Rehabilitation Center Of South Georgia
Inspection history, citations, penalties and survey trends for this long-term care facility in Tifton, Georgia.
- Location
- 2002 Tift Avenue North, Tifton, Georgia 31794
- CMS Provider Number
- 115676
- Inspections on file
- 21
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Rehabilitation Center Of South Georgia during CMS and state inspections, most recent first.
The facility failed to serve food at safe and appetizing temperatures, affecting 115 residents. Observations revealed that lunch items were initially too hot, and by the time they were served, they were below acceptable temperature levels. The discrepancy was due to inconsistent thermometer readings, confirmed by the Dietary Manager.
The facility failed to properly dispose of and contain garbage, as two out of three dumpsters were found open, exposing trash. This was observed in the presence of the Dietary Manager, who acknowledged the responsibility to keep dumpsters closed. The facility's policy requires dumpsters to be closed and free of litter.
The facility failed to implement comprehensive care plans for residents, leading to improper fall interventions and lack of personalized activities. Observations showed beds not in the lowest position and fall mats misplaced, while residents in the memory care unit had limited engagement despite care plan directives. Staff interviews confirmed these deficiencies.
A facility failed to provide an ongoing activity program for residents in the memory care unit, affecting four residents with severe cognitive impairments. These residents had specific preferences for activities, but the facility's schedule was limited, with no weekend activities. Observations showed residents often left sitting with the television on, without engagement in meaningful activities. The Activity Director acknowledged the lack of individualized activities and the Administrator noted no current improvement plan to address the issue.
A resident in a long-term care facility was unable to get out of bed for seven days due to a lack of lift pads necessary for transfers, despite being cognitively intact and desiring to participate in activities. Staff interviews revealed that the issue was known but unresolved, with no clean lift pads available. The facility administrator was unaware of the situation, although numerous lift pads had been purchased previously.
The facility failed to protect residents from abuse by other residents, as evidenced by incidents involving residents with severe cognitive impairments. A resident with Alzheimer's disease exhibited aggressive behaviors, slapping another resident and engaging in altercations with others. Another resident, known for aggression, grabbed a fellow resident's face. Staff misunderstood these incidents as behaviors rather than abuse, and the facility's actions and inactions led to the deficiency.
The facility did not follow its Abuse Prohibition Policy by failing to conduct reference checks for three employees, including the Administrator, DON, and a CNA. This oversight was confirmed by HR, who discovered the lapse during an audit, and the Administrator acknowledged the expectation for reference checks to be completed before hiring.
The facility failed to conduct thorough investigations of resident-to-resident incidents, lacking written statements from witnesses or staff, despite policy requirements. Incidents involved residents with severe cognitive impairments, and an LPN confirmed witnessing an incident but was not interviewed. The Administrator acknowledged the absence of necessary documentation.
A facility failed to provide necessary transfer documentation for a resident hospitalized for syncope evaluation. Despite the facility's policy requiring a transfer summary and telephone report, no documentation was found in the resident's EMR. Interviews with the Corporate Nurse and an LPN confirmed the absence of documentation, potentially impacting the care provided by the receiving facility.
A facility failed to provide written notification to a resident, their responsible party, and the Ombudsman regarding a hospital transfer. The resident, with multiple health conditions, was transferred for syncope evaluation after becoming unresponsive. Despite policy requirements, only verbal notifications were given to families, and the Ombudsman was not informed.
A facility failed to provide a written bed hold notice to a resident or their representative within 24 hours of an emergency hospital transfer, as required by their policy. The policy mandates informing residents of the bed hold policy upon admission and prior to any transfer. In this case, there was no documentation indicating that the resident or their representative received the required notice following an emergency transfer for a syncope evaluation. The Financial Coordinator admitted to contacting the representative by phone on the third day if the resident is out for three days or more, but not sending any written notice.
The facility failed to implement fall prevention measures for two high-risk residents. One resident, severely cognitively impaired and dependent on staff, was observed with her bed not in the lowest position as required. Another resident, with a history of falls, had a fall mat incorrectly placed at the foot of the bed instead of the right side. These deficiencies were confirmed by staff observations and interviews.
