Pruitthealth - Macon
Inspection history, citations, penalties and survey trends for this long-term care facility in Macon, Georgia.
- Location
- 2255 Anthony Road, Macon, Georgia 31204
- CMS Provider Number
- 115288
- Inspections on file
- 23
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pruitthealth - Macon during CMS and state inspections, most recent first.
A resident who was dependent on staff for toileting assistance was assisted by an Activities Assistant with her briefs while the door was open and no privacy curtain was used, contrary to facility policy requiring full visual privacy during care. Both the staff member and the DHS acknowledged that doors should be closed during care, but this was not consistently done.
Surveyors found that four resident rooms were not maintained in a clean and homelike condition, with thick dust on vent filters, sticky and stained floors, and food residue on a television. Facility staff confirmed that vents and filters had not been cleaned or changed in years, and that extra cleaning was needed but not always performed.
Two residents with significant mental health diagnoses, including bipolar disorder and schizoaffective disorder, were not referred for required PASRR Level II evaluations despite documentation of psychiatric conditions and use of psychotropic medications. Facility staff confirmed the absence of these evaluations in both cases.
A resident with a history of impaired mobility, CVA with hemiparesis, and a recent major injury from a fall did not receive all care plan interventions for fall prevention. Observations showed the absence of fall mats and non-skid socks, despite these being listed in the care plan. Staff interviews confirmed the resident's high fall risk and revealed gaps in communication and understanding of required interventions among CNAs and nursing staff.
A resident with moderate hearing impairment, as documented in the MDS and care plan, did not receive an audiology referral or assessment. Despite the resident's ongoing difficulty hearing and requests for communication accommodations, no follow-up or audiology services were provided, and staff confirmed the lack of referral or evaluation.
A resident with a history of CVA, hemiplegia, and hemiparesis did not receive a physician-ordered left hand orthotic, as confirmed by multiple observations and staff interviews. The resident reported rarely wearing the brace, and staff were unsure if it was ever applied, despite an order for daily use. This failure to provide restorative nursing for the upper extremity was confirmed by the DHS.
Three residents who smoked did not have complete and accurate smoking assessments, and one lacked a care plan related to smoking. One resident with moderate cognitive impairment was observed smoking without any assessment or care plan, another with severe cognitive impairment had an incomplete assessment, and a third had an inaccurate quarterly assessment despite being seen smoking. The facility's required procedures for assessment and care planning were not followed, as confirmed by the DHS.
Two residents with respiratory conditions did not receive oxygen therapy as ordered by their physicians. One resident's oxygen flow was set below the prescribed rate, and she reported not feeling the oxygen flow. Another resident's nasal cannula was not consistently in place, and the oxygen flow meter was set below the ordered rate on several occasions. Nursing staff and leadership confirmed that oxygen settings were not consistently checked against physician orders.
Staff did not consistently perform hand hygiene between glove changes during wound care for a resident with multiple stage four pressure ulcers, and personal care supplies such as a wash basin and urinal were found unlabeled and uncovered in a restroom. The Director of Health Services confirmed these practices did not meet facility infection control policies.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
Staff failed to provide care in a manner that maintained or enhanced a resident's dignity by not ensuring privacy during personal care. Specifically, an Activities Assistant was observed assisting a resident with her briefs while the door to the room was open and no privacy curtain was pulled. This action was in direct contradiction to the facility's policy, which requires staff to provide full visual privacy during routine care and treatment by closing doors and using privacy curtains. The resident involved was dependent on staff for toileting assistance, as documented in her Annual Minimum Data Set (MDS) assessment. Her care plan also indicated the need for skilled assistance with toileting and transfers to reduce fall risk. During interviews, both the Activities Assistant and the Director of Health Services acknowledged that the expectation was to close doors during care, but this was not always maintained. The failure to provide privacy during care had the potential to diminish the resident's quality of life.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in four resident rooms, as evidenced by observations of significant dust and particle buildup on ceiling and wall vent filters, sticky and discolored floors, and food residue on a television. Specifically, rooms F11, F13, F15, and F21 were found to have these deficiencies, with some vent filters having approximately two inches of thick dust and particle buildup, and floors in multiple rooms exhibiting sticky substances and discoloration. In one room, a television had food particles built up on the top and sides. Interviews with the Housekeeping Supervisor and Maintenance Director confirmed awareness of these issues. The Housekeeping Supervisor indicated that a calendar system was used to schedule deep cleaning, but acknowledged that extra cleaning was sometimes needed. The Maintenance Director admitted that vents and filters had not been cleaned or changed in years, and that these tasks were overdue. The Administrator stated that her expectation was for adequate staffing, training, and quality checks, but the observed conditions indicated these standards were not met in the affected rooms.
Failure to Complete PASRR Level II Evaluations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that two sampled residents with mental health diagnoses were referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. One resident was admitted with diagnoses including bipolar disorder, major depressive disorder, and anxiety, and their medical record and care plan documented ongoing psychiatric and mood disorders. Despite these diagnoses, there was no evidence in the electronic medical record of a completed PASRR Level II evaluation, and the Director of Health Services confirmed that this had not been done and could not provide an explanation for the omission. Another resident was documented as receiving antipsychotic, antianxiety, and antidepressant medications, with care plan problem areas including behavioral symptoms, psychotropic drug use, elopement risk, and cognitive loss/dementia. This resident's diagnoses included schizoaffective disorder and bipolar disorder, yet there was also no PASRR Level II evaluation present in the medical record. The Social Worker confirmed that, based on the resident's diagnoses, a PASRR Level II should have been submitted but was not.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
Staff failed to implement the individualized care plan for a resident identified as high risk for falls. The resident's care plan, last revised on 4/28/2025, included interventions such as placing frequently used items within reach, using a right leg knee immobilizer, assisting the resident when agitated, providing non-skid socks, placing fall mats, and encouraging the use of the call light. Despite these documented interventions, multiple observations revealed that fall mats were not present next to the resident's bed and non-skid socks were not on the resident during several checks. The resident was observed both lying in bed and sitting up without these safety measures in place. Staff interviews confirmed that the resident was at high risk for falls due to impaired mobility, a history of CVA with hemiparesis, behaviors, and a recent major injury from a fall. The LPN acknowledged the absence of fall mats and non-skid socks, and the Director of Health Services stated that interventions should be visible to CNAs via the care assist dashboard and communicated in reports. However, a CNA reported uncertainty about where to find intervention details and noted that no shift report was conducted, relying instead on nurses to communicate changes. These actions and inactions led to the failure to implement the care plan as written.
Failure to Provide Hearing Services for Resident with Documented Hearing Impairment
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including paraplegia and hearing impairment, was not provided with appropriate hearing services. The resident's Minimum Data Set (MDS) documented moderate difficulty with hearing, and the care plan acknowledged the hearing impairment, listing interventions such as facing the resident when speaking and providing written communication materials. However, there was no evidence in the physician's orders or medical record of a referral to audiology or further assessment for hearing services since admission. During interviews and observations, the resident reported not having a hearing aid, difficulty hearing, and needing staff to repeat questions or remove masks to facilitate lip reading. The Social Services Director confirmed that the resident was not on the audiology referral list and had not been seen by an audiologist, despite a note referencing a referral in January with no follow-up. The Director of Health Services also confirmed that no audiology referrals had been made for the resident, despite documentation of hearing difficulties in the care plan and MDS.
Failure to Provide Ordered Restorative Nursing for Upper Extremity
Penalty
Summary
A resident with a history of cerebrovascular accident (CVA), hemiplegia, and hemiparesis had a physician's order for a left upper extremity (LUE) hand orthotic to be worn three to four hours daily as tolerated. The resident's Minimum Data Set (MDS) assessment indicated upper extremity impairment on one side, but did not document receipt of restorative nursing or splint/brace assistance. Multiple observations over several days revealed that the resident did not have the prescribed hand brace on her left hand, and the resident reported rarely wearing the brace and not having worn it in a couple of weeks. Interviews with staff confirmed that the resident received restorative care for her lower body but not for her upper body, and that there was uncertainty among staff regarding whether the resident ever wore the splint. The Director of Health Services confirmed the existence of the physician's order for the left hand splint and stated that staff were expected to ensure the splint was applied as ordered. The failure to provide the ordered restorative nursing intervention had the potential to place the resident at risk for decreased range of motion in her left hand.
Failure to Complete Smoking Assessments and Care Plans for Residents Who Smoke
Penalty
Summary
The facility failed to ensure that three residents who smoked had complete and accurate smoking assessments, and did not provide a care plan related to smoking for one of these residents. Specifically, one resident with moderate cognitive impairment and a history of tobacco use was observed smoking in the designated area but had no smoking assessment or care plan addressing smoking. Another resident with severe cognitive impairment and nicotine dependence was identified as a smoker, but their smoking assessment was incomplete and marked as in process. The third resident, also with severe cognitive impairment and a history of tobacco use, had a care plan indicating the need for supervised smoke breaks, but the quarterly assessment inaccurately documented their smoking status, despite observations of the resident smoking in the designated area. The facility's policy required that residents who smoke be assessed upon admission, re-admission, with significant change, and at least quarterly thereafter, with care plans developed based on these assessments. However, record reviews, staff interviews, and direct observations revealed that these procedures were not consistently followed. The Director of Health Services confirmed the lack of completed or accurate smoking assessments and care plan interventions for the affected residents, acknowledging that this failure could result in staff not knowing what to monitor regarding residents' smoking behaviors.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
Staff failed to administer oxygen therapy as prescribed by physicians for two residents with respiratory conditions. One resident with diagnoses including sarcoidosis, shortness of breath, and eosinophilic asthma had a physician's order for oxygen at 3 liters per minute (LPM) via nasal cannula as needed. However, observation revealed the oxygen flow rate was set between 1.5 and 2 LPM, and the resident reported not feeling the oxygen flow, prompting her to call for a nurse. The resident's care plan and medical record confirmed the need for oxygen at the ordered rate. Another resident with a diagnosis of acute respiratory failure with hypoxia had a physician's order for continuous oxygen at 3 LPM. Observations showed the nasal cannula was not consistently in place, and the oxygen flow meter was set below the prescribed rate on multiple occasions, including 2.5 LPM and 1 LPM. Interviews with nursing staff and the Director of Health Services confirmed that the expectation was for staff to review and monitor oxygen orders and settings each shift, but this was not consistently done.
Failure to Follow Infection Control Practices During Wound Care and Improper Storage of Personal Care Supplies
Penalty
Summary
Staff failed to follow infection control practices during wound care for a resident with multiple stage four pressure ulcers. During wound care, an LPN was observed preparing supplies, washing hands, and donning gown and gloves, but did not perform hand hygiene between removing and donning new gloves at several points in the procedure. The LPN also assisted with removing fecal matter and again failed to perform hand hygiene before continuing wound care. The facility's policy required staff to implement infection prevention and control procedures, and the Director of Health Services confirmed that staff had been educated on these requirements. Additionally, personal care supplies, including a wash basin and urinal, were observed in a resident restroom unlabeled, uncovered, and exposed to the environment on multiple occasions. The Director of Health Services confirmed that these items should have been covered and labeled, and stated they would be discarded. These observations indicate lapses in infection control practices related to both direct resident care and the storage of personal care items.
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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