Pruitthealth - Palmyra
Inspection history, citations, penalties and survey trends for this long-term care facility in Albany, Georgia.
- Location
- 1904 Palmyra Road, Albany, Georgia 31702
- CMS Provider Number
- 115628
- Inspections on file
- 20
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Pruitthealth - Palmyra during CMS and state inspections, most recent first.
The facility did not develop or implement care plan interventions for routine weekly skin assessments for multiple residents at risk for pressure ulcers, resulting in missed assessments and delayed identification of new or worsening wounds. Several residents with significant risk factors, including those with existing pressure ulcers and severe cognitive or physical impairments, did not receive the required weekly skin inspections as outlined in facility policy.
Multiple high-risk residents did not receive consistent weekly skin assessments or timely wound care treatments as ordered, resulting in delayed identification and management of pressure ulcers. Gaps in documentation, missed treatments, and unclear staff responsibilities contributed to the deficiency, with several residents developing new or worsening wounds that were only discovered during a facility-wide skin sweep.
Administration did not ensure that licensed nurses consistently performed and documented weekly skin assessments and wound treatments as ordered, impacting six residents at risk for or with existing wounds. The facility also lacked effective oversight and a QAPI process for its skin integrity program, and did not develop a Performance Improvement Plan despite identified issues. Staffing instability further contributed to lapses in wound care and documentation.
The facility's QAPI committee did not provide effective oversight to ensure staff performed weekly skin assessments, resulting in missed identification and treatment of pressure ulcers. Despite wound care issues being identified and recommendations for a Performance Improvement Plan, the facility did not implement timely corrective actions or conduct required audits, leading to a situation with the likelihood to cause serious harm to residents.
The facility did not have a Certified Dietary Manager (CDM) overseeing the kitchen after the previous CDM left, and the Registered Dietitian did not fully assume responsibility for the Dietary Services Department. Staff interviews and observations showed that cleaning schedules and duty assignments were not maintained, and dietary staff operated without clear direction, impacting the provision of oral meals to most residents.
Surveyors identified multiple deficiencies in food service operations, including unsanitary conditions in the ice machine, improper dishwashing procedures, inadequate food storage and labeling, and unclean kitchen floors. Staff failed to follow proper sanitation protocols for both equipment and food handling, and the dishwasher did not consistently reach required temperatures for effective sanitation.
The facility did not ensure that grievances raised by residents during council meetings were tracked, resolved, or communicated back to the residents, as required by policy. Staff interviews confirmed that while complaints were documented and forwarded to department heads, there was no consistent follow-up or resolution process in place.
The facility experienced repeated delays in meal service, with observations showing backlogs of dirty dishes and late delivery of meals, including the use of Styrofoam containers when plates were unavailable. An LPN and a CNA confirmed late meal deliveries, and a resident reported consistently late dinners. The Dietary Supervisor cited dishwashing issues and a shortage of dry plates as causes for the delays, affecting the majority of residents receiving oral diets.
Three cognitively intact residents who wished to vote in the November 2024 election were not assisted by staff with obtaining absentee ballots or renewing necessary identification, despite available resources and a visit from voter registrars. Staff interviews confirmed a lack of follow-up and awareness regarding which residents wanted to vote.
The facility did not promptly notify a physician about a resident's repeated episodes of low blood pressure and fainting, nor did it inform a responsible party about another resident's diagnostic test results and a new leg wound. These failures involved residents with complex medical conditions and resulted in missed communication regarding significant changes in condition and care.
A resident admitted with an indwelling Foley catheter, and with multiple complex diagnoses, did not have a physician's order for the catheter documented in their medical record. Facility policy required verification of such orders, but this was not completed, and staff confirmed the ongoing use of the catheter without a physician's order.
A resident with intact cognition and a documented dislike for broccoli was served broccoli at lunch, despite the facility's policy to honor food preferences. The resident reported not being asked about menu choices and regularly receiving unwanted foods.
A resident with multiple complex medical conditions developed a Stage 2 pressure ulcer that was not consistently or thoroughly assessed and documented according to facility policy. After the initial identification and measurement, no further weekly wound assessments were recorded until the resident was seen by an outside wound care clinic, and no subsequent documentation was found before the resident's discharge.
A resident with an unsteady gait and intermittent confusion slipped and fell in the memory care unit after water leaked from the ceiling, with trash cans placed to collect the water. The roof had a history of leaks, and although temporary fixes and repair quotes were documented, no permanent repairs had been completed, resulting in a persistent hazard.
