitive impairment, was observed receiving oxygen at 3 LPM instead of the ordered 2 LPM. Additionally, there was no humidifier bottle attached to the oxygen concentrator. The DHS and Unit Manager confirmed the incorrect setting through photographic evidence and acknowledged the deficiency. They emphasized the responsibility of licensed nursing staff to monitor residents' oxygen saturation levels. Resident R29, with little to no cognitive impairment, was observed receiving oxygen at 3 LPM instead of the prescribed 2 LPM. The tubing and humidifier bottle were not dated, contrary to the facility's expectations. The DHS stated that it was not the facility's policy to label or date tubing or humidifiers. Resident R34, diagnosed with COPD, had issues with oxygen masks not being stored in bags when not in use, posing an infection control risk. Interviews with staff confirmed the expectation for oxygen masks to be covered to prevent infections.
Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication management protocols, as evidenced by several observations and staff interviews. A medication cart was found unlocked on the 200 long hallway, which was confirmed by an LPN who stated that the cart had been unable to lock since the previous week. The LPN admitted that the cart was placed against the wall with the drawers facing the wall when not in use, but it was not in full sight from the nurses' station, posing a risk of unauthorized access to medications. The Director of Health Services (DHS) was unaware of the issue and emphasized that medication carts should always be locked when not in use to prevent residents from accessing potentially harmful medications. Additionally, expired medications and medications without open dates were found on various medication carts. A bottle of Bisacodyl 5 mg tablets with an expiration date of 9/2024 was discovered, and an RN confirmed the medication was expired, noting that expired medications lose effectiveness. Furthermore, containers of insulin, glucometer strips, and eyedrops were found without open dates, which is crucial for diabetic management. The DHS expressed that staff should remove expired medications and label open dates to ensure effective treatment and prevent adverse reactions. An LPN confirmed the absence of open dates on medication containers, acknowledging the importance of this practice.
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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