Pruitthealth - Magnolia Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Moultrie, Georgia.
- Location
- 3003 Veterans Parkway S, Moultrie, Georgia 31788
- CMS Provider Number
- 115326
- Inspections on file
- 15
- Latest survey
- November 1, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pruitthealth - Magnolia Manor during CMS and state inspections, most recent first.
The facility failed to properly label, date, and discard expired food items, as observed in the dietary department. Additionally, a CNA was seen feeding a resident with her fingers and placing the plate on her lap, contrary to sanitary practices. These actions were confirmed by staff and had the potential to affect the sanitary delivery of food to residents.
The facility failed to submit Level II PASARR applications for five residents with significant mental health diagnoses, as revealed through staff interviews and record reviews. Despite being on psychiatric medications and displaying behaviors warranting further assessment, these residents did not receive the necessary evaluations. The Social Service Director admitted to not making any Level II referrals and was unclear about the criteria, contributing to the deficiency.
The facility failed to conduct necessary nutrition assessments for three residents, leading to significant weight loss and inadequate nutritional care. A resident with severe cognitive impairment lost 10 lbs without an admission assessment, while another with heart failure lost 41 lbs without being assessed for weight changes. A third resident experienced a 51 lbs weight loss with minimal RD oversight. Staffing shortages and lack of RD coverage contributed to these deficiencies.
The facility failed to maintain infection control during medication administration and dining. An LPN placed a glucometer and lancet on a bed without a barrier and pocketed a used needle. Another LPN did not sanitize hands after administering nasal spray, and medication was poured into bare hands. Staff did not sanitize hands between serving trays or offer residents hand hygiene before meals. A stained sheet was found on a PPE cart, and an old IV tubing was left in a resident's room.
A resident with little cognitive impairment requested the removal of facial hair, which was not addressed for two weeks, impacting her dignity. Despite being told to wait for shower days, the grooming was not performed, causing distress. A CNA confirmed the delay, and the DHS stated that such requests should be fulfilled promptly.
A resident with a BIMS score indicating little cognitive impairment was found with expired prescription medication at their bedside, which they occasionally used without being assessed for self-administration. The LPN confirmed the medication's presence, and the DHS was unaware of it, acknowledging the risk of expired medication use.
The facility failed to provide four residents with written information about their rights to accept or refuse medical treatment and to formulate an advance directive. This deficiency was identified through record reviews and staff interviews, revealing that the required Advance Directive Checklist was not completed for these residents, denying them the opportunity to make informed healthcare decisions.
The facility failed to maintain a safe and clean environment, with issues such as a stained pillow for a resident, trip hazards from electrical sockets, a cracked toilet, and unsanitary water fountains. These deficiencies were observed across multiple halls, and staff were unaware of these conditions until they were pointed out.
The facility failed to inform residents about the grievance process, including the identity of the Grievance Official and how to file a grievance. During a Resident Council meeting, several residents were unaware of these details, and there was confusion among staff about the Grievance Official's identity. Meeting minutes from the past year showed that resident rights and grievance procedures were not discussed, leading to the deficiency.
The facility failed to implement comprehensive care plans for several residents, resulting in missed showers, inadequate incontinence care, and lack of psychiatric and vision services. Observations revealed residents left in soiled conditions and without necessary services, despite care plans outlining these needs. Staff interviews confirmed a lack of adherence to care plans, highlighting communication gaps and oversight in resident care.
The facility failed to provide adequate ADL care for six residents, resulting in deficiencies in personal hygiene and care. One resident missed scheduled showers and was not assisted with facial hair removal, while another was left soiled in bed without timely incontinence care. Additionally, four residents had long and dirty fingernails, indicating a lack of personal hygiene care. Staff interviews revealed confusion about responsibilities and a lack of a clear policy on ADL care.
The facility failed to provide vision services to two residents, one with moderate cognitive impairment and another with worsening vision due to cataracts. Despite recommendations for eyeglasses and reports of vision issues, there was a lack of follow-up and communication, resulting in delays in obtaining necessary vision care.
A resident with a left-hand contracture did not receive the prescribed application of a resting hand splint, as staff failed to follow the OT Restorative Nursing Program recommendation. Despite a physician's order and care plan, the resident was observed without the splint on multiple occasions. Interviews revealed that CNAs were either unaware or not trained to apply the splint daily, and the resident confirmed the lack of assistance. The Therapy Director and OT highlighted the risk of further contractures without the splint, while the DHS expected staff to adhere to the orders.