A resident with Alzheimer's and dementia did not receive a physician-ordered rivastigmine patch due to a failure in reordering the medication in time. The LPN reported the medication was never ordered, and the facility's policy to reorder medications four to five days in advance was not followed.
A facility failed to ensure monthly medication regimen reviews by the consultant pharmacist included monitoring of antibiotic usage for a resident with a history of UTIs. The resident was initially prescribed an ineffective antibiotic, and the facility's infection control program did not maintain an order of events, leading to a failure in recognizing the incorrect administration.
A medication error rate of 7.41% was observed in an LTC facility, exceeding the acceptable rate of 5%. An LPN crushed and administered enteric-coated aspirin instead of the prescribed chewable form to a resident with dementia. Additionally, the LPN documented a refusal of Colace without confirming with the resident. The Corporate Nurse and Administrator acknowledged the errors.
A medication cart was left unlocked and unattended by an LPN, allowing a resident with diabetes, bipolar disorder, and heart failure to access medications not prescribed for them. The LPN confirmed she could not see the cart or the medications when away, and another LPN stated the cart should always be locked when unattended.
The facility failed to follow infection control guidelines during wound care, medication administration, and contact precautions. An LPN did not change gloves or perform hand hygiene during a dressing change, while another LPN handled medications with bare hands. Staff also entered a contact isolation room without proper PPE. These actions were against the facility's policies and posed a risk of infection spread.
A facility failed to monitor and evaluate antibiotic use for a resident with a history of UTIs, leading to inappropriate antibiotic prescriptions. The resident experienced multiple infections and was prescribed various antibiotics, some of which were not suitable for the identified bacteria. The facility's antibiotic stewardship program was not effectively implemented, resulting in a lack of proper tracking and evaluation of antibiotic use. Staff interviews revealed a lack of communication and coordination among the healthcare team.
The facility failed to ensure that the Social Service Director (SSD) had the proper qualifications for a facility with over 120 beds. The SSD, promoted on 11/3/2023, had an Associate of Arts degree and a Certificate of Completion for a Social Worker 4-Day Virtual Training Course. The Administrator expressed concerns about the SSD not having a Bachelor's degree but was told not to worry since the SSD was working towards her degree. The SSD confirmed she was 26 percent away from completing her Social Worker degree.
Deficiency in Serving Food at Safe Temperatures
Penalty
Summary
The facility failed to provide food at a safe and appetizing temperature during an observed meal, potentially affecting the satisfaction and palatability of food for 115 out of 119 residents. The facility's policy on food serving temperatures mandates that hot foods should be maintained at a minimum holding temperature of 140 degrees Fahrenheit and served at a point of service temperature between 120-140 degrees Fahrenheit or based on resident preference. However, during an observation, the temperatures of lunch items on the steam table were significantly higher than the required holding temperatures, with beef tips measuring up to 200 degrees Fahrenheit and lima beans up to 206 degrees Fahrenheit. A test tray was prepared and served to the 500 Hallway, where the food was found to be below acceptable temperature levels. The beef tips on the test tray measured 100 degrees Fahrenheit, mashed potatoes 130 degrees Fahrenheit, and lima beans 104 degrees Fahrenheit, all confirmed by the Dietary Manager (DM) as cold to warm. The discrepancy in temperature readings was attributed to the use of different thermometers, with the analog thermometer showing a 45-degree cooler reading than the digital one, despite being properly calibrated. This inconsistency in temperature monitoring led to the deficiency in serving food at the appropriate temperature.
Improper Garbage Disposal and Containment
Penalty
Summary
The facility failed to ensure proper disposal and containment of garbage, as observed during a survey. Two out of three dumpsters located in the parking lot behind the kitchen were found with their side doors pushed back and left open, exposing boxes and bags of trash. This observation was made in the presence of the Dietary Manager (DM), who acknowledged that the dumpsters should be closed and noted that while others use the dumpsters, it is the facility's responsibility to keep them closed. The facility's policy on Garbage and Rubbish Disposal, dated 1/8/2009, mandates that garbage and rubbish containing food wastes must be stored to be inaccessible to vermin, and outside dumpsters must be kept closed and free of litter around the area.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement a person-centered comprehensive care plan with measurable goals and plans related to fall and activity interventions for several residents. For one resident, the care plan directed staff to place the bed in the lowest position due to a fall risk, but observations on multiple occasions showed the bed was not in the correct position. Another resident's care plan required a fall mat to be placed on the right side of the bed, but it was observed at the foot of the bed with a wheelchair parked on top of it. Interviews with staff confirmed these discrepancies, indicating a lack of adherence to the care plans. Additionally, residents in the memory care unit were observed to have limited engagement in activities that met their individual needs. Despite care plans indicating preferences for activities such as watching television, reading, and listening to music, residents were seen lined up against walls with minimal interaction from staff. The television and music were on, but there were no personalized engagement activities provided. Interviews with staff confirmed that care plan interventions were not being implemented as expected.
Deficiency in Activity Program for Memory Care Unit Residents
Penalty
Summary
The facility failed to provide an ongoing activity program tailored to meet the individual interests and needs of residents in the memory care unit, specifically affecting four residents with severe cognitive impairments. These residents, diagnosed with various forms of dementia, had specific preferences for activities such as listening to music, participating in religious activities, and engaging in group activities. However, the facility's activity schedule was limited, with group activities like Bible study, music, and crafts scheduled only once a day and no activities planned for weekends. Observations revealed that residents were often left sitting in chairs lined up against the walls with the television on, tuned to the Hallmark station, without any engagement in meaningful activities. Staff interviews indicated that the activity department did not provide individual activities for the memory care unit residents, and there were no materials available for engagement, such as puzzles or arts and crafts. The Activity Director acknowledged the lack of a weekend schedule and the need for more individualized activities, noting that the facility had not yet implemented the Music and Memory program. The Administrator, new to her position, was aware of the deficiency in activities for the memory care unit but stated there was no current performance improvement plan to address the issue. The absence of a dedicated activity staff member for the memory care unit and the lack of implementation of planned programs contributed to the deficiency, leaving residents without adequate engagement and potentially disruptive due to the lack of stimulation.
Resident's Right to Self-Determination Compromised Due to Equipment Shortage
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing the necessary equipment to allow the resident to get out of bed as desired. The resident, who was cognitively intact and required substantial assistance for mobility due to multiple sclerosis and contractures, was unable to leave the bed for seven days. This was due to the unavailability of lift pads needed for the mechanical lift used for transfers. Despite the facility's policy supporting resident choice, the lack of equipment hindered the resident's ability to participate in daily activities and social interactions, leading to feelings of isolation. Interviews with staff, including CNAs, LPNs, and the housekeeping supervisor, revealed that the issue of missing lift pads was known but unresolved. Staff reported that they frequently lacked the necessary lift pads to assist the resident, and the housekeeping supervisor confirmed that there were no clean lift pads available for exchange. The central supply staff mentioned that lift pads had been ordered, but their whereabouts were unknown. The facility administrator was unaware of the situation until informed by surveyors, despite having purchased a significant number of lift pads since the previous year.
Failure to Protect Residents from Abuse by Other Residents
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by multiple incidents involving residents with severe cognitive impairments. Resident R60, diagnosed with early Alzheimer's disease, exhibited physical and verbal behavioral symptoms towards others. On one occasion, R60 slapped another resident, R101, who also had severe cognitive impairment and no prior behaviors directed towards others. This incident was witnessed by staff, and although no injuries were reported, it was documented as resident-to-resident abuse. Another incident involved resident R93, who had a history of physical and verbal aggression towards others. R93, while agitated, grabbed the face and jaw of R60, but staff intervened, and no injuries were reported. This incident was also marked as resident-to-resident abuse. Additionally, R60 was involved in another altercation with resident R55, where R60 attempted to take R55's tea and subsequently hit and grabbed R55's arm, leaving no injuries. Interviews with staff, including LPN4, revealed a misunderstanding of the nature of these incidents, with some staff considering them as behaviors rather than abuse. The facility's administrator acknowledged the potential for abuse between residents but noted the lack of intent due to the residents' cognitive impairments. Despite these acknowledgments, the facility's actions and inactions in preventing and addressing these incidents led to the deficiency in protecting residents from abuse.
