Pruitthealth - Richmond, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Augusta, Georgia.
- Location
- 1227 West Wheeler Parkway, Augusta, Georgia 30909
- CMS Provider Number
- 115147
- Inspections on file
- 17
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pruitthealth - Richmond, Llc during CMS and state inspections, most recent first.
A resident with cognitive and physical impairments was unable to reliably use the call light system due to difficulty pressing the button and vision deficits. After a new call light system was installed, no assessment was conducted to ensure the resident could use the device, and previously used touch pads were found incompatible. Staff confirmed the resident's inability to activate the call light independently, and the lack of assessment following the system change contributed to the deficiency.
The facility experienced delays in completing and transmitting Minimum Data Set (MDS) assessments for thirteen out of thirty-four residents. The delays were linked to a transition to a new company, which left resident records in the previous company's electronic systems, and a shortage of staff. Interviews with the MDS Coordinator and RN MDS Coordinator revealed that Admission MDS assessments for residents admitted in April 2024 were not completed due to time constraints. Additionally, an incomplete Admission MDS assessment for one resident indicated a lack of interview to determine activity preferences, as required for accurate assessment.
The facility did not ensure proper labeling and dating of food items in the dry storage room, with opened containers missing labels and dates. Additionally, kitchen equipment used for food preparation was found to be unclean, with substances observed inside the ovens. These issues had the potential to impact 77 out of 79 residents receiving an oral diet from the kitchen. Observations on multiple occasions confirmed these deficiencies. Interviews with the Dietary Manager and Administrator revealed that staff were expected to follow food policies on labeling, dating, and cleaning, but turnover in the Dietary Department posed challenges in maintaining compliance.
The facility experienced a One-Star Staffing Rating and low weekend staffing metrics due to inaccurate reporting of direct care staffing data to CMS for Q1 FY 2024. The issue arose from a management change where salaried employees did not consistently clock in and out, and agency staff did not use the facility's time clock system until February.
The facility did not provide evidence of a process for periodic review of antibiotic prescribing practices and failed to document follow-up measures for three months of infection control data. This deficiency could hinder the development of an action plan for infection concerns by the Infection Control Committee. Facility policies showed gaps in monitoring and documenting antibiotic stewardship activities, including tracking infection and antibiotic usage patterns, antibiotic resistance trends, and the appropriateness of antibiotic prescriptions. The Antibiotic Stewardship Log was underutilized, and there was a lack of documentation of surveillance data and communication with physicians regarding residents receiving antibiotics that did not meet criteria for true infections. Interviews with the Director of Health Services and Administrator revealed reliance on the McGeer infection Report from the electronic medical records system, but discrepancies were found in categorizing residents receiving antibiotics. The Director of Health Services acknowledged the lack of monitoring and surveillance of the program and the incorrect inclusion of residents not meeting criteria for true infections in monthly infection rate calculations.
The facility failed to ensure a medication cart on Richmond Hall was locked and secured when not in use. An LPN left the cart unlocked and unattended with a cup of pills on top and the EHR open, visible to anyone passing by. The LPN admitted to being nervous due to the presence of state surveyors. The DON confirmed that medication carts should always be locked when unattended and that nurses should cover or log out of the EHR when not in use.
A resident with muscle weakness and hemiparesis expressed a preference to get up between 6:00 am and 6:30 am, but the facility failed to honor this preference due to staffing issues. Despite being listed on the 11-7 get-up list, the resident was often not gotten up until after 10:00 am, leading to dissatisfaction and complaints. Staff interviews confirmed the issue, and the resident's concerns were known to the Social Service Director and Administrator, but no effective action was taken.
The facility failed to maintain a safe, clean, and comfortable environment on Richmond Hall, as evidenced by a persistent urine odor. Staff interviews and observations confirmed that residents' dirty laundry was stored in their rooms for up to a week before being laundered, contributing to the odor. Despite deep cleaning efforts, the issue persisted.
The facility failed to develop a baseline care plan for one resident and did not address essential care needs or include a discharge care plan for another. The facility's policies require baseline care plans to be initiated within 24 hours and completed within 48 hours of admission, but these requirements were not met.
