Reserve At Appling Of Journey Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Appling, Georgia.
- Location
- 6698 Washington Road, Appling, Georgia 30802
- CMS Provider Number
- 115424
- Inspections on file
- 16
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Reserve At Appling Of Journey Llc, The during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure the dietary ice machine was free from dark brown and black buildup, despite staff attempts to clean it. The Maintenance Director, responsible for cleaning the machine, was unaware of the buildup until the survey, and the issue was confirmed by the Administrator. This deficiency had the potential to impact 76 residents receiving nutrition or hydration from the kitchen.
The facility failed to provide the required Notice of Medicare Noncoverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) forms to three residents discharged from Medicare Part A services. Interviews with the Social Services Director and the Administrator confirmed that no residents received notification of their Medicare benefits ending or information about their right to appeal the decision.
The facility failed to accurately report direct care staffing data to CMS for Q1 of FY 2024, resulting in a one-star staffing rating and other deficiencies. The Director of Finance relied on incomplete data from the time clock system and occasional emails from the Administrator, leading to inaccurate PBJ submissions.
The facility failed to ensure that two residents had their call lights within reach while they were in bed, potentially delaying the addressing of their needs. Observations revealed that the call lights for both residents were on the floor and not accessible, despite their care plans indicating the need for call lights to be within reach.
The facility failed to maintain a safe, clean, and comfortable home-like environment in seven resident rooms across three halls. Observations revealed issues such as dirty floors and walls, dirty privacy curtains, scuffed walls, chipped paint, and peeling wallpaper. Interviews with staff confirmed that the facility's Preventive Maintenance Program was not effectively implemented, leading to these deficiencies.
The facility failed to complete the Medication Administration Clinical Skills Checklist for 11 of 12 certified Medication Aides, as required by their own standards. Interviews with staff confirmed the absence of these checklists, indicating a lapse in ensuring competency before allowing unlicensed staff to administer medications.
The facility failed to provide education, offer, or administer pneumonia vaccinations for three residents. Clinical records showed no evidence of pneumonia or influenza vaccines being administered, and there were missing consent forms and documentation in the EMR and MAR. The Assistant Director of Nursing confirmed the lack of documentation for these residents' vaccinations.
The facility failed to maintain residents' rights and dignity by posting a sign in the lobby prohibiting visitation for a resident and by not ensuring full visual privacy during perineal care for another resident. The first resident was unaware of the visitation restrictions and desired visits from friends, while the second resident received care without privacy curtains fully pulled and window blinds open.
The facility failed to conduct care plan meetings and ensure that residents and/or their families were invited to participate in care planning. A review of a resident's clinical record revealed no documentation of family invitations or meetings held, and interviews confirmed that care plan meetings had not been taking place due to high turnover in MDS Coordinators.
The facility failed to ensure that two residents were assessed for Level II PASRR and coordinate services as needed. Both residents had diagnoses indicating the need for a Level II assessment, but there was no evidence of completed assessments, and the facility did not contact the screening authority upon discovering discrepancies.
The facility failed to update a resident's care plan to reflect their current Do Not Resuscitate (DNR) status, despite the presence of a signed POLST form and physician's order. The MDS Coordinator admitted to not updating care plans, and the Regional Nurse Consultant acknowledged the oversight, citing high turnover among MDS Coordinators.
The facility failed to document and administer the COVID-19 vaccine to a resident with severe cognitive impairment. The resident's legal guardian did not submit the necessary consent forms, and the staff responsible for obtaining and documenting these consents did not complete the process. The resident later tested positive for COVID-19, underscoring the importance of the missed vaccination.
