Pruitthealth - Rome
Inspection history, citations, penalties and survey trends for this long-term care facility in Rome, Georgia.
- Location
- 2 Three Mile Road Ne, Rome, Georgia 30165
- CMS Provider Number
- 115719
- Inspections on file
- 16
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pruitthealth - Rome during CMS and state inspections, most recent first.
A facility failed to develop and implement complete, resident-specific care plans for ADL refusals, ROM, and nail/oral care. One resident with severe cognitive impairment and multiple psychiatric and mobility diagnoses had no care plan addressing intermittent verbal refusal of ADL care, and during agitated care assistance, slid from a wheelchair and sustained a right femur fracture. Another resident with quadriplegia, hand contractures, and diabetes was observed with tightly fisted hands without splints or rolls, and received AM care without hand washing, mouth care, or foot care, despite dependence for hygiene and a care plan that lacked ROM or contracture interventions and resident-specific nail care directions. A third resident with vascular dementia and respiratory disease had long, jagged fingernails and overgrown, discolored toenails curling into the skin, while the care plan only generally directed staff to check nails for cleanliness; CNAs gave conflicting accounts of who was responsible for nail care, and nursing leadership confirmed the absence of resident-specific nail care interventions or documentation of refusals.
A resident with severe cognitive impairment, dementia, and dependence for dressing was being assisted with a pull‑over shirt by a CNA while already agitated and resisting care. Despite prior in‑service training and facility policies directing staff to stop care, ensure safety and dignity, and obtain help when a resident becomes combative or agitated, the CNA continued the dressing task as the resident pushed against her, leading to the resident sliding from the wheelchair to the floor. The resident was initially documented as having no apparent injury, but later complained of right leg pain, and imaging confirmed a right supracondylar femur fracture.
The facility failed to follow COVID-19 infection control policies, leaving doors open for COVID-positive residents and not using proper PPE. Dishes from COVID-positive residents were not bagged, and the dishwashing machine did not meet temperature requirements. An LPN did not follow hand hygiene protocols during medication administration, using long false nails and handling medication improperly.
The facility's kitchen failed to maintain proper sanitation and equipment standards, affecting all residents receiving meals. The dish machine did not meet required temperatures, and a Dietary Aide handled clean dishes without washing hands after touching soiled trays. Observations also noted unsanitary conditions, including soiled drawers, grease accumulation, and mold-like substances. The kitchen had not been updated since 2013, and cleaning schedules were inadequately documented.
The facility failed to invite residents and/or their representatives to care planning conferences, as required by policy. This deficiency was identified for four residents with varying medical conditions and cognitive impairments. Despite facility records indicating invitations were sent, there was no documented evidence of receipt, and family members confirmed not receiving them. The Director of Nursing acknowledged the lack of documentation and compliance with the policy.
The facility failed to inform residents and/or their representatives about the risks of psychotropic medications for five residents, as revealed through policy review, interviews, and record reviews. The facility's policy did not require discussing risks versus benefits, leading to uninformed treatment decisions. Residents, including those with cognitive impairments and those who were cognitively intact, were administered psychotropic medications without documented discussions of risks and benefits. The Director of Nursing confirmed the absence of such documentation.
A facility failed to assess a resident's ability to self-administer medication, as required by policy. The resident, with a history of stroke and hemiplegia, was cognitively intact but had no documentation or assessment for self-administration. An LPN left Biofreeze Gel with the resident, unaware of the lack of assessment. The DON confirmed the oversight, creating potential for medication error.
A resident's funds were misappropriated by a CNA who wrote and cashed checks from the resident's account for personal gain. The resident, who was cognitively intact, had trusted the CNA to assist with check writing. The incident was reported, and an investigation confirmed the misappropriation, leading to the CNA's termination. The facility's policy prohibits such exploitation, and the DON and Administrator emphasized the expectation of resident protection from abuse.