The facility failed to develop comprehensive care plans for two residents. One resident did not have a discharge care plan despite multiple diagnoses, and another resident lacked care plans for nutrition, behaviors, and psychotropic medication use. These deficiencies were confirmed by the MDS Coordinator.
The facility failed to revise the care plan for a resident with a pressure ulcer. Despite the resident having an unstageable pressure ulcer to the sacrum, the care plan was not updated to reflect this condition. Interviews confirmed that the interdisciplinary team did not fulfill their responsibility to update the care plan as required.
The facility failed to reconcile and document pre-discharge medications with post-discharge medications for a resident, R126, and did not provide documentation that the medications were transferred at discharge. The resident reported not receiving all medications, and staff interviews confirmed the lack of proper procedure and documentation.
The facility failed to provide an individualized activities program for a resident with multiple psychiatric diagnoses. Despite repeated requests for a coloring book and crayons documented in her psychiatry notes, there was no evidence that these requests were fulfilled. The resident spent most of her time lying in bed, expressing dissatisfaction with the activities provided. The facility had been without an Activities Director for two months, and the Administrator acknowledged that the resident's specific requests had been overlooked.
A resident's medications were crushed and combined by an RN without a physician's order, contrary to the facility's policy and the physician's instructions to take the medications whole. The DON confirmed that medications should be administered as per physician's orders, and any resident preference should be followed up with a physician to obtain the necessary order.
The facility failed to ensure puree recipes were followed, resulting in improperly prepared food for eight residents on a puree diet. Dietary Cook CC did not measure the liquid added to the hamburger meat, leading to a thinned and watery consistency.
Failure to Provide Accessible Call Device for Resident with Impairments
Penalty
Summary
A deficiency occurred when a resident with non-traumatic brain dysfunction, non-Alzheimer's dementia, and depression was not provided with a call device that accommodated their needs. The resident, who had one-sided impairment and was dependent for eating and hygiene, was documented as being at risk for falls and having a vision deficit. The care plan required the call light to be kept within reach. However, multiple observations and interviews revealed the resident was unable to reliably activate the call light due to numbness in their hands and difficulty pressing the button. The call light did not activate consistently, and the resident could not visually confirm if it was working due to their vision deficit. Staff interviews indicated that after the installation of a new call light system, no formal assessment was conducted to ensure each resident could use the new devices. The touch pad call lights previously used were incompatible with the new system, and the facility had not completed call device assessments with the new system. The maintenance director and nursing staff confirmed the lack of compatibility and assessment, and the administrator acknowledged that he was not present during the installation to verify resident accommodation.
Delayed Completion and Transmission of MDS Assessments Due to Transition and Staffing Issues
Penalty
Summary
The facility failed to ensure timely completion and transmission of Minimum Data Set (MDS) assessments for multiple residents, as identified during the survey. Thirteen out of thirty-four residents had at least one or more MDS assessments completed late, with examples including Quarterly Assessments and Admission MDS assessments not being completed or transmitted within the required timeframes. Staff interviews revealed that the delay in assessments was attributed to a transition to a new company in October 2023, resulting in resident records being in the previous company's electronic systems, coupled with a shortage of staff hindering timely completion and transmission of assessments. Furthermore, interviews with the MDS Coordinator and RN MDS Coordinator highlighted instances where Admission MDS assessments for residents admitted in April 2024 were not completed or transmitted, with reasons cited such as lack of time to complete assessments. The facility's policy emphasized the importance of accurate MDS assessments reflecting the acuity and medical status of each resident, yet deficiencies in completing assessments within required timeframes were evident. Additionally, a specific case involving Resident R22 highlighted incomplete sections in the Admission MDS assessment, indicating a lack of interview with the resident to determine activity preferences, as required for accurate assessment completion.