Failure to Maintain Cleanliness of Dietary Ice Machine
Penalty
Summary
Surveyors observed that the facility failed to maintain the dietary ice machine in a clean and sanitary condition, as required by facility policy and professional standards. During an inspection in the kitchen area, the interior of the ice machine was found to contain dark brown and black buildup. The Dietary Manager confirmed the presence of this buildup and stated that both she and the kitchen staff had attempted to remove it without success. The facility's policy specifies that ice machines must be cleaned according to manufacturer instructions or as needed to prevent soil or mold accumulation, and assigns responsibility for cleaning to the Maintenance Director or a designee. Interviews with the Dietary Manager and Maintenance Director revealed that the Maintenance Director was responsible for cleaning the ice machine and reported doing so monthly. However, the Maintenance Director was unaware of the buildup prior to the surveyor's observation and confirmed the presence of the dark brown substance inside the machine. The Administrator also confirmed the buildup and stated that both the Maintenance Director and kitchen staff are expected to clean the ice machine regularly and thoroughly. This deficiency had the potential to affect the 76 residents who received nutrition or hydration from the kitchen.
Failure to Provide Required Medicare Noncoverage Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Noncoverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) forms to three residents who were discharged from Medicare Part A services. The facility's policy mandates that these notices be issued to residents or their representatives when Medicare-covered services are ending, regardless of whether the resident is leaving the facility or remaining. However, a review of the clinical records for three residents revealed that these forms were not provided before their discharge dates. Specifically, one resident was admitted for rehab services for multiple rib fractures and lumbar vertebrae dislocation, another for skilled services for generalized muscle weakness and gastronomy status, and the third for rehab services for a displaced intertrochanteric fracture of the right femur and muscle wasting and atrophy. None of these residents received the required notices before their discharge from the facility. Interviews with the Social Services Director (SSD) and the Administrator further confirmed the deficiency. The SSD admitted that no residents received notification of their Medicare Part A benefits ending or information about their right to appeal the decision. The Administrator was unaware of this issue and stated that the Regional Nurse Manager would educate the SSD on the process of issuing the Beneficiary Notices and the appeal process. This lack of notification was identified during a review of the facility's records and interviews with staff, highlighting a significant lapse in compliance with Medicare notification requirements.
Inaccurate Reporting of Direct Care Staffing Data
Penalty
Summary
The facility failed to accurately report direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of Fiscal Year 2024. The Payroll Based Journal (PBJ) report indicated several deficiencies, including a one-star staffing rating, excessively low weekend staffing, and a lack of licensed nursing coverage for specific dates. The facility census was 89 residents during this period. The Administrator revealed that the Director of Finance was responsible for submitting the staffing data, which was retrieved from the time clock system. However, salaried employees and agency staff were not consistently clocking in and out, leading to incomplete data. The Director of Finance confirmed that he relied on the time clock system and occasionally on emails from the Administrator to fill in missing hours, but he did not always have access to agency staff invoices at the time of submission. Further review of the Administrator's nursing hours sheets from October 2023 to April 2024 showed that the facility did have licensed nurses present 24 hours a day and did not have excessively low weekend staffing. This information was verified by comparing schedules, time sheets of agency staff, and time clock punches. Despite this, the PBJ report submitted to CMS did not reflect the accurate staffing levels due to the inconsistent recording and reporting practices. The Administrator provided copies of the staffing agency invoices to confirm the presence of weekend staff and 24-hour licensed nursing coverage, but this information was not included in the initial PBJ submission.
Failure to Ensure Call Lights Were Within Reach
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach while they were in bed, which could potentially delay addressing their needs. The policy titled 'Call Lights: Accessibility and Timely Response' mandates that call lights should be within reach of residents and secured as needed. However, observations on two separate occasions revealed that the call lights for two residents were on the floor and not accessible to them. Resident R20, who has poor cognition and is at risk for falls, was observed with the call light on the floor during two separate checks. Similarly, Resident R15, who has moderate cognitive impairment and is also at risk for falls, was found with the call light on the floor during two separate observations. Resident R20 was admitted with diagnoses including dementia, anxiety, and mood disturbance, and has a care plan that includes keeping the call light within reach. Despite this, the call light was found on the floor during observations. Resident R15, admitted with dementia, mood disturbance, and muscle weakness, also had a care plan that included keeping the call light within reach. Observations showed that the call light was on the floor and not accessible to the resident. The facility's administrator confirmed that call lights should be within reach of residents at all times.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable home-like environment in seven resident rooms across three halls. Observations revealed various issues including dirty floors and walls, dirty privacy curtