Pruitthealth - Lithonia, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lithonia, Georgia.
- Location
- 2816 Evans Mill Road, Lithonia, Georgia 30058
- CMS Provider Number
- 115473
- Inspections on file
- 20
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pruitthealth - Lithonia, Llc during CMS and state inspections, most recent first.
Surveyors found that staff failed to maintain required cold holding temperatures for orange juice during breakfast meal service. Facility policy required the Dietary Manager or designee to ensure all potentially hazardous cold foods were held at or below 41°F, including keeping items on ice during tray line and limiting time on trays before service. During an observation, a cook measured three four-ounce containers of orange juice at temperatures above 51°F instead of 41°F or below. The cook acknowledged the correct standard, and the RD later confirmed that cold items should be kept on ice during tray line. This failure had the potential to affect most residents receiving an oral diet.
The facility failed to ensure proper food storage and sanitation, with expired and unlabeled food items found in storage areas. The ice machine showed signs of inadequate cleaning, and wet nesting of clean kitchenware was observed. The Dietary Manager and Registered Dietitian acknowledged these issues, indicating ongoing staff training and audits.
A facility failed to assess a resident with dementia for self-administration of medication, leaving pain-relieving ointments unsecured at the bedside. Another resident with intact cognition had medications left unattended in her room, contrary to facility policy. Staff interviews revealed a lack of awareness and adherence to procedures, posing risks of unauthorized access and medication interactions.
A resident with paranoid schizophrenia was not screened for PASRR level two, despite facility policy requiring such assessments for significant mental illnesses. The resident, taking anti-psychotropic and anti-depressant medications, was not referred for further evaluation as she exhibited no triggering behaviors. Staff interviews confirmed the oversight, potentially impacting the resident's access to appropriate care.
A CNA failed to clean a shared blood pressure cuff between uses on two residents, contrary to the facility's infection control policy. The CNA initially claimed to have cleaned the cuff but later admitted she had not, citing nervousness. The ADON confirmed the requirement for cleaning before and after each use.
The facility failed to resolve grievances related to lost personal items for three residents, as required by its grievance policy. Multiple clothing items went missing, and grievances were not documented or followed up in a timely manner. Interviews revealed a lack of clear procedures and accountability in handling grievances and lost items, leading to unresolved issues and dissatisfaction among residents and their families.
A resident with end-stage renal disease and bilateral amputations was not offered showers as per her care plan, despite being cognitively intact and expressing a preference for showers. The facility's records showed she was scheduled for showers twice a week, but she often received bed baths instead. Staff interviews revealed a lack of awareness of her preferences, and the DON confirmed she was not on the daily showers list, leading to inadequate hygiene care.
A facility failed to develop a person-centered care plan for a resident, a bilateral amputee with end-stage renal disease, regarding her bathing preferences. Despite being cognitively intact and expressing a preference for showers, the resident was not offered showers as per her care plan. Instead, she received bed or sponge baths, and staff were unaware of her preferences. The DON confirmed the resident was not on the Daily Showers list, leading to her receiving only one shower since admission.
A facility failed to maintain mechanical lifts in a state of readiness, affecting a resident with mobility and cognitive impairments. The resident, dependent on mechanical lifts for daily activities, was left waiting in discomfort due to an uncharged lift. Observations revealed multiple lifts not plugged in, and the DON acknowledged the issue, despite new lifts being purchased.