A resident with severe cognitive impairment and receiving hospice care was found with unnecessary bed rails raised, despite being completely dependent on staff for movement. The facility failed to conduct a proper assessment or obtain informed consent for the use of side rails, as required by their policy. Staff interviews confirmed the rails were not needed, and the DON acknowledged their discontinuation.
A CNA failed to use proper PPE while caring for two residents in isolation for 2019-nCoV, wearing only an N95 mask and gloves instead of the full required PPE. Despite completing training on PPE use, the CNA did not adhere to the guidelines, as confirmed by the DON and camera footage.
A resident with dementia and severe cognitive impairment was observed wandering into other residents' rooms and taking personal items. The facility's care plan for the resident did not include their preferred activities, such as books and music, as interventions for wandering. Staff primarily relied on redirection, which was insufficient to prevent the behavior. The DON acknowledged the issue but did not effectively implement strategies to address it.
Failure to Develop and Implement Resident-Specific Care Plans for ADL Refusals, ROM, and Nail/Oral Care
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, resident-specific care plans addressing all identified needs, including refusals of care, range of motion (ROM), and nail and oral care. For one resident with Alzheimer’s disease, major depressive disorder, generalized anxiety disorder, schizoaffective disorder, osteoarthritis, and gait/mobility abnormalities, the quarterly MDS showed severe cognitive impairment with an inability to complete the BIMS interview. Despite this, the care plan did not include interventions for intermittent verbalization or refusal of ADL care. On the morning of 1/13/2026, a CNA reported that when she entered this resident’s room, the resident was already agitated, and during an attempt to assist with ADL care, the resident slid from the wheelchair onto the floor. Progress notes documented a witnessed fall while the resident was being adjusted in the wheelchair, resulting in a supracondylar fracture of the right femur. For a second resident with aphasia following cerebral infarction, quadriplegia related to CVA, hand contractures, multiple-site muscle contractures, and type 2 diabetes, observations on multiple dates showed the resident lying on his back with both hands tightly closed in fists and no splints or rolls in place. During AM care, staff did not wash the resident’s hands or provide mouth or foot care, and when socks were removed, the great toe nail was thickened with debris buildup and yellowish discoloration. The MDS documented severe impairment in decision-making and total dependence on staff for personal hygiene, including nail care. The care plan identified dependence for dressing, oral hygiene, personal hygiene, and bathing, and directed staff to check nails for cleanliness, but contained no interventions for upper extremity contractures or ROM. An LPN confirmed there were no resident-specific interventions for nail care, no care plan for contractures, and no documentation of care refusal or attempted interventions. For a third resident with vascular dementia, emphysema, and COPD, observations showed long, jagged fingernails and overgrown toenails on both feet that were curling into the skin, cloudy/tan in color, and curling up on the sides, pulling away from the nailbed. The admission MDS showed moderate cognitive impairment and a need for staff assistance with setup/cleanup for personal hygiene. The care plan, initiated after a decline in ADL self-care related to recent hospitalization, stated that staff should check nails and ensure they are clean and that the resident required staff assistance for ADL care. Interviews with CNAs revealed inconsistent understanding of who was responsible for nail care, with one CNA stating she usually did nail care during showers but not toenails, and another stating she trimmed the resident’s nails, that it was painful for the resident, and that she did not know who normally trimmed the resident’s nails. The DHS and an LPN acknowledged that the resident did not have resident-specific interventions for nail care and that there was no documentation of refusal of care or attempted care-planned interventions, despite facility policies requiring comprehensive, resident-specific care plans and timely updates with changes in condition.