The facility failed to maintain a safe environment by not securing an oxygen tank, allowing aerosol cans in a resident's room, and not providing adequate supervision for high fall-risk residents. An unsecured oxygen tank posed a risk, aerosol cans were against policy, and fall prevention measures were inconsistently applied, leading to falls and injuries.
The facility failed to provide proper respiratory care for two residents, leading to potential infection risks. One resident had oxygen masks uncovered and on the floor, and an oxygen cylinder was left free-standing in the room for almost a month despite requests for removal. Another resident's oxygen tubing was improperly stored and not labeled when changed. Staff interviews confirmed these issues, and the DHS acknowledged the risks and responsibilities involved.
The facility failed to provide necessary mental health services to three residents, despite their diagnoses of depression, PTSD, and other mental health conditions. One resident did not receive counseling or psychiatric services, another did not receive psychiatric services after admission, and a third was taking antipsychotic medications without a psychiatric consult. The Social Services Director and Director of Health Services confirmed the lack of follow-through on psychiatric referrals.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to its policy on labeling, dating, and storage of food items, as observed during a survey. In the dietary department, several items were found to be improperly labeled or expired. Specifically, a stand-up cooler contained two pitchers of liquid that were neither labeled nor dated, and a bottle of mayonnaise with an expired date. In the dry pantry area, a box of flour tortillas was found to be expired. Additionally, a walk-in cooler contained a large package of diced ham that had been opened but was not labeled with an open or use-by date. These observations were confirmed by the Dietary Aide and later by the Dietary Manager, who acknowledged the failure to follow the facility's policy. In the 500-hall dining room, a Certified Nursing Assistant (CNA) was observed assisting a resident with eating in an unsanitary manner. The CNA used her fingers instead of utensils to feed the resident and placed the resident's plate on her lap rather than on the table. This practice was confirmed by the CNA and was contrary to the expectations outlined by the Unit Manager/Registered Nurse and the Director of Health Services, who stated that utensils should be used and plates should remain on the table. These actions had the potential to affect the sanitary delivery of food to residents, increasing the risk of foodborne illnesses.
Failure to Conduct PASARR Level II Assessments
Penalty
Summary
The facility failed to submit applications for Level II PASARR (Pre Admission Screening and Resident Review) to the appropriate state designated mental health authority for evaluation and determination of the need for specialized services for five residents. This deficiency was identified through observations, staff interviews, and record reviews. The facility did not provide a policy on PASARR when requested, indicating a lack of procedural guidance. Resident 15 had multiple psychiatric diagnoses, including major depressive disorder and psychotic disorder with delusions, but only had a PASARR Level I assessment. The Social Service Director (SSD) acknowledged the absence of a Level II assessment despite the resident's significant mental health diagnoses. Similarly, Resident 16, who was admitted with anxiety and dementia, displayed irrational behaviors and was on psychiatric medications, yet did not have a PASARR Level II assessment. The SSD and other staff interviews confirmed the lack of a system to monitor and apply for Level II assessments when new psychiatric diagnoses were made post-admission. Residents 61, 65, and 23 also lacked PASARR Level II assessments despite having significant mental health diagnoses and being on psychotropic medications. Interviews with the SSD and medical records staff confirmed the absence of these assessments. The SSD admitted to not making any Level II referrals since working at the facility and was unsure of the criteria for such assessments, mistakenly believing only schizophrenia required a Level II assessment. This lack of knowledge and procedural oversight contributed to the deficiency, potentially impacting the residents' access to necessary mental health services.
Failure to Conduct Nutrition Assessments
Penalty
Summary
The facility failed to provide evidence of completed nutrition assessments by a Registered Dietitian (RD) for three residents, leading to deficiencies in nutritional care. Resident R66, admitted with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and heart disease, experienced a weight loss from 130 lbs to 120 lbs without an admission nutrition assessment being conducted. Despite being on a puree diet and Ensure supplement, the care plan noted hydration deficits, and the resident continued to decline with a poor appetite. The RD confirmed that R66 was not seen for an admission assessment. Resident R44, with diagnoses including heart failure and a history of stroke, was not assessed for weight changes despite a significant weight loss from 208 lbs to 167 lbs. The RD last saw R44 in February, and the care plan identified risks related to nutrition and hydration. Resident R46, with Alzheimer's and other conditions, was seen by the RD only twice, despite a significant weight loss from 181 lbs to 130 lbs. The RD noted the lack of coverage and the inability to perform necessary assessments due to staffing shortages, with the Dietary Manager filling in for some duties. The facility's failure to conduct timely and adequate nutrition assessments contributed to the deficiencies identified by surveyors.