Failure to Conduct Employee Reference Checks
Penalty
Summary
The facility failed to implement its Abuse Prohibition Policy and Procedures by not conducting reference checks for three out of ten employees whose files were reviewed. The policy, dated January 2017, mandates a thorough investigation of potential hires, including checking references and information from previous or current employers to uncover any criminal prosecutions. However, the employee files for the Administrator, Director of Nursing (DON), and a Certified Nursing Assistant (CNA) did not include any reference checks, despite the policy's requirements. During interviews, the Human Resources (HR) department confirmed the absence of reference checks for the mentioned staff members. HR attributed this oversight to a previous HR employee who failed to complete the reference checks, which was discovered during an audit of employee files. The Administrator also stated that reference checks were expected to be completed before hiring to ensure applicants were suitable to work in the residents' home, indicating a lapse in following the established hiring procedures.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations of resident-to-resident incidents, as required by their policy titled 'Abuse Investigation.' This deficiency was identified for four residents who were reviewed for abuse. The policy mandates that all reports of resident abuse, neglect, misappropriation of resident property, and injuries of an unknown source be promptly and thoroughly investigated, including interviews with the person(s) reporting the incident and any witnesses, with witness reports being documented in writing. However, the investigations involving these residents lacked written statements from witnesses or staff, which is a critical component of the investigation process. The report highlights specific incidents involving residents with severe cognitive impairments, as indicated by their Brief Interview for Mental Status (BIMS) scores. For instance, one resident had a BIMS score of zero, indicating severe cognitive impairment. Despite the presence of witnesses, such as an LPN who confirmed witnessing an incident and documented it in the clinical records, the facility's investigations did not include interviews or written statements from these witnesses. The Administrator acknowledged the absence of such documentation and stated that interviews should have been conducted and statements collected, but they were not found in the incident files.
Failure to Provide Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to provide the receiving facility with necessary documentation regarding the transfer of a resident, identified as R86, who was hospitalized. According to the facility's policy titled 'Discharging the Resident,' a transfer summary and a telephone report should be completed and communicated to the receiving facility when a resident is transferred. However, upon review of R86's Electronic Medical Record (EMR), there was no documentation or record of information provided to the hospital. This oversight was confirmed during interviews with the Corporate Nurse and a Licensed Practical Nurse (LPN), who both acknowledged the absence of documentation indicating what information was sent with the resident. R86 was admitted to the facility with diagnoses including nonrheumatic mitral valve insufficiency, occlusion and stenosis of the right carotid artery, and hypertension. A change in condition was noted on 6/26/2024, when R86 experienced an episode of syncope, leading to a decision to send the resident to the hospital for evaluation. Despite this critical situation, the facility did not ensure that the necessary transfer documentation was completed and sent with the resident, potentially affecting the care provided by the receiving facility.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to a resident, their responsible party, and the Ombudsman regarding a transfer to the hospital. The facility's policy, titled 'Notice of Transfer/Discharge,' mandates that such notifications include the reason for transfer, effective date, location, appeal rights, and contact information for the state long-term care ombudsman. However, the policy did not address the requirement to provide written information to the resident, their representative, and the Ombudsman. This oversight was identified during a review of the facility's records and staff interviews. The deficiency involved a resident who was admitted with conditions including nonrheumatic mitral valve insufficiency, occlusion and stenosis of the right carotid artery, and hypertension. On a specific date, the resident experienced a change in condition, becoming unresponsive and requiring a hospital transfer for syncope evaluation. Despite the facility's policy, there was no documentation of written notification being provided to the resident, their responsible party, or the Ombudsman. Interviews with facility staff revealed that only verbal notifications were given to families, and the Ombudsman was not notified of hospital transfers.