Labeling and Sanitation Issues in Food Storage and Kitchen Equipment
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the dry storage room, with opened food containers lacking labels and dates. Additionally, kitchen equipment used for food preparation was found to be unclean and unsanitary, with substances observed inside the ovens. The deficiency had the potential to impact 77 out of 79 residents receiving an oral diet from the kitchen. Observations on multiple occasions revealed the lack of labeling and dating on food containers, as well as unclean kitchen equipment. Interviews with the Dietary Manager and Administrator indicated expectations for staff to follow food policies on labeling, dating, and cleaning kitchen equipment. The Administrator mentioned previous in-services with dietary staff on these topics, highlighting turnover in the Dietary Department as a challenge in ensuring compliance with food safety protocols.
Inaccurate Staffing Data Reporting Leads to One-Star Rating
Penalty
Summary
The facility failed to accurately report direct care staffing data to CMS for the first quarter of Fiscal Year 2024, resulting in a One-Star Staffing Rating and Excessively Low Weekend Staffing metrics being triggered. The deficiency stemmed from a recent change in management, where salaried employees did not consistently clock in and out, and agency staff did not use the facility's time clock system until February of that year.
Deficiency in Antibiotic Stewardship and Infection Control Monitoring
Penalty
Summary
The facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices and to document follow-up measures in response to the data for three months of infection control data reviewed. The deficiency had the potential to prevent the development of an action plan related to identified infection concerns within the facility by the Infection Control Committee. The review of facility policies revealed gaps in monitoring and documenting antibiotic stewardship activities, including tracking infection and antibiotic usage patterns, antibiotic resistance trends, and appropriateness of antibiotic prescriptions. The Antibiotic Stewardship Log was found to be underutilized, and there was a lack of documentation of surveillance data and communication with physicians regarding residents receiving antibiotics that did not meet criteria for true infections. During interviews with the Director of Health Services and Administrator, it was revealed that the facility relied on the McGeer infection Report from the electronic medical records system to determine if infections met criteria, but there was a discrepancy in how residents receiving antibiotics were categorized. The Director of Health Services acknowledged the lack of monitoring and surveillance of the program, as well as the incorrect inclusion of residents not meeting criteria for true infections in the monthly infection rate calculations.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that one of two medication carts on the Richmond Hall was locked and secured when not in use. An observation revealed that the cart was left unlocked and unattended with a plastic 30 ml medicine cup containing pills on top of the cart, and the Electronic Health Record (EHR) was open with resident information visible on the computer screen. The Licensed Practical Nurse (LPN) responsible for the cart confirmed that he left it unlocked and unattended because he was nervous due to the presence of state surveyors. The cart remained unsecured for four minutes. The Director of Nursing (DON) stated that medication carts should always be locked when unattended and that nurses are expected to administer medication immediately after it is pulled and to lock the cart before walking away. Additionally, the DON expects nurses to cover the computer screen or log out when not in use.
Failure to Honor Resident's Preference for Scheduled Times to Get Out of Bed
Penalty
Summary
The facility failed to honor a resident's preference for scheduled times to be gotten out of bed, which had the potential to affect the resident's psycho-social well-being. The resident, who had diagnoses including generalized muscle weakness, right hand contracture, and hemiplegia and hemiparesis following a cerebral infarction, expressed a preference to get up between 6:00 am and 6:30 am. Despite being listed on the facility's 11-7 get-up list, the resident reported that his preference was not honored, attributing this to staffing issues. Observations confirmed that the resident was often not gotten up until after 10:00 am, leading to dissatisfaction and complaints from the resident. Interviews with staff, including a CNA and LPN, corroborated the resident's claims, indicating that the night shift staff often failed to get the resident up due to staffing shortages. The Social Service Director and the Administrator were aware of the resident's preference and had spoken to the staff about it, but the issue persisted. The resident had also voiced his concerns during a resident council meeting, but no effective action had been taken to address the issue. The facility's failure to honor the resident's preference for getting up early in the morning was a clear deficiency in promoting and facilitating resident self-determination and choice.