A resident with multiple complex medical conditions experienced significant, unmonitored weight loss over several months. The facility did not follow its own policy for re-weighing, weekly weight monitoring, or timely referral to a Registered Dietician. Additionally, a Speech Therapy evaluation for swallowing difficulties was not ordered until prompted by a surveyor, despite earlier indications it was needed.
A resident with multiple sclerosis and other conditions did not receive scheduled doses of Kesimpta for several months due to late or missing pharmacy deliveries and lack of timely ordering. Medication administration records and staff interviews confirmed that the medication was not available on the scheduled dates, resulting in missed doses.
Failure to Develop and Implement Weekly Skin Assessment Interventions in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with measurable interventions and timetables for residents at risk for skin breakdown, as required by its own policy. Specifically, the care plans for several residents did not include interventions for routine weekly skin assessments, and for some residents, the existing care plan interventions for weekly skin inspections were not implemented. This deficiency was identified through observation, record review, and interviews, revealing that multiple residents with significant risk factors for pressure ulcers did not receive timely or documented weekly skin assessments. For example, one resident with end stage renal disease, diabetes, and a history of pressure ulcers had a care plan that lacked interventions for routine weekly skin assessments, and documentation showed missed weekly assessments over several months. Another resident with multiple Stage III and IV pressure ulcers and severe cognitive impairment also had a care plan without weekly skin assessment interventions, and only two assessments were documented over a two-month period. Additional residents with high or moderate risk for skin breakdown, as indicated by Braden Scale scores and other medical conditions, similarly lacked appropriate care plan interventions or did not receive weekly skin assessments as required. In several cases, new or worsening pressure ulcers were only identified during a facility-wide skin sweep, rather than through ongoing, routine monitoring. The surveyors determined that the facility's noncompliance with care planning and implementation requirements had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The deficiency was found to have existed for several months prior to the survey, affecting multiple residents with complex medical histories and significant risk factors for skin breakdown. The facility's own policy required person-centered care plans with measurable goals and regular updates, but these requirements were not met for the residents reviewed.
Failure to Consistently Assess and Treat Pressure Ulcers in High-Risk Residents
Penalty
Summary
The facility failed to perform consistent weekly skin assessments for residents at high risk for skin breakdown, resulting in delayed identification of pressure ulcers and inadequate documentation. Multiple residents with significant risk factors, such as immobility, cognitive impairment, and existing wounds, did not receive the required weekly skin assessments as outlined in the facility's own policy. For example, one resident with a history of Stage IV sacral pressure ulcer and multiple comorbidities did not have weekly skin assessments documented for several months, and new or recurrent wounds were only identified during a facility-wide skin sweep prompted by concerns about another resident. Other residents at high risk, including those with severe cognitive impairment, paraplegia, and malnutrition, also had significant gaps in their skin assessment documentation, with some going weeks or months without any recorded assessment. In addition to the lack of timely skin assessments, the facility failed to perform wound treatments as ordered by physicians or recommended by the wound care nurse practitioner for several residents. Medication Administration Records (MARs) revealed missed wound care treatments on multiple occasions, and in some cases, treatments were not initiated until days after wounds were identified. For instance, one resident with multiple Stage III and IV pressure ulcers had several missed wound care treatments, and another resident with an unstageable pressure ulcer to the left heel did not receive a physician's order or treatment until two days after the wound was first identified. There were also instances where wound care orders were not restarted after a resident returned from the hospital, resulting in a lack of wound care for over a month. Interviews with staff and review of facility records indicated systemic issues with the implementation and oversight of the skin integrity and wound care program. Staff responsible for weekly skin assessments were not consistently performing them, and there was confusion or lack of accountability regarding who was responsible for monitoring the program. High turnover among treatment nurses contributed to inconsistent documentation and missed treatments. The facility's own leadership acknowledged gaps in the completion of Braden Scale assessments and weekly skin audits, as well as difficulties in maintaining adequate staffing for wound care. These failures led to the delayed identification and treatment of pressure ulcers in multiple high-risk residents.