Failure to Provide Timely Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or their representative within 24 hours of an emergency hospital transfer, as required by their policy. The policy, dated 1/19/2022, mandates that residents be informed of the bed hold policy upon admission and prior to any transfer for hospitalization or therapeutic leave. In cases of emergency transfers, the policy specifies that the facility must provide the resident or their representative with written information about the bed hold policy within 24 hours, including any charges and the time limit for holding the bed as per the State Medicaid Plan. In the case of the resident identified as R86, there was no documentation in the electronic medical record indicating that the resident or their representative received the required written notice following an emergency transfer to the hospital for a syncope evaluation. The Financial Coordinator admitted during an interview that they typically contact the resident's representative by phone on the third day if the resident is out for three days or more, but do not send any written notice regarding the bed hold. This oversight created a potential gap in communication, leaving the resident and their representative without necessary information to safeguard the resident's return to the facility.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to implement accident prevention measures for two residents, R43 and R84, who were at high risk for falls. R43, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed multiple times with her bed not in the lowest position, contrary to her care plan directives. Despite being identified as a high fall risk, the staff did not ensure the bed was adjusted accordingly, as confirmed by interviews with the CNA and RN responsible for her care. Similarly, R84, who had a history of falls and was also severely cognitively impaired, was supposed to have a fall mat placed on the right side of the bed as per the care plan. However, observations revealed that the fall mat was incorrectly placed at the foot of the bed with a wheelchair parked on top of it. This misplacement was confirmed by multiple staff members, including CNAs and an RN, indicating a failure to adhere to the prescribed fall prevention measures.
Failure to Provide Physician-Ordered Medication
Penalty
Summary
The facility failed to provide a physician-ordered medication for a resident during a medication administration observation. The resident, who was diagnosed with Alzheimer's disease with late onset and dementia, had a physician's order for a rivastigmine (Exelon) patch to be applied transdermally once a day. However, during the observation, the Licensed Practical Nurse (LPN) stated that the medication was never ordered, and there was no patch available to replace the one that had been removed. The facility's policy on medication ordering and receiving from the pharmacy, dated May 1, 2020, requires medications to be reordered four to five days in advance to ensure an adequate supply. Despite this policy, the medication was not reordered in time, leading to its unavailability. The Corporate Nurse indicated that reordering should occur when down to one or two patches, but this was not adhered to, resulting in the deficiency.
Failure to Monitor Antibiotic Usage in Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the monthly medication regimen reviews (MRRs) conducted by the consultant pharmacist included appropriate monitoring of antibiotic usage for a resident. The facility's policy required the consultant pharmacist to perform a comprehensive MRR at least monthly, evaluating the resident's response to medication therapy and reporting findings to relevant staff. However, the MRRs for the resident from June 2023 to June 2024 did not contain any information about antibiotic use or the number of antibiotics prescribed, which was a requirement under the facility's Antibiotic Stewardship Program. The resident in question had a history of diabetes, chronic kidney disease, dementia, psychotic disorder with hallucinations, and urinary tract infections. The resident was hospitalized for altered mental status and dysuria, and was initially prescribed an antibiotic that was not effective against the bacteria present. The facility later prescribed a different antibiotic. During interviews, it was revealed that the pharmacy's monthly reviews did not include antibiotic reviews, and the facility's infection control program did not maintain an order of events, leading to a failure in recognizing the incorrect antibiotic administration and the need for changes.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.41 percent during a medication administration observation. This deficiency was identified through observation, staff interviews, and record reviews. Specifically, two medication errors were made for one resident out of 27 opportunities. The errors involved the administration of an incorrect form of aspirin and the premature documentation of a medication refusal. The facility's policy on crushing medications was not followed, as enteric-coated aspirin was crushed and administered to the resident. The resident involved, identified as R77, was admitted with diagnoses of dementia, constipation, and cardiac murmur, and had a severely impaired cognitive status with a BIMS score of five out of 15. The resident had physician orders for aspirin 81 mg chewable tablet and Colace 100 mg, with instructions to crush medications. However, the LPN administered crushed enteric-coated aspirin instead of the chewable form and documented the refusal of Colace without confirming with the resident. The Corporate Nurse confirmed the error, and the Administrator stated that medications should be administered correctly.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that one of six medication carts was locked and that a cup of medications was not left unattended, which had the potential to affect a resident, R79. During an observation, LPN 9 was seen preparing medication for another resident when R79 approached the medication cart. LPN 9 left the cart unlocked and went into a resident's room, leaving the cart unattended. Upon returning, LPN 9 locked the cart but left a cup of pills on top of it and again went to the doorway of a resident's room, leaving the medication cup unattended and accessible to R79. Interviews conducted with LPN 9 confirmed that she could not see the front side of the medication cart or the cup of medications when she was away from the cart. Another LPN, LPN 5, stated that the cart should always be locked when the nurse is not with it. R79, who was sitting near the cart, had access to both the drawers of the medication cart and the cup of pills left on top, posing a risk of accessing medications not prescribed for him.