Improper Cold Holding Temperatures for Orange Juice During Meal Service
Penalty
Summary
The facility failed to ensure that cold food, specifically orange juice, was maintained at or below 41°F in accordance with its policy titled “Food Temperatures.” The policy, revised on 10/21/2025, states that the Dietary Manager or designee is responsible for ensuring all food reaches and maintains proper temperatures prior to tray assembly, and that all potentially hazardous cold foods must be held at 41°F or less, including being held on the line in an ice bath and not set up on trays more than 15 minutes before meal service unless kept chilled. During a breakfast observation on 03/05/2026 at 7:29 a.m., a cook used the facility’s thermometer to check three four-ounce plastic containers of orange juice, which each registered above 51°F instead of the required 41°F or below. The cook acknowledged that the orange juice should have been at or below 41°F. A subsequent interview with the Registered Dietician on 03/06/2026 confirmed that cold items should be kept on ice during tray line service and that she had spoken with dietary staff about this practice. This deficiency had the potential to affect 134 of 141 residents receiving an oral diet by promoting the growth of pathogens that cause foodborne illness. No specific individual resident medical histories or conditions at the time of the deficiency were described in the report.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices in the dietary department, as observed during a survey. Opened food items in the dry storage and walk-in refrigerator were not securely wrapped, labeled, or dated, and some were past their expiration dates. Specific items included expired thickened orange juice, nutritional drinks, stuffing mix, sour cream packets, cottage cheese, cream cheese icing, and a cabbage and carrot mix. Additionally, a head of lettuce was found without a label or date. The Dietary Manager (DM) acknowledged the responsibility of all staff to check expiration dates and admitted to ongoing in-services for new staff regarding storage, labeling, and dating. The DM also confirmed that the ice machine, which had not been deep cleaned since a previous date, showed signs of a reddish-black substance, indicating a lack of routine maintenance. Furthermore, the facility did not maintain sanitary cleanliness in the kitchen, as evidenced by wet nesting of clean pots, pans, and baking trays. The sanitizing process involved rewashing dishes through a low-temperature dishwasher, but wet nesting was still observed. The Registered Dietitian (RD) confirmed that kitchen audits were conducted monthly, focusing on equipment base, labeling, dating, and cleanliness. However, the RD did not physically label or date food items, relying on staff to do so when deliveries arrived. The RD also noted that she had reported the need for ice machine cleaning in the previous month's report. Both the DM and RD acknowledged the issue of wet nesting and discussed plans to address it, but these actions were not part of the deficiency findings.
Failure to Secure Medications and Assess Self-Administration
Penalty
Summary
The facility failed to assess a resident, identified as R88, for self-administration of medication and did not secure medications properly. R88, who has a diagnosis of Alzheimer's disease with early onset and dementia, was observed with pain-relieving ointments on his bedside table. Despite the facility's policy requiring a prescriber's order and an assessment for self-administration, there was no documentation or care plan indicating that R88 was authorized to self-administer these medications. Interviews with staff, including a CNA and an LPN, revealed a lack of awareness regarding R88's self-administration of medication, highlighting a gap in communication and adherence to the facility's procedures. Another resident, R43, was found with medications left unattended at her bedside, despite having intact cognition as indicated by a BIMS score of 15. The medications, which included ointments for various conditions, were reportedly left by nurses for CNAs to apply after the resident's bath. This practice was contrary to the facility's expectations, as stated by the Registered Nurse Supervisor and the Director of Nursing, who both emphasized that medications should not be left unattended in residents' rooms. Interviews with CNAs confirmed that this was a recurring issue, with medications being left at the bedside at least twice a week. The deficient practices observed in both cases had the potential to allow unauthorized access to medications by residents and visitors, posing a risk of medication interactions or overmedication. The facility's failure to adhere to its own policies regarding medication security and self-administration assessments contributed to these deficiencies, as evidenced by the lack of proper documentation and communication among staff members.
Failure to Conduct PASRR Level Two Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to conduct a Pre-Admission Screening and Resident Review (PASRR) level two for a resident diagnosed with paranoid schizophrenia, which is a significant mental illness. The facility's policy requires that residents with significant mental illness or intellectual/developmental disabilities undergo a PASRR level two assessment to ensure they receive care in the most integrated setting appropriate to their needs. However, the resident, who was admitted with a diagnosis of paranoid schizophrenia and was taking anti-psychotropic and anti-depressant medications, was not screened for PASRR level two. The care plan for the resident included interventions for paranoid schizophrenia and bipolar disorder, but there was no focus area for PASRR level two screening. Interviews with facility staff, including the RN Supervisor, Director of Nursing, and Social Services Director, revealed that the resident was not referred for a PASRR level two assessment because she did not exhibit any behaviors that would trigger such a referral. The Social Services Director confirmed that the resident was not referred for PASRR level two, as the facility's practice was to refer residents only if they exhibited behaviors indicative of a major mental disorder. This oversight had the potential to prevent the resident from receiving necessary specialized services.
