Pruitthealth - West Atlanta
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Georgia.
- Location
- 2645 Whiting Street N.w., Atlanta, Georgia 30318
- CMS Provider Number
- 115512
- Inspections on file
- 22
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Pruitthealth - West Atlanta during CMS and state inspections, most recent first.
A resident with cognitive impairment and extensive care needs experienced an unwitnessed fall and was later found to have a femur fracture after being hospitalized. The facility's investigation into the injury of unknown source was incomplete, as it did not include interviews with direct care staff, the resident, the resident's representative, or other relevant individuals, and only two statements from department heads were collected. This did not meet the facility's own policy requirements for investigating such incidents.
A resident with a documented NPO status and gastrostomy tube order was given a food tray, resulting in the resident being found with food in their mouth. This failure to follow the care plan was followed by a significant decline in the resident's respiratory status, requiring hospital transfer and intensive care interventions.
A resident with a history of dysphagia, pneumonia, and a G-tube was repeatedly provided food despite NPO orders, due to failures in staff assessment, communication, and the meal ticket system. The resident was given sandwiches and later a food tray, resulting in aspiration events and hospitalizations. Staff interviews confirmed that dietary orders were not properly clarified or communicated, and the facility's policies for reviewing and implementing specialized diets were not followed.
The facility failed to prevent two garbage dumpsters from overflowing, which prohibited the lids and side doors from closing, creating a potential for pests, rodents, and insects. One dumpster was also missing a plug, leading to potential leakage of garbage contaminants. The Dietary Manager and Maintenance Director confirmed the issues, with the latter unaware of the overflow and missing plug.
The facility failed to ensure a dignified dining experience for three residents. One resident received breakfast 10 minutes after others, another was the last to receive lunch, and a resident was pulled backwards in a geriatric chair. Staff were also heard referring to residents as 'feeders'. The DHS confirmed these actions were inappropriate and indicated a lack of staff training on resident dignity.
The facility failed to provide bed hold information in writing at the time of transfer or within 24 hours for three residents transferred to the hospital in the last 120 days. Staff interviews revealed a lack of awareness and clarity about who was responsible for providing the bed hold notices, and the required documentation was not provided.
The facility failed to ensure that residents were seen by a physician at the required intervals, with four residents not receiving the mandated visits. Staff interviews confirmed the requirement for regular visits, but the protocol was not followed, leading to the deficiency.
The facility failed to ensure all food items on the steam table were held above 135°F, affecting nine residents on a puree diet. The puree beef patty was found at 132°F, and the Dietary Manager confirmed the deficiency.
A resident with multiple diagnoses was found with over-the-counter medications at her bedside without being assessed for the ability to self-administer. An LPN confirmed the oversight and removed the items, and the Director of Health Services was unaware of the situation prior to it being reported.
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to a resident who was discharged from Medicare Part A coverage and remained in the facility. The Financial Controller was unaware of the requirement, and the resident and/or the responsible party did not receive the necessary notice.
A facility failed to provide specialized psychiatric services for a resident with schizophrenia as recommended by the PASRR Level II summary. Despite having a care plan and being on antipsychotic medication, there was no documented evidence that the resident received the necessary psychiatric and psychotherapy services.
The facility failed to develop care plans for antipsychotic and anti-anxiety medications for a resident with dementia and anxiety, and did not adhere to dietary restrictions for another resident with a lactose allergy, leading to potential gaps in treatment and care.
A resident with a documented lactose allergy was repeatedly served food items containing lactose, despite clear indications on the meal tray ticket and physician orders. The Dietary Manager confirmed the oversight and revealed the absence of a facility policy regarding therapeutic diets and food allergies.
A resident with dementia and anxiety was receiving multiple psychotropic medications, including haloperidol. The facility failed to conduct an annual Gradual Dose Reduction (GDR) assessment for the resident's antipsychotic medication, as required by their policy. The last documented GDR was over a year ago, and this deficiency was confirmed by the Director of Health Services.
The facility failed to ensure medications were dated when opened, discarded on the discard dates, and stored according to manufacturer recommendations on one of three medication carts. Observations revealed several medications were either not labeled with open and discard dates or were stored improperly. Interviews confirmed that all nurses and Unit Managers were responsible for ensuring proper storage, labeling, and discarding of medications.
The facility failed to ensure the ice scoop bin and beverage dispenser were free from green and black buildup on one unit. Observations revealed that the ice scoop was stored in a container with black buildup and used by CNAs to deliver ice to residents. The water dispenser also had green and black buildup. Staff confirmed the buildup and the lack of a cleaning schedule for the ice scoop.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate a serious bodily injury of unknown source for one of ten sampled residents. The resident in question had multiple diagnoses, including cognitive communication deficit, vascular dementia, and required extensive assistance with activities of daily living. The resident experienced a fall that was unwitnessed, and later was found to have a right femur intertrochanteric fracture, which was discovered only after the resident was sent to the hospital for unrelated symptoms. The facility's policies required that, in the event of an injury of unknown source, interviews should be conducted with the resident, staff who provided care, other residents, and any pertinent outside sources, as well as gathering signed statements and observing the resident for behavioral clues to the injury's cause. Upon review, the investigation conducted by the facility was found to be incomplete. Only two witness statements were collected, both from department heads, and there was no evidence that direct care staff, the resident, the resident's representative, other residents, or outside sources were interviewed. There was also no documentation of observations of the resident or an evaluation of whether the resident felt safe. The investigation did not address the potential connection between the unwitnessed fall and the subsequent discovery of the fracture. Interviews with facility staff, including a Certified Medication Aide, the Unit Manager, the Director of Health Services, and the Administrator, confirmed that the standard practice was to collect statements for injuries of unknown source but not for unwitnessed falls. The Administrator, who served as the abuse coordinator, stated that the investigation was inconclusive and acknowledged that not completing a thorough investigation could result in not finding the true root cause. The documentation provided by the facility was confirmed to be the complete investigation, which lacked the required thoroughness as outlined in facility policy.
Failure to Follow NPO Care Plan Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident who was designated as nothing by mouth (NPO) due to multiple diagnoses, including pneumonia, dysphagia, respiratory failure with hypoxia, and cognitive communication deficit. The resident's care plan, initiated on 10/16/2025, specified the use of a gastrostomy tube for nutrition and water flushes as ordered, with a physician's order confirming NPO status. Despite these documented interventions, the resident was observed with a food tray and food in his mouth, specifically three shrimps, on 11/15/2025. The incident was documented in the electronic medical record, and the kitchen staff was subsequently educated about the resident's NPO status. Following this event, the resident experienced a significant change in condition, including decreased oxygen saturation and respiratory distress, which required escalation of oxygen therapy and eventual transfer to the hospital. Hospital records indicated the resident was admitted with acute respiratory distress, hypoxic respiratory failure, and required intensive care interventions, including thoracentesis and ventilatory support. The Director of Health Services confirmed that the resident's NPO restriction was documented in the care plan and acknowledged that the care plan was not followed when the resident was given a food tray.
Failure to Follow NPO Orders and Ensure Nutritional Safety
Penalty
Summary
The facility failed to provide appropriate nutritional treatment and services for a resident with dietary orders for nothing by mouth (NPO). Upon admission, the resident had a history of pneumonia, dysphagia, respiratory failure, and required a gastrostomy tube (G-tube) for nutrition. Despite clear orders and documentation indicating the resident was NPO and at high risk for aspiration, staff did not properly assess or clarify dietary needs at admission. On the day of admission, an LPN provided the resident with two ham and cheese sandwiches and ice water, without confirming the hospital discharge orders or recognizing the presence of a G-tube. This resulted in the resident aspirating and subsequently being hospitalized for aspiration pneumonia. The deficiency was further compounded when, after the resident's return to the facility, a food tray was again provided to the resident despite ongoing NPO orders and clear recommendations from speech therapy. The meal ticket system failed to reflect the correct NPO status, and a CNA unfamiliar with the resident gave the food tray, which led to the resident having food in his mouth. The error was identified and corrected by a supervisor, but not before the resident was exposed to further risk. Interviews with staff confirmed that communication breakdowns occurred between nursing, dietary, and therapy departments, and that the meal ticket system did not always accurately display specialized diets. Throughout the resident's stay, there were multiple documented instances of aspiration, pneumonia, and hospitalizations directly related to the failure to follow NPO orders. Staff interviews revealed that the admitting nurse did not verify discharge orders upon admission, and that subsequent communication lapses and system errors led to repeated provision of food to the resident. The facility's own policies required timely review and clarification of dietary orders, but these were not consistently followed, resulting in the resident not receiving the necessary care and services to meet nutritional needs.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to prevent two garbage dumpsters from overflowing with excess garbage, which prohibited the top lids and side doors from closing. This situation created a potential for pests, rodents, and insects. Observations revealed that one dumpster had trash bags overflowing from the top and sides, while the other had a large cardboard box and a garbage bag with a tan-colored liquid hanging out of the side door. Additionally, one of the dumpsters was missing a plug, which could lead to potential leakage of garbage contaminants. The Dietary Manager confirmed the overflow and the missing plug, stating that the dumpsters are emptied daily by a waste management company, and he makes rounds two to three times a day to ensure the area is clean. The Maintenance Director revealed that the dumpsters are emptied twice a week, typically in the afternoon, and that early pick-up can be arranged if needed. However, he was not aware that the dumpsters were full and overflowing and did not realize that one of the dumpsters was missing a plug. The Maintenance Director mentioned that he would likely need to purchase a plug to address the issue. The facility census was 101 residents at the time of the observation.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents on the [NAME] Unit. Specifically, one resident did not receive her breakfast until 10 minutes after others had already been served and some had finished eating. Another resident was the last to receive her lunch tray, which led her to question staff about the delay. Additionally, a resident was pulled backwards in his geriatric chair by an LPN when leaving the dining area, and staff were heard referring to residents as 'feeders' during lunch. These actions were observed during meal times and were corroborated by staff interviews. The Director of Health Services (DHS) was unaware of these incidents and confirmed that residents should be treated with respect, receive meals at the same time, and not be referred to as 'feeders'. The DHS also stated that residents in geriatric chairs should not be pulled backwards. The facility's document titled 'Your Rights as a Patient' emphasizes the right to be treated with respect and dignity, which was not upheld in these instances. Interviews with staff revealed a lack of training related to the dignity of residents, contributing to the observed deficiencies.
Failure to Provide Bed Hold Information at Time of Transfer
Penalty
Summary
The facility failed to provide bed hold information in writing at the time of transfer or within 24 hours for three residents who were transferred to the hospital in the last 120 days. The facility policy requires that a bed hold notice be given during admission and another at the time of transfer. However, for Resident 106, there was no documented evidence of a bed hold notification being provided when the resident was transferred to the hospital. Interviews with staff, including LPNs and the Admissions Coordinator, revealed a lack of awareness and clarity about who was responsible for providing the bed hold notices. The Director of Health Services confirmed that the required documentation was not provided for Resident 106's transfer on 3/31/2024. Similarly, Resident 68 was transferred to the hospital on 4/8/2024, and there was no evidence in the EMR that a bed hold policy was provided. Interviews with the Financial Counselor and LPN Unit Manager indicated that nursing staff had not been sending out the bed hold notice forms but would start doing so in the future. For Resident 19, who was transferred to the hospital on 4/20/2024, there was also no documented evidence of a bed hold notification being provided. The DHS confirmed that nursing staff are supposed to send the bed hold policy with a resident when going to the hospital, but this was not done in these cases.