Infection Control Deficiencies in Medication Administration and Dining Practices
Penalty
Summary
The facility failed to maintain effective infection control practices during medication administration for three residents. For one resident, the LPN placed a glucometer and lancet on the bed without a barrier during a fingerstick blood sugar check and later put a used needle in his pocket before discarding it in the sharps container. Another resident received nasal spray medication without the LPN sanitizing his hands after glove removal, and the medication container was placed on the cart without a barrier or cleaning. A third resident's medication was poured into the LPN's bare hands without gloves. In the dining room, staff did not wash or sanitize their hands between serving trays or offer residents hand hygiene before meals. A CNA assisted a resident with eating without sanitizing her hands. The Unit Manager and other staff were unaware of the policy regarding hand hygiene during meal assistance, although it was expected that staff should sanitize hands before assisting residents or handling food. Additionally, a PPE cart was found with a stained sheet lying uncovered next to PPE items, and an IV tubing coated with brown substances was left in a resident's room, despite the resident not requiring an IV. The tubing was identified as belonging to a previous resident and was removed after being reported by the current resident.
Failure to Honor Resident's Grooming Request
Penalty
Summary
The facility failed to honor a resident's request for personal grooming, specifically the removal of facial hair, which impacted the resident's dignity and self-determination. The resident, who had a BIMS score indicating little to no cognitive impairment, required moderate assistance with personal hygiene. Despite her requests, the staff did not remove the facial hair on her chin for approximately two weeks, telling her to wait until her designated shower days. However, even on those days, the grooming was not performed, leading the resident to stop requesting assistance, which caused her distress. Observations confirmed the presence of thick facial hair on the resident's chin over several days. Interviews with the resident and a CNA corroborated the resident's account, with the CNA acknowledging the delay in addressing the resident's request. The Director of Health Services stated that the expectation was for such requests to be fulfilled promptly, without the resident having to wait for specific days. This deficiency highlights a failure in the facility's care practices, as the resident's right to dignity and respect was not upheld.
Unauthorized and Expired Medication Found at Resident's Bedside
Penalty
Summary
The facility failed to ensure that unauthorized and expired medications were not stored at the bedside of a resident, identified as R16. During an observation, a bottle of expired prescription medication, labeled as premium saline moisturizing nasal spray, was found on R16's bedside table. The medication had a discard date of 10/28/2023, and the resident was not assessed to self-administer medications. The facility did not provide a policy on self-administering medications when requested. R16 had a BIMS score of 15, indicating little to no cognitive impairment, and had diagnoses including unspecified dementia, paroxysmal atrial fibrillation, chronic kidney disease stage 4, and pulmonary hypertension. During an interview, R16 acknowledged using the medication occasionally and was unaware of its expiration. The LPN confirmed that residents are not allowed to have medications in their rooms unless assessed. The Director of Health Services was unaware of the medication in R16's room and acknowledged the risk of residents using expired medication.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide residents and/or their representatives with written information regarding their rights to accept or refuse medical or surgical treatment, as well as to formulate an advance directive. This deficiency was identified for four residents out of a sample of 28. The facility's policy, dated 2014, required that an Advance Directive Checklist be completed upon admission, but this was not adhered to for the residents in question. For Resident 52, the medical record lacked signed acknowledgment or evidence of receipt of information about their rights. Resident 65's record also did not contain an Advance Directive Checklist, and the Social Services Director confirmed this omission. Similarly, Resident 15's record showed a lack of proper documentation and acknowledgment of advance directive information, despite having a DNR order. The Social Services Director and Administrator acknowledged the absence of the checklist, noting that a revised version was in use. Resident 29's record also lacked evidence of providing written information about their rights, with the Social Services Director unaware of whether the facility currently provided such information. These failures collectively denied the residents the opportunity to make informed choices about their healthcare decisions.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment across three of its halls, specifically Halls 600, 700, and 800. Observations revealed several deficiencies, including a stained pillow for a resident identified as R53, trip hazards from electrical sockets on the floor in the common areas of the 700 and 800 halls, a cracked toilet in the 600 hall, and unsanitary conditions of three water fountains covered in a thick beige/white hard scale substance. These issues were confirmed through staff interviews and record reviews, indicating a lack of awareness and maintenance in these areas. The resident R53, who was admitted with conditions such as muscle weakness, dysphagia, and type 2 diabetes mellitus, was observed lying on a soiled, yellow-stained pillow without a pillowcase over several days. The Director of Health Services expressed that it was expected for staff to replace soiled pillows and provide clean pillowcases, highlighting a lapse in meeting these expectations. Additionally, the Maintenance Director and Administrator were unaware of the cracked toilet and the condition of the water fountains until the environmental tour, indicating a lack of regular monitoring and maintenance in the facility.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were informed about the grievance process, including the identity of the Grievance Official and how to file a grievance. The facility's policy, titled 'Grievances: Healthcare Centers,' designates the Administrator as the Grievance Official responsible for overseeing the grievance process, maintaining confidentiality, and issuing written decisions. However, during a Resident Council review meeting, it was revealed that three out of seven residents did not know how to file a grievance or the name of the Grievance Official. Additionally, there was confusion among staff, as the Resident Council President incorrectly identified the Social Services Director as the Grievance Official, and the Activities Director, who was new to the position, did not confirm this information. The Activities Director admitted to not reviewing resident rights, the grievance filing process, or the name of the Grievance Official during previous meetings. A review of the Resident Council meeting minutes from the past year confirmed that these topics were not discussed. This lack of communication and education regarding the grievance process led to the deficiency, as residents were not adequately informed about their rights and the procedures for voicing grievances.