Infection Control Deficiencies in Wound Care, Medication Administration, and Contact Precautions
Penalty
Summary
The facility failed to adhere to proper infection control guidelines during a dressing change for a resident with a wound on the left second toe. The Licensed Practical Nurse (LPN) performing the wound care did not use a barrier on the bedside table, placed the dirty bandage on the bed, and did not have a trash receptacle nearby. The LPN did not change gloves after cleaning the wound and proceeded to clean bottles with the same gloves, without allowing the disinfectant to dry for the required two minutes. The LPN also failed to perform hand hygiene after removing gloves and did not use a barrier on the treatment cart. Another deficiency was observed during the administration of oral medications to a resident with severe cognitive impairment. The LPN placed pills on a notepad and handled them with bare hands before administering them to the resident. This was against the facility's policy, which requires medications to be placed in a medicine cup and handled with gloves. The LPN acknowledged the mistake during an interview, and the Infection Preventionist confirmed that handling medications with bare hands was not in compliance with the policy. The facility also failed to implement contact precautions for a resident with a urinary tract infection requiring isolation. Staff members, including a Resident Assistant and a Housekeeper, entered the resident's room without donning the required personal protective equipment (PPE). The Resident Assistant believed PPE was not necessary if not providing direct care, and the Housekeeper admitted to not wearing a gown and gloves. The Infection Preventionist confirmed that PPE should be applied before entering and removed before exiting the room, which was not followed by the staff.
Failure to Monitor and Evaluate Antibiotic Use
Penalty
Summary
The facility failed to effectively monitor and evaluate antibiotic use for a resident, leading to potential safety risks related to antibiotic usage. The resident, who had a history of urinary tract infections, was admitted with multiple diagnoses including diabetes, chronic kidney disease, and dementia. Over several months, the resident experienced multiple urinary tract infections and was prescribed various antibiotics, some of which were not appropriate for the bacteria identified in cultures. The facility's antibiotic stewardship program, as outlined in their policy, was not adequately implemented, resulting in a lack of proper tracking and evaluation of antibiotic use. The facility's Infection Preventionist (IP) and Nurse Practitioner (NP) did not adequately track the resident's antibiotic usage and catheterization events, leading to missed opportunities to identify inappropriate antibiotic prescriptions. The IP admitted that the facility's infection control program did not maintain a clear order of events, which contributed to the oversight. Additionally, the NP did not ensure that cultures were obtained before prescribing antibiotics, and there was a lack of communication and coordination among the healthcare team regarding the resident's care. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's antibiotic treatment and catheterization history. The IP acknowledged that the pharmacy's monthly medication reviews did not include antibiotics, and the NP did not respond to questions about the overall management of the resident's condition. The facility administrator emphasized the need for the entire team, including pharmacy, to be informed and aligned on infection control and antibiotic stewardship practices.
Unqualified Social Service Director in Facility with Over 120 Beds
Penalty
Summary
The facility failed to ensure that the Social Service Director (SSD) had the proper qualifications for a facility with over 120 beds. The facility is licensed for 178 beds. The personnel file review revealed that the SSD, promoted on 11/3/2023, had an Associate of Arts degree with a concentration in elementary education and a Certificate of Completion for a Social Worker 4-Day Virtual Training Course from the Georgia Health Care Association. The Administrator expressed concerns to corporate about the SSD not having a Bachelor's degree but was told not to worry since the SSD was working towards her Bachelor's Degree in Social Work. The SSD confirmed she did not have a four-year degree or a Social Worker degree and was currently 26 percent away from completing her Social Worker degree. The previous SSD was let go, and management felt the current SSD could do the job despite her lack of qualifications.
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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