Failure to Clean Shared Blood Pressure Cuff
Penalty
Summary
The facility failed to adhere to its policy on cleaning and disinfecting shared medical equipment, specifically a blood pressure cuff, before and after use between residents. The policy, reviewed on 12/29/2023, mandates that shared equipment such as blood pressure cuffs and pulse oximeters be cleaned with soap and water or an appropriate cleaner and then disinfected prior to and after use on different patients. However, an observation on 9/4/2024 revealed that a Certified Nurses Aid (CNA) did not clean the blood pressure cuff between taking vital signs of two residents in the same room. The CNA was observed removing the electronic blood pressure cuff from one room and using it on two residents without cleaning it in between. When questioned, the CNA initially claimed to have cleaned the cuff but later admitted she had not done so, citing nervousness. The Assistant Director of Nurses confirmed that the protocol requires cleaning before and after each use. The CNA was seen searching for disinfecting wipes at the nurse's station after completing her rounds, indicating a lapse in following the established infection control procedures.
Failure to Resolve Grievances Related to Lost Personal Items
Penalty
Summary
The facility failed to appropriately resolve grievances related to lost personal items for three residents. The facility's grievance policy requires that grievances be resolved within a reasonable time frame and that the complainant be kept informed of the progress. However, the facility did not adhere to this policy. For one resident, multiple clothing items went missing in April 2023, but only one unrelated grievance was documented in December 2023. The family expressed distrust in the facility's ability to keep items safe. Another resident filed a grievance for missing clothing in February 2024, but no follow-up was completed until the survey investigation in March 2024. A third resident filed a grievance in September 2022 for missing a large amount of clothing, but no resolution was documented. Interviews with facility staff revealed a lack of clear procedures and accountability in handling grievances and lost items. The Administrator acknowledged the need for improvement in the lost and found process and the absence of a policy for laundry services. The Social Service Specialist indicated that grievances should be investigated and followed up within 14 days, but this was not consistently done. The Laundry Staff reported issues with labeling and returning laundry, and unclaimed items were kept in a container for an unknown period. The facility's failure to follow its grievance policy and effectively manage lost items led to unresolved grievances and dissatisfaction among residents and their families.
Failure to Offer Resident Scheduled Showers
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not offering her the choice of showers, which was part of her care plan. The resident, identified as R2, was a bilateral amputee with end-stage renal disease on hemodialysis. Despite being cognitively intact and expressing a preference for showers, she was not offered this option. The facility's records showed that R2 was scheduled for showers on Mondays and Thursdays, but she often received bed baths instead. Interviews with staff revealed a lack of awareness and understanding of R2's preferences and care plan, leading to her not being offered showers. The Dialysis Social Worker reported that R2 arrived for treatment in the same clothes over several days and had poor hygiene, indicating a lack of proper bathing. The Director of Nursing confirmed that R2 was care planned for showers twice a week but was not on the daily showers list, and her shower days coincided with her dialysis days, which did not accommodate her needs. This oversight resulted in R2 not receiving showers as per her care plan, affecting her comfort and hygiene.
Failure to Implement Resident's Bathing Preferences
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident, identified as R2, regarding her bathing preferences. R2, a bilateral amputee with end-stage renal disease on hemodialysis, was cognitively intact and expressed that it was somewhat important for her to choose between different bathing options. Despite this, the facility's ADL care plans did not include her preferences for showers or baths. The care plans dated March 13, 2024, lacked any goals or interventions related to her bathing preferences. Observations and interviews revealed that R2 was not offered showers as per her care plan, which stated she should receive showers on Wednesday and Saturday evenings. Instead, she was given bed or sponge baths, and staff were unaware of her preference for showers. The Director of Nursing confirmed that R2 was not on the Daily Showers list, despite being care planned for showers twice a week. This oversight led to R2 receiving only one shower since her admission in November 2023.
Mechanical Lift Readiness Deficiency
Penalty
Summary
The facility failed to maintain mechanical lifts in a state of readiness, impacting the care of a resident with significant mobility and cognitive impairments. The resident, who has a history of arthritis, Alzheimer's Disease, cerebrovascular accident, dementia, and hemiplegia or hemiparesis, was observed to be dependent on mechanical lifts for all activities of daily living. During an observation, multiple mechanical lifts were found in the hallways, not in use, and most were not plugged into power sockets, rendering them unavailable for immediate use. On a subsequent observation, a resident was found in discomfort, requesting assistance to be moved from a wheelchair to a bed. A CNA indicated that the mechanical lift near the resident's room was not charged, necessitating a wait for assistance. The Director of Nursing acknowledged issues with the mechanical lifts, noting that new lifts had been purchased and additional ones were approved for purchase. Despite an in-service training, the deficiency persisted, as staff were expected to ensure all lifts were charged and ready for use.
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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