Deficiencies in Care Plan Implementation and Resident Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. For one resident, identified as R36, the facility did not adhere to the scheduled bathing preferences, resulting in missed showers and inadequate personal hygiene. Observations revealed that the resident was left in soiled bed linens with a strong odor of urine, indicating a lack of attention to incontinence care. The Unit Manager was unaware of these issues, highlighting a communication gap and failure to follow the care plan. Another resident, R52, experienced similar neglect in incontinence care. Despite being dependent on staff for toileting assistance, the resident was found in a soiled state multiple times, with staff failing to provide timely care. Interviews with staff revealed a lack of adherence to the care plan, which required checks every two hours and assistance with toileting. The Director of Health Services and other staff confirmed the expectation for regular incontinence care, yet it was not consistently provided. Additionally, the facility did not provide necessary psychiatric and vision services for residents R25, R65, and R56. R65 and R25 did not receive psychiatric consultations despite their diagnoses and care plan requirements. R56, who required vision services, did not receive prescribed eyeglasses following an eye exam. These oversights were confirmed through interviews with staff, including the Social Services Director and the Director of Health Services, who acknowledged the failure to implement the care plans as intended.
Deficiencies in ADL Care and Hygiene in LTC Facility
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for six residents, leading to deficiencies in personal hygiene and care. One resident, with a BIMS score indicating little to no cognitive impairment, reported not receiving assistance with facial hair removal and missed showers on scheduled days, particularly on weekends. Despite having a shower in her bathroom, the resident was told by staff that showers were only provided on weekdays, forcing her to wash at the sink, which she could not do thoroughly due to physical limitations. The Unit Manager was unaware of these missed showers, indicating a lack of communication and oversight. Another resident, with a BIMS score indicating cognitive impairment, was found lying in bed soiled with urine, with the room having a strong urine smell. The resident reported being left in this state since the previous night and expressed that this was a frequent occurrence. Despite being dependent on staff for toileting assistance, the resident was not checked for incontinence care until late in the morning. Interviews with staff revealed a failure to perform regular checks and provide necessary care, with the Director of Health Services acknowledging the need for more frequent rounds. Additionally, four residents were observed with long and dirty fingernails, indicating a lack of personal hygiene care. Interviews with staff revealed confusion and inconsistency regarding nail care responsibilities, with some staff believing it was not part of standard ADL care. The facility lacked a clear policy on ADL care, contributing to the oversight in maintaining residents' personal hygiene. The Director of Health Services confirmed that fingernails should be cleaned during baths and trimmed when needed, but this was not consistently documented or communicated among staff.
Failure to Provide Vision Services to Residents
Penalty
Summary
The facility failed to obtain vision services for two residents, R56 and R78, as required by their policy on specialty services. R56, who has moderate cognitive impairment and impaired vision, had an eye exam over four months ago, and glasses were recommended. However, the glasses were never ordered due to a lack of follow-up by the social worker, as confirmed by the Director of Health Services. R56 expressed concern about not receiving his eyeglasses, which were prescribed in May 2024. R78, who has little to no cognitive impairments, was observed using broken readers instead of prescription glasses. R78 reported worsening vision due to cataracts and difficulty with daily activities like watching television and completing word puzzles. Despite informing staff about his vision issues and broken glasses, no action was taken to arrange an eye examination. The social worker was unaware of R78's vision problems and had not made a referral for an eye exam, as the resident had not met the 90-day stay requirement for vision services. The facility's policy requires that all residents be screened for vision services, regardless of their status. However, the Director of Health Services was unaware of R78's vision problems, indicating a communication breakdown within the facility. Both residents experienced delays in receiving necessary vision care, highlighting a failure in the facility's process for managing specialty services and ensuring timely follow-up on physician recommendations.
Failure to Apply Splint Device as Ordered
Penalty
Summary
The facility failed to adhere to an Occupational Therapy Restorative Nursing Program recommendation for a resident with a left-hand contracture, which required the application of a progressive resting hand splint. The resident, who had a BIMS score indicating little to no cognitive impairment, was observed on multiple occasions without the splint device, despite a physician's order and care plan specifying its use for 6-7 hours daily. Interviews with the resident confirmed that staff were not assisting with the application of the splint, and the resident had ceased requesting help due to lack of assistance. Interviews with Certified Nursing Assistants (CNAs) revealed a lack of awareness and training regarding the splint application. CNA QQ admitted to not applying the splint during her shifts, while CNA NN was unaware of the requirement to apply the splint daily. The Therapy Director and Occupational Therapist confirmed the necessity of the splint to prevent further contractures, and the Director of Health Services expressed an expectation for staff to follow the physician's orders. The deficiency in care had the potential to result in the progression of the resident's contractures.
Deficiencies in Safety and Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from potential accident hazards for its residents. One resident receiving oxygen therapy had an unsecured oxygen tank in their room, which posed a risk of tipping over and potentially exploding. Despite the resident's awareness of the risk and requests for staff to secure the tank, it remained free-standing for nearly a month. The Director of Health Services acknowledged the risk and confirmed that staff are expected to monitor rooms for safety. Another resident was found with numerous aerosol cans in their room, which is against the facility's policy. The resident was unaware of the policy, and staff interviews confirmed that aerosol cans are not permitted in resident rooms. The Director of Health Services stated that staff should remove such items and have family members retrieve them. The facility also failed to provide adequate supervision for residents at high risk for falls. One resident had a fall mat ordered but it was found leaning against the wall instead of on the floor. Another resident, who had a history of falls, was found without fall mats at the bedside. A third resident fell while attempting to use the bathroom because they could not reach the call light, and there was no indication of neuro checks being conducted post-fall. Staff interviews revealed that fall prevention measures were not consistently implemented, and the Director of Health Services expected adherence to the facility's fall protocol.
Improper Respiratory Care and Equipment Handling
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents receiving oxygen therapy, leading to potential infection risks. For one resident, oxygen masks were found uncovered and resting on the floor, and an oxygen cylinder was left free-standing in the room, posing a safety hazard. Despite the resident's awareness of the risk and requests for removal, the oxygen cylinder remained in the room for almost a month. Interviews with staff confirmed the presence of the cylinder and acknowledged the associated risks. For another resident, the oxygen tubing was not stored properly, as it was found laying across the oxygen concentrator without being bagged. The resident did not use the oxygen equipment consistently, and the tubing was not labeled when changed. Interviews with staff revealed that nurses were responsible for changing the tubing, but there was a lack of clarity on the labeling process. The Director of Health Services confirmed that not all residents required humidified oxygen and that nurses were responsible for contacting doctors if issues arose.
Failure to Provide Mental Health Services to Residents
Penalty
Summary
The facility failed to provide necessary mental health services to three residents, as required by their policy. Resident 61, diagnosed with major depressive disorder, PTSD, and depression, did not receive counseling or psychiatric services despite experiencing periods of depression and confusion. The Social Services Director (SSD) was unaware of the resident's depression and did not follow up on counseling refusals, which were not documented. The resident's care plan included a referral for psychiatric evaluation, but no such evaluation was conducted. Resident 65, with diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, PTSD, and dementia, also did not receive psychiatric services after admission to the facility. Despite the care plan indicating a need for psychotropic drug monitoring and psychiatric consultation, the SSD and Director of Health Services (DHS) confirmed that no psychiatric services were provided, which could have potentially benefited the resident's quality of life. Resident 25, admitted with conditions such as anxiety disorder and depression, was taking two antipsychotic medications but had not received a psychiatric consult. The care plan noted the need for a psychiatric consultation, but the SSD did not make the referral, and the DHS confirmed that the SSD should have followed through with the referral process. The resident expressed feelings of sadness and a desire to talk to someone, highlighting the lack of mental health support provided by the facility.
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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