Failure to Follow Dementia Care and Safety Interventions During ADL Assistance Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and interventions were provided during ADL care, resulting in a fall and right femur fracture. On the morning of 1/13/2026, progress notes documented that the resident slid from her wheelchair to a sitting position on the floor while being adjusted in the wheelchair, with no apparent injury and no pain reported at that time; she was assisted back into the wheelchair. Later that morning, the resident complained of right leg pain, was given Tylenol, evaluated by the Nurse Practitioner, and an x‑ray was ordered. That evening, the x‑ray confirmed a supracondylar fracture of the right femur, and an IDT fall note later documented that the resident was sent to the emergency room for evaluation and treatment. The resident had been admitted with diagnoses including Alzheimer’s disease, major depressive disorder, generalized anxiety disorder, schizoaffective disorder, osteoarthritis, and gait/mobility abnormalities. A quarterly MDS dated 1/6/2026 showed a BIMS score of 99, indicating severe cognitive impairment, severely impaired daily decision‑making, continuous inattention with disorganized thinking, and dependence for upper and lower body dressing. Despite this profile, during a telephone interview the CNA who provided care on 1/13/2026 stated that when she entered the resident’s room, the resident was already agitated. The CNA reported that she was putting a pull‑over shirt on the resident while the resident was pushing against her to get the shirt off, and as the CNA continued to push the shirt down, the resident slid from the wheelchair onto the floor on her left side. The CNA stated she called for the nurse, who assessed the resident and found no injury, and the resident was assisted from the floor back into the wheelchair. The CNA further reported that she and another CNA later assisted the resident to the edge of the bed, at which point the resident began complaining of right leg pain and the nurse was notified. The CNA acknowledged she had received education on caring for combative or agitated residents, including in‑services instructing staff to stop care, ensure safety and dignity, and obtain help when a resident becomes combative or agitated. Facility leadership, including the Education Coordinator and DHS, stated their expectation that staff stop what they are doing, ensure the resident’s safety, and seek additional help when a resident is agitated, resistant to care, and unable to be redirected. Facility policies on Occurrences and Dementia Care emphasized assessing risk, implementing appropriate interventions, and using respectful, patient approaches for residents with dementia, but these expectations were not followed during the incident.
Infection Control Deficiencies in COVID-19 Management
Penalty
Summary
The facility failed to adhere to its COVID-19 infection prevention and control policies, resulting in multiple deficiencies. Observations revealed that doors to rooms housing COVID-positive residents were left open, contrary to the facility's policy requiring them to be closed to contain the virus. This was observed in both the long (male) and short (female) hallways, affecting several residents who had tested positive for COVID-19. Additionally, staff members, including a CNA and a housekeeper, were observed entering these rooms without wearing the full required PPE, such as gowns and eye protection, despite clear signage indicating the need for such precautions. The facility also failed to properly manage the transport and cleaning of dishes from COVID-positive residents. The Dietary Manager confirmed that trays were not bagged during transport from the COVID hall to the kitchen, which was against the facility's policy. Furthermore, the dishwashing machine was not operating at the manufacturer's recommended temperatures, with observed wash and rinse cycles falling below the required levels. This failure to maintain proper sanitation procedures posed a risk of spreading infection within the facility. In addition to these issues, infection control procedures were not followed during medication administration for a resident. An LPN was observed administering medication without performing adequate hand hygiene, using long false nails, and failing to use a clean barrier on surfaces. The LPN also handled medication directly with bare fingers after it had come into contact with the medication cart, which was against the facility's policy. These actions demonstrated a lack of adherence to infection control protocols, potentially compromising resident safety.
Removal Plan
- Ensure room doors remain closed for residents who tested positive for COVID-19.
- Ensure staff apply proper PPE when entering COVID-positive resident rooms, including wearing an N95 mask, gloves, gown, and eye protection.
- Ensure dishes removed from COVID-positive resident rooms are covered for transport to the kitchen.
- Ensure dishwashing is done at the manufacturer's recommended temperatures.
- Provide management-level staff oversight to ensure conformance with facility's infection control policies and procedures.