Failure to Ensure Regular Physician Visits
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals. Specifically, four residents were not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. For instance, Resident 52, who had multiple diagnoses including paranoid schizophrenia and type 2 diabetes mellitus, had no documented physician visits for the past year. Similarly, Resident 74, who was admitted under commercial insurance and later transitioned to Medicaid, was only seen by a physician twice, with no further visits documented. The Director of Health Services and the physician both acknowledged the requirement for regular visits but failed to ensure compliance. Additionally, Resident 1, who was readmitted with acute respiratory failure and COPD, had no documented physician visits from January 2023 through May 2024. Resident 50, who had diagnoses including lack of coordination and unspecified dementia with behavior disturbances, also had no documented physician visits for the last 12 months. Interviews with staff, including the Corporate Nurse Consultant, confirmed that each resident should have an in-person physician or nurse practitioner visit every 30 days, with the physician alternating visits with the nurse practitioner every 60 days. However, this protocol was not followed, leading to the deficiency.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to ensure all food items on the steam table were held above 135 degrees Fahrenheit to prevent bacteria growth. This deficiency affected nine residents ordered a puree consistency diet out of a total of 99 residents receiving an oral diet. During an observation, the puree beef patty was found to have a temperature of 132 degrees Fahrenheit. The Dietary Manager confirmed the temperature and acknowledged that all food items on the steam table need to be held at or above 135 degrees Fahrenheit. The Dietary Manager also noted that there had not been any previous issues with the steam table maintaining food temperatures until that meal.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident (R71) for the ability to self-administer medications before allowing medications to be left at the bedside. The resident, who had diagnoses including schizophrenia, major depressive disorder, anemia, and chronic kidney disease, was observed with over-the-counter products (vapor rub and cough drops) on the nightstand. The resident reported that her family had brought the items for her, and she kept them in her room. However, there was no documentation in the electronic medical record indicating that R71 had been assessed for the ability to self-administer medications. During an interview, an LPN confirmed that residents could have medications at their bedside if assessed to do so, but verified that R71 had not been assessed. The LPN then removed the items from the bedside. The Director of Health Services later reported that she was unaware of the resident having over-the-counter medications in the room prior to the nurse bringing the items to her attention. This oversight had the potential to allow access to medications not prescribed by a physician to other residents, staff, or visitors.
Failure to Provide SNF ABN to Resident Discharged from Medicare Part A
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to a resident who was discharged from Medicare Part A coverage. Specifically, the resident was discharged from Medicare Part A skilled services and remained in the facility with benefit days remaining. There was no documented evidence that the SNF ABN was provided to the resident or the responsible party. During an interview, the Administrator revealed that the Financial Controller was new and only familiar with Medicare Part B, and was unaware that the SNF ABN was a required notice for residents discharged from Medicare Part A skilled services who remained in the facility. The Administrator confirmed that the resident and/or the responsible party did not receive an SNF ABN.
Failure to Provide Specialized Psychiatric Services
Penalty
Summary
The facility failed to provide specialized psychiatric services for a resident with a serious mental illness (SMI) as recommended by the Preadmission Screening and Resident Review (PASRR) Level II summary. The resident, who was admitted with a diagnosis of schizophrenia and was receiving antipsychotic medication, had a care plan that included behavioral health assessment/service plan and diagnostic/ongoing psychiatric care. However, a review of the electronic medical record (EMR) revealed no documented evidence that the resident received the recommended specialized services. Observations over several days showed the resident was pleasant and exhibited no behaviors. Interviews with staff, including a registered nurse and a social worker, confirmed that the resident should have been receiving psychiatric and psychotherapy services. The social worker believed the services were already in place but was unable to locate any documentation to support this. An email communication indicated that the consent and paperwork for treatment were resent, but there was no evidence that the services had been provided up to that point.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to potential gaps in their treatment and care. For one resident, who had diagnoses of dementia and anxiety, the facility did not create care plan areas for the use of antipsychotic and anti-anxiety medications, despite these medications being prescribed and administered regularly. Interviews with staff revealed that the comprehensive care plans should have included these medications, and the oversight was acknowledged by the Case Management Director and the Director of Health Services. This failure persisted despite multiple quarterly assessments and updates to the care plan, indicating a systemic issue in the care planning process. Another resident, who was on a controlled carbohydrate diet and had a lactose allergy, was not provided with meals that adhered to these dietary restrictions. Despite the care plan and meal tray ticket indicating the lactose allergy, the resident was served foods containing lactose, such as cream sauce and sherbet. The Dietary Manager confirmed this discrepancy during an observation. This failure to implement the care plan as ordered highlights a lapse in the facility's dietary management and adherence to prescribed dietary needs.
Failure to Provide Lactose-Free Diet as Ordered
Penalty
Summary
The facility failed to ensure that a resident (R77) was served a lactose-free diet as ordered by the physician. Despite the resident's meal tray ticket indicating an allergy to lactose, R77 was repeatedly served food items containing lactose. This included a cheese omelet and regular milk for breakfast, as well as country fried steak with cream sauce and sherbet for lunch. The Dietary Manager confirmed that these items contained lactose and acknowledged that the resident should not have been served these foods. Additionally, the Dietary Manager revealed that there was no facility policy regarding therapeutic diets, food allergies, or lactose intolerance. R77 had a medical history that included type 2 diabetes, hemiplegia/hemiparesis, chronic kidney disease, and moderate protein calorie malnutrition. The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Despite the clear documentation of the lactose allergy in the electronic medical record and on the meal tray ticket, the facility's failure to adhere to the prescribed diet resulted in the resident being served inappropriate food items. This deficiency was identified through observations, resident and staff interviews, and record reviews conducted by the surveyors.
Failure to Conduct Annual GDR Assessment for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a Gradual Dose Reduction (GDR) assessment was completed at least annually for a resident (R50) who was receiving antipsychotic medication. According to the facility's policy titled Monitoring of Antipsychotics, a GDR assessment should be conducted annually after the first year of antipsychotic medication use. However, the last documented GDR for R50's haloperidol was dated 4/27/2023, and no other GDRs were completed in the last 12 months. This failure was confirmed by the Director of Health Services (DHS) during an interview, who acknowledged that the pharmacist normally conducted a GDR for antipsychotic medications at least annually and that one should have been completed for R50. R50's medical records revealed that the resident had active diagnoses of dementia and anxiety and was receiving multiple psychotropic medications, including haloperidol, Xanax, mirtazapine, and PRN lorazepam. Despite regular psychiatric evaluations and medication management, no changes were recommended by the psychiatric clinician in progress notes dated 10/23, 1/24, and 4/24. The DHS verified that the pharmacist's email dated 5/18/2024 confirmed the resident's medication regimen but did not include a recent GDR assessment for haloperidol, highlighting the facility's failure to adhere to its own policy and regulatory requirements.
Failure to Properly Store, Label, and Discard Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were dated when opened, discarded on the discard dates, and stored according to manufacturer recommendations on one of three medication carts (East Unit Cart 2). Observations revealed that several medications, including insulin vials, insulin pens, ophthalmic solutions, and inhalers, were either not labeled with open and discard dates or were stored improperly. Specifically, medications such as Novolog insulin, Levemir insulin, Humalog Kwik Pen, Incruse Ellipta inhaler, Trelegy Ellipta inhaler, and Anoro Ellipta inhaler were found to be opened with expired discard dates. Additionally, unopened medications with pharmacy labels instructing refrigeration until opened were not stored in the refrigerator as required. Interviews with the LPN and the Director of Health Services (DHS) confirmed that the medications should have been labeled with open and discard dates and stored according to manufacturer and pharmacy instructions. The LPN acknowledged that medications administered past the discard date could be less effective, potentially causing altered effects for the residents. The DHS stated that all nurses working on the medication carts were responsible for ensuring proper storage, labeling, and discarding of medications, and that Unit Managers were expected to check the medication carts weekly for compliance. The failure to adhere to these protocols created the potential for residents to receive medications with altered effectiveness.
Failure to Maintain Clean Ice Scoop Bin and Beverage Dispenser
Penalty
Summary
The facility failed to ensure the ice scoop bin and beverage dispenser were free from green and black buildup on one of two units (West). Observations revealed that the ice scoop was stored in a clear container with black buildup and water along the edges. This ice scoop was used by CNAs to deliver ice to residents' rooms. Additionally, the water dispenser on the same unit had green and black buildup on the rubber parts inside the dispenser. The Dietary Manager confirmed the buildup and reported that the container was cleaned daily, but more attention to cleaning might be needed. There was no documentation of the last cleaning for the ice scoop container. Interviews with staff, including an LPN and the Director of Health Services (DHS), confirmed the presence of the buildup and the lack of a cleaning schedule for the ice scoop on the units. The DHS acknowledged the need to develop a system for regular cleaning moving forward. The facility policy titled Cleaning Procedures: Serving Equipment, last revised on 9/29/2022, was reviewed and indicated that the ice scoop and holding bin should be washed, sanitized, and air-dried daily, but this procedure was not followed as observed during the survey.
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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