Persistent Malodorous Smell on Richmond Hall
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable home-like environment on Richmond Hall, as evidenced by a persistent malodorous smell throughout the hall. Observations revealed a strong stale urine odor on multiple occasions, and staff interviews confirmed the presence of the odor. The Director of Health Services, Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistants, and the Administrator all acknowledged the odor but were unsure of its exact origin. The odor was noted to be different and more pronounced on Richmond Hall compared to other areas of the facility. The issue was attributed to the storage of residents' dirty laundry in hampers within their rooms, which were only collected and washed once a week due to limited laundry facilities. The facility's policy on Infection Control - Housekeeping Services, revised on 10/16/2023, mandates routine and consistent housekeeping to maintain an orderly, sanitary, and comfortable environment. However, the policy was not effectively implemented on Richmond Hall. The Housekeeping Supervisor and Laundry Aide confirmed that residents' dirty laundry remained in their rooms for up to a week before being laundered, contributing to the persistent odor. Despite deep cleaning the carpet, the issue persisted, indicating that the primary source of the odor was the unbagged dirty laundry stored in residents' rooms.
Failure to Develop Baseline and Discharge Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan that included essential components based on the resident's stay for two residents. Specifically, the facility did not ensure that one resident had a baseline care plan developed after admission, and another resident's care plan did not address essential care needs or include a discharge care plan. The facility's policies require that a baseline care plan be initiated within 24 hours and completed within 48 hours of admission, and that discharge care plans be established at the time of admission and updated as needed. However, these requirements were not met for the two residents in question. One resident was admitted with multiple diagnoses, including chronic obstructive pulmonary disease (COPD), anxiety disorder, and chronic respiratory failure (CRF). The resident's baseline care plan was incomplete and did not capture the overall care needs, including the use of psychotropic medications. The MDS Coordinator confirmed that the baseline care plan was missing essential components such as communication, activities of daily living (ADL), and pain management. Another resident was admitted and later discharged to the hospital without a baseline care plan being developed by the facility staff. The MDS Coordinator stated that baseline care plans are the responsibility of the admitting nurse and should be completed within 48 hours of admission, but this was not done for the resident in question.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the specific needs of two residents. For one resident, admitted with multiple diagnoses including a fracture, pulmonary disease, hypertension, diabetes, and chronic kidney disease, the facility did not create a discharge care plan. This omission was confirmed by the MDS Coordinator, who acknowledged that the discharge care plan should have been implemented at the time of admission but was overlooked due to the responsibilities being managed by remote MDS staff. Another resident, admitted with diagnoses including pseudobulbar affect, mood disorder, vascular dementia, and protein-calorie malnutrition, did not have a comprehensive care plan addressing nutritional status, behaviors, or the use of psychotropic medications. This deficiency was confirmed by the MDS Coordinator, who acknowledged the absence of the necessary care plans for this resident.
Failure to Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with a pressure ulcer. The resident was admitted with diagnoses including Parkinson's disease, myasthenia gravis, anorexia, and a pressure ulcer of an unspecified site. The comprehensive care plan, last revised on 4/26/2024, indicated the resident was at risk for skin breakdown due to incontinence, impaired mobility, and impaired joint range of motion, with a deep tissue pressure injury to the left heel. However, the care plan did not reflect the actual condition of the resident, who had an unstageable pressure ulcer to the sacrum with an onset date of 3/14/2024. Interviews with the Minimum Data Set (MDS) Coordinators confirmed that it is the responsibility of the interdisciplinary team to update care plans. Despite this, the resident's care plan was not updated to reflect the actual wound condition. This failure to update the care plan as required by the facility's policy and the OBRA MDS schedule led to the deficiency identified in the report.
Failure to Reconcile and Document Medications at Discharge
Penalty
Summary
The facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications for one resident, R126. The facility also did not provide documentation that R126's medications were transferred with her at the time of discharge. R126, who had a BIMS score indicating little to no cognitive impairment, reported that the facility nurse did not give her all her medications and informed her that she would receive them by mail in two weeks. A review of the resident's physician orders revealed multiple medications prescribed, but there was no evidence in the Electronic Medical Record (EMR) that these medications were reconciled or given to the resident at discharge. The Regional Consultant confirmed the lack of documentation, and the Register Nurse (RN) involved could not recall if she provided the medications, nor did she reconcile or sign off on them. The RN also reported not receiving education on the proper procedure for medication reconciliation and documentation at discharge. The Director of Health Services (DHS) outlined the correct procedure for discharging residents, which includes reviewing medications with the Medical Director, dating and timing medication packages, and providing education to the resident or responsible party. However, this procedure was not followed in the case of R126. The DHS confirmed that the nurse should have documented the medication reconciliation and provided the medications to the resident, but this did not occur. The failure to follow the discharge planning policy and properly document and reconcile medications led to the deficiency identified in the report.