Kitchen Sanitation and Equipment Deficiencies
Penalty
Summary
The facility failed to maintain proper sanitation and equipment standards in the kitchen, which had the potential to affect all 82 residents receiving meals. Observations revealed that the dish machine was not operating at the manufacturer's required temperatures, with wash cycles measuring between 104 to 118 degrees Fahrenheit and rinse cycles between 110 to 122 degrees Fahrenheit, below the required 120 and 130 degrees Fahrenheit, respectively. The Dietary Manager (DM) was unaware if the hot water supply was sufficient for all dishes, and the dish machine company was scheduled to check the machine. Additionally, a Dietary Aide (DA1) was observed handling clean dishes without washing hands after loading soiled trays, which the DM acknowledged as improper practice. Further observations noted unsanitary conditions in the kitchen, including soiled drawers with hardened food particles, grease and food accumulation on the range and fryer, and a mold-like substance on the wall above the three-compartment sink. The baseboard in the dish room was missing, and painted surfaces were broken. The DM mentioned that kitchen updates had not occurred since 2013, and the Registered Dietitian (RD) emphasized the importance of preventing cross-contamination and maintaining cleanliness. The facility's cleaning schedules were not adequately documented, with no weekly or monthly cleaning records provided.
Failure to Invite Residents to Care Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited to participate in care planning conferences, as required by their policy. This deficiency was identified for four residents, each with varying degrees of cognitive impairment and medical conditions. For instance, one resident with severe cognitive impairment and multiple diagnoses, including dementia and cerebral infarction, had no evidence of their representative being invited to care conferences, despite the facility's policy requiring such documentation. The resident's family member confirmed not receiving invitations for several years, and the facility staff acknowledged the lack of documentation. Another resident with a diagnosis of heart failure and severe cognitive impairment also lacked evidence of care conference invitations in their electronic medical record. The resident's representative stated they had not been invited to recent care conferences, despite the facility's records indicating otherwise. Similarly, a resident with a stroke and aphasia had no documented evidence of being invited to care conferences, and the resident confirmed not receiving invitations. Additionally, a resident with amyotrophic lateral sclerosis (ALS) and no cognitive impairment was not documented as being invited to care conferences, despite the facility's records suggesting invitations were sent. The Director of Social Services and the Director of Nursing acknowledged the requirement to invite residents and/or their representatives but could not provide a policy or evidence of compliance. The lack of documentation and communication regarding care conference invitations was a consistent issue across the cases reviewed.
Failure to Inform Residents of Psychotropic Medication Risks
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed of the risks associated with psychotropic medications for five residents. This deficiency was identified through policy review, interviews, and record reviews. The facility's policy on Unnecessary Medications Use and Monitoring did not include a requirement to discuss the risks versus benefits of psychotropic medications. This omission led to residents and their representatives making uninformed decisions about their treatment, potentially increasing the risk of adverse reactions. For Resident 83, the facility obtained verbal consent from a family member for the administration of Buspar and Lexapro, but there was no evidence that the risks versus benefits were discussed. The Social Service Director was unaware of the requirement to discuss these risks, and a family member confirmed that only permission was requested without any discussion of risks. Similarly, Resident 29, who was cognitively intact, was not provided with information on the risks versus benefits of their antianxiety and antidepressant medications. Resident 37, who had memory problems, was administered antipsychotic and antidepressant medications without documentation of risks versus benefits being discussed. The Director of Social Services confirmed the absence of such documentation. Resident 33, who was severely cognitively impaired, also lacked documentation of risks and benefits discussions for their psychotropic medications. Lastly, Resident 58, who was cognitively intact, was receiving antidepressant medication without evidence of risks versus benefits being discussed. The Director of Nursing confirmed the lack of documented evidence for all five residents.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was capable of self-administering medication, as required by their policy. The resident, who had a history of stroke and hemiplegia affecting the right side, was observed to be cognitively intact with a BIMS score of 15 out of 15. However, there was no documentation in the resident's care plan or physician's orders to address self-administration of medication, nor was there an assessment conducted to determine the resident's ability to self-administer medication. An LPN was observed leaving a medication cup with Biofreeze Gel for the resident to apply later, despite the resident not being assessed for self-administration. The LPN was unaware that the medication should not have been left unattended with the resident. The Director of Nursing confirmed that the resident had not been appropriately assessed for self-administration, and no care plan or physician's orders were in place for this practice. This oversight created the potential for a medication error due to the resident's inability to properly self-administer the medication.