Failure to Ensure Weekly Skin Assessments and Oversight of Wound Management
Penalty
Summary
Administration failed to ensure that staff performed weekly skin assessments and wound treatments as ordered, and did not provide adequate oversight and monitoring of the skin integrity program. This deficiency affected six residents who were either at risk for skin breakdown or had existing wounds. Specifically, weekly skin inspections were not implemented for two residents, and interventions for routine weekly skin assessments were not developed for four other residents at risk for skin breakdown. Additionally, licensed nursing staff did not consistently perform or document weekly skin assessments and treatment orders for several residents. The facility also did not utilize an effective Quality Assurance and Performance Improvement (QAPI) process to identify and address concerns related to the wound management system. Despite recommendations from the Regional Nurse Consultant to develop a Performance Improvement Plan after identifying problems with the skin management program, there was no indication that such a plan was created. Staffing instability was noted, with five treatment nurses employed over several months and periods when only one treatment nurse was available, making documentation and wound care challenging.
Failure of QAPI Oversight for Weekly Skin Assessments
Penalty
Summary
The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) committee that provided oversight and monitoring to ensure staff were performing weekly skin assessments for timely identification and treatment of pressure ulcers. Review of the QAPI committee meeting agendas and minutes for two meetings showed no indication that the committee identified the staff's failure to perform these assessments. The facility's policy required a comprehensive, data-driven QAPI program with regular review and prioritization of performance improvement projects (PIPs), but there was no evidence that a PIP addressing wound care or skin assessments was implemented in a timely manner, despite identified problems. Interviews revealed that the Regional Nurse Consultant had identified wound care issues and recommended a PIP, but the facility did not act on this recommendation. Additionally, required monthly audits for residents with wounds were not completed. The Administrator acknowledged that a PIP was not implemented until after the survey team arrived, and attributed missed actions to ongoing leadership changes. The noncompliance was determined to have caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
Failure to Employ Certified Dietary Manager and Ensure Dietitian Oversight
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) to oversee the kitchen and did not ensure that the Registered Dietitian assumed full responsibility and accountability for the Dietary Services Department. Observations revealed that after the former CDM's last day, there was no CDM present in the kitchen, and the duties were not being properly managed. The facility's job descriptions for both the Dietitian and Dietary Manager outlined responsibilities for oversight, quality assurance, and staff direction, but these were not being fulfilled due to the absence of a CDM. On one occasion, a CDM from an affiliated facility was observed overseeing the kitchen, but this was not a consistent arrangement. Interviews with staff indicated that the Registered Dietitian attempted to assist the dietary supervisor but was not able to fully assume the required responsibilities. The Dietary Supervisor admitted to not making cleaning schedules or duty assignments, resulting in staff cleaning as they saw fit without assigned responsibilities. The staff list provided by the facility confirmed the absence of a CDM, and the Administrator acknowledged that the former CDM had left and had not been replaced. The deficiency affected the provision of oral meals to 184 of 203 residents.
Widespread Food Service Sanitation and Storage Deficiencies
Penalty
Summary
Multiple deficiencies were identified in the facility's food service operations, including improper sanitation and maintenance of kitchen equipment and surfaces. Observations revealed that the ice machine contained visible black and pink substances on the chute, and the ice bin was dirty and left open to air. Staff interviews confirmed that the ice machine had never been sanitized with the appropriate cleaning solution since its purchase, as the cleaning solution had never been ordered. Additionally, the kitchen floors were found to have food debris, dirt, and dried spills, and blankets were used on the floor to absorb water from a leaking dishwasher sprayer. The facility failed to ensure proper dishwashing procedures, as the dishwasher did not consistently reach the required water temperatures for effective sanitation, and the three-compartment sink was not used according to manufacturer recommendations. Staff were observed washing pots and pans without using the rinse or sanitizer steps, and sometimes dried cookware with cloth towels instead of allowing them to air dry. Instructional posters for proper sink use were present, but staff did not consistently follow them. The dishwasher was temporarily converted to use chlorine sanitizer due to ongoing hot water issues, but water temperatures remained below recommended levels during multiple cycles. Food storage and handling practices were also deficient. Opened food items in the walk-in refrigerator, such as turkey breast slices, cheddar cheese, liquid eggs, and cornbread, were not properly dated or labeled. Food on the steam table was observed at temperatures below 135°F, and clean dishes were stored on surfaces with visible food particles. Scoops were stored inside dry goods bins instead of in designated holders, and a no-touch trash can was not available near the sink, leading staff to use a large trash can with a lid that was manually opened. These practices had the potential to increase the spread of foodborne illness among residents receiving oral diets.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised by residents during council meetings for four out of seven months reviewed. Record review showed that issues such as lack of tea, late meals, inability to eat in the dining room on weekends, timing of evening meals, absence of coffee, and broken kitchen equipment were documented in the Patient/Resident Council Minutes/Report Forms. However, there was no evidence that these grievances were tracked, resolved, or that written decisions were issued to the individuals who filed them, as required by the facility's grievance policy. Interviews with staff revealed that while the Activity Director documented complaints and forwarded them to the relevant department heads, there was no follow-up with residents regarding the outcomes of their grievances. The Social Worker (BSW) confirmed that grievances were discussed in morning meetings but was not involved in resolving them, and the Social Worker (MSW) had not previously reviewed grievances from the council minutes. The Administrator acknowledged that staff should be educated on the grievance process and that any staff member could write a grievance, but the process for tracking and resolving grievances was not consistently followed.