Failure to Provide Individualized Activities Program
Penalty
Summary
The facility failed to provide an individualized activities program for one resident (R22) as required by their policy. R22, who was admitted with multiple psychiatric diagnoses including generalized anxiety disorder, major depressive disorder, and schizoaffective disorder, had repeatedly requested a coloring book and crayons as part of her recreational activities. Despite these requests being documented in her psychiatry follow-up notes over several months, there was no evidence in her electronic medical records that an Activities Assessment had been completed or that her requests had been fulfilled. Observations and interviews revealed that R22 spent most of her time lying in bed, with her television being her only source of activity when it was working. She expressed dissatisfaction with the activities provided and confirmed that staff had not offered her the requested coloring book and crayons. The facility had been without an Activities Director for about two months, during which time the Administrator, who is a certified activities director, and an Activities Assistant were responsible for providing activities. However, the Activities Assistant had not completed an activities preference interview with R22 and was unaware of her specific requests. The Social Services Director and the Administrator also confirmed that they were not aware of the recommendations for a coloring book and crayons documented in R22's psychiatry notes. The Administrator acknowledged that these recommendations had been overlooked and that there were no activity notes or assessments completed for R22 in the electronic medical records. During multiple observations and interviews, R22 was consistently found lying in bed without the requested coloring book and crayons. She reported that staff had not offered her any one-to-one activities or encouraged her to participate in group activities. The Administrator confirmed that activity notes and assessments were documented on paper and kept in her office, but these were not provided before the survey exit. The lack of individualized activities and failure to address R22's specific requests highlight a significant deficiency in the facility's activities program.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer medication to a resident (R22) as prescribed by the physician. Specifically, the resident's medications were supposed to be taken whole, but the Registered Nurse (RN) crushed and combined multiple medications without a physician's order. The medications included Allopurinol, Amlodipine, Aspirin, Bisacodyl, Buspar, Colace, Gabapentin, Klonopin, Metoprolol Tartrate, Singulair, Oxcarbazepine, Oxybutynin Chloride, Sodium Chloride, Effexor, Pravastatin, and Cranberry Extract. The RN then mixed the crushed medications with vanilla pudding before administering them to the resident. This action was contrary to the facility's policy and the physician's orders, which required medications to be taken whole unless otherwise indicated by a physician's order. The RN stated that the resident preferred their medications crushed, but no such order was present in the medical record. The Director of Nursing (DON) confirmed that medications should be administered as per physician's orders and that any preference by the resident to have medications crushed should be followed up with a physician to obtain the necessary order. The RN involved had been working at the facility for about six months and had received in-service training on medication administration during orientation. This incident highlights a failure to adhere to prescribed medication administration protocols, leading to a significant medication error for the resident involved.
Failure to Follow Puree Recipe Guidelines
Penalty
Summary
The facility failed to ensure puree recipes were followed to conserve the nutritive value of food items served to eight residents receiving a puree consistency diet. During an observation, Dietary Cook CC was seen preparing food for these residents. She placed 10 pieces of hamburger meat into a food processor and pureed it for approximately one minute. She then left the area to get beef gravy and beef base from the cooler, returning with a half-filled container of a liquid substance. The Surveyor did not observe the actual measurement of the liquid added, and the resulting puree hamburger meat appeared thinned and watery, not meeting the required puree consistency. Interviews with Dietary Cook CC, the Administrator, and the Dietary Manager revealed that the dietary staff were expected to follow the recipes. However, the provided recipe for pureed hamburgers did not specify the amount of meat or liquid needed, leading to inconsistency in the preparation. The Dietary Cook claimed to have followed the recipe, but the observation and the resulting product indicated otherwise, highlighting a failure in adhering to the recipe guidelines for pureed diets.
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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