Misappropriation of Resident Funds by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal funds by a staff member. A Certified Nursing Assistant (CNA4) exploited the resident's trust by writing and cashing checks from the resident's personal checking account for her own benefit. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had previously requested CNA4's assistance in writing checks, which he would then sign himself. This inappropriate access led to the CNA writing checks to herself and depleting the resident's funds. The incident was reported by the resident to the facility administration, prompting an investigation involving the local police and the resident's bank. The investigation confirmed the misappropriation, and CNA4 was subsequently terminated. The facility's Abuse Prevention and Reporting Policy explicitly prohibits exploitation, and the Director of Nursing (DON) and Administrator confirmed the expectation that residents should be free from such abuse. Despite the resident's previous good relationship with CNA4, this breach of trust resulted in significant financial harm to the resident.
Inappropriate Use of Bed Rails for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure the appropriate use of side rails for a resident, identified as R3, who was severely cognitively impaired and receiving hospice services. R3 was completely dependent on staff for movement and was observed with quarter side rails raised on her bed, despite her inability to use them for mobility or positioning. The facility's policy required an assessment for safety risks and informed consent for bed rail use, but there was no indication that these steps were followed for R3. The resident's care plan and assessments did not support the necessity of side rails, and staff interviews confirmed that the rails were not needed for the resident's current condition. Observations and interviews with facility staff, including an LPN and the DON, revealed that the side rails were in use without a clear purpose, as R3 could not utilize them for mobility or repositioning. The DON acknowledged that the rails were unnecessary and confirmed their discontinuation. The facility's failure to adhere to its policy on bed rail use created a potential risk for the resident, as the rails were installed and used without proper assessment or consent.
Improper PPE Use by CNA in Isolation Rooms
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA3) adhered to the proper use of Personal Protective Equipment (PPE) while providing care to residents in isolation for 2019-nCoV. CNA3 was observed providing care to two residents, R35 and R58, who were on special droplet isolation, without wearing the full required PPE. Specifically, CNA3 was only wearing an N95 mask and gloves, neglecting to wear a gown and protective eyewear as mandated by the facility's infection control protocols. Despite having completed multiple training sessions on the proper use of PPE, including a specific in-service on isolation precautions, CNA3 did not follow the established guidelines. During an interview, CNA3 admitted to not reading the posted signs on the residents' doors that outlined the necessary PPE requirements. The Director of Nursing confirmed that CNA3 had been educated on PPE use and acknowledged the failure to comply with the protocols, as verified by hallway camera footage.
Failure to Implement Resident-Specific Activities for Wandering Behavior
Penalty
Summary
The facility failed to provide resident-specific activities as interventions for a resident diagnosed with dementia, who displayed wandering behaviors. The resident, identified as R77, was observed wandering into other residents' rooms and taking personal belongings. Despite having a care plan that included redirection and diversion to activities such as getting coffee, the plan did not incorporate the resident's identified preferences for activities like books, music, and religious services. Staff interventions primarily involved redirecting the resident, but these measures were insufficient to prevent the resident from intruding into other residents' spaces. Observations and interviews revealed that staff, including an LPN and CNA, were aware of the resident's wandering behavior but relied mainly on redirection as the sole intervention. The Director of Nursing acknowledged the issue and mentioned involving the resident in activities and one-on-one staff monitoring, but these strategies were not effectively implemented. The facility's policy on wandering residents was not fully adhered to, as it lacked the incorporation of the resident's preferred activities, which could have potentially mitigated the wandering behavior.
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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