Delayed Meal Service Due to Dishwashing Backlog and Plate Shortage
Penalty
Summary
The facility failed to ensure that resident meals were served in a timely manner, as required by posted mealtimes and resident needs. Multiple observations during kitchen visits revealed significant delays in dishwashing, with breakfast dishes remaining unwashed late into the morning and a backlog of dirty dishes waiting to be cleaned. These delays contributed to late meal service, as evidenced by lunch trays being delivered well after the scheduled lunch time on several occasions, including meals being served in Styrofoam containers due to a shortage of clean plates. Staff interviews confirmed that meal delivery was consistently late, with one resident reporting that dinner often arrived between 6:30 pm and 8:00 pm, despite the posted supper time of 4:30 pm. The Dietary Supervisor acknowledged responsibility for ensuring timely meal service and attributed the delays to issues with the dishwasher and insufficient dry plates for the next meal. The facility had recently purchased additional dinner plates, but this measure had not resolved the ongoing delays. The deficiency had the potential to affect 184 of 203 residents who received an oral diet, as timely meal service was not consistently maintained according to residents' needs, preferences, and posted schedules.
Failure to Assist Residents with Voting Rights
Penalty
Summary
The facility failed to assist three residents with the process of voting in the November 2024 election, despite their expressed wishes and cognitive ability to do so. Resident 14, who had intact cognition and significant physical disabilities, reported needing help to renew his state identification card in order to vote, but did not receive any assistance. Resident 28, also cognitively intact, had the necessary identification but was not provided with an absentee ballot or assistance to obtain one, despite her desire to vote. Resident 29, a registered voter, similarly did not receive an absentee ballot and expressed that he wanted to vote. Interviews with facility staff revealed a lack of follow-up and organization regarding residents' voting needs. The social worker with a master's degree stated she would survey residents with a BIMS score greater than 10 to determine voting interest and assist with identification, but was not employed during the relevant election period. The social worker with a bachelor's degree acknowledged that voter registrars had visited the facility but did not know which residents wanted to vote or provide follow-up assistance. The county voter registrar confirmed that resources were available online for assisting with voter registration and absentee ballots, but these were not utilized by the facility for the residents in question.
Failure to Notify Physician and Responsible Party of Significant Changes and Test Results
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding abnormal vital signs for one resident and did not notify the responsible party about diagnostic test results and a new skin impairment for another resident. For one resident with multiple diagnoses including heart disease, hypertension, and hypotension, therapy staff documented several episodes of low blood pressure and fainting during therapy sessions. Despite these significant changes in condition, there was no documentation that the physician or nurse practitioner was notified of the abnormal blood pressure readings until several days later, even though the therapy staff requested physician input regarding blood pressure parameters and medication regimen. For another resident with dementia, diabetes, and a gastrostomy, the facility failed to notify the responsible party of a diagnostic procedure to verify gastrostomy tube placement and did not communicate the results. Additionally, the responsible party was not informed about a new wound on the resident's leg, which was discovered during an observation with nursing staff. The nurse responsible for skin integrity was unaware of the wound prior to the observation, and there was no evidence that appropriate orders were obtained for the dressing applied to the wound.
Failure to Obtain Physician Order for Indwelling Catheter
Penalty
Summary
A resident with multiple complex medical conditions, including malignant neoplasm of the prostate, Stage IV pressure ulcer, multiple myeloma not in remission, paraplegia, and a colostomy, was admitted to the facility from a hospital with an indwelling Foley catheter in place. Review of the resident's admission orders and all subsequent orders up to several months after admission revealed there was no physician's order for the continued use of the indwelling urinary catheter. Facility policy for indwelling urinary catheters required verification of orders, but this step was not followed. Nursing progress notes documented the presence and replacement of the Foley catheter, and staff interviews confirmed the ongoing use of the catheter without a physician's order.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's documented food preferences as required by its policy and regulatory standards. According to the resident's medical record, the individual had intact cognition and had clearly indicated a dislike for broccoli on the Diet Review/Food & Beverage Preference List. Despite this, an observation of the resident's lunch meal tray revealed that broccoli was served. The resident reported never being asked about menu choices and consistently receiving foods he did not like, such as broccoli. The facility's policy states that food preferences and choices should be honored within reason according to the resident's diet order and available menu selections, but this was not followed in this instance.
Failure to Consistently Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly and consistently assess and document a pressure ulcer for one resident, as required by its own policy. The policy mandates weekly wound observations and comprehensive nursing assessments, including detailed measurements and descriptions of the wound and surrounding tissue. For the resident in question, who had multiple diagnoses including hemiplegia, vascular dementia, and was dependent on staff for all activities of daily living, a Stage 2 pressure ulcer was identified and measured on the sacrum. However, after the initial assessment, there were no further wound assessments or measurements documented for over a month, until the resident was evaluated by an external wound care clinic. Following the wound care clinic's evaluation, there continued to be no further assessments of the sacral pressure ulcer documented in the clinical record. The resident was later discharged to the hospital. The Director of Health Services confirmed that there was no weekly descriptive documentation of the resident's pressure ulcer, as required by facility policy.
Resident Fall Due to Ongoing Ceiling Leak
Penalty
Summary
A deficiency occurred when a resident slipped and fell due to water leaking from the ceiling in the memory care unit. Observations revealed that water was actively leaking from the ceiling, with trash cans placed on the floor and a table to collect the dripping water. The incident involved a resident who was ambulatory with an unsteady gait, used a cane, and was sometimes confused. The fall happened in the dayroom, and there was no documented injury as a result of the incident. Review of facility records and staff interviews indicated that the roof had a history of leaking, particularly during heavy rain, and that temporary measures such as applying tar had been used. Multiple invoices and proposals for roof repairs were present, but none specified the exact section needing repair, and no repairs had been completed in 2024. The Maintenance Director confirmed the ongoing nature of the leak and the lack of permanent repairs, contributing to the continued presence of the hazard.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and address significant weight loss for one resident, who had multiple diagnoses including hemiplegia, dysphagia, diabetes, and major depressive disorder. Despite the facility's policy requiring weekly weights and re-weighs for significant weight changes, the resident experienced an 8.2% weight loss in one month, a 16.4% loss in three months, and a 23.6% loss in six months. There was no evidence that the resident was re-weighed after the initial significant weight loss, nor was the Registered Dietician consulted in a timely manner. The resident was not placed on weekly weights as required by policy, and the Weight Loss/Gain Checklist and other interventions were not documented as completed. Additionally, the resident reported coughing and choking with eating, which prompted a Nurse Practitioner to order a Speech Therapy (ST) evaluation. However, the ST evaluation was not ordered until after the state surveyor's inquiry, despite the earlier recommendation. The Director of Health Services confirmed that the required re-weigh and dietician notification did not occur, and the ST evaluation order was delayed.
Failure to Ensure Timely Ordering and Administration of Specialty Medication
Penalty
Summary
The facility failed to ensure timely ordering and administration of Kesimpta, an injectable medication used to treat multiple sclerosis, for one resident. Observations revealed that the medication was present in the refrigerator on one date but missing on a subsequent date when the next dose was due. Review of the resident's records showed that Kesimpta was not administered for several months, specifically in April, May, June, and July, due to the medication being unavailable or not delivered on time. Pharmacy delivery records confirmed late deliveries in April, May, and July, and no evidence of delivery in June. Medication administration records also indicated that the medication was not given because it was not available on the scheduled dates. The resident involved had multiple diagnoses, including multiple sclerosis, cognitive communication deficit, seizures, and hypertension. Staff interviews confirmed that the medication was not administered when it was not available, and the Director of Health Services acknowledged that specialty medications due monthly should be ordered prior to the due date. There was no evidence that the resident received Kesimpta for the months in question, resulting in a failure to comply with requirements for timely medication ordering and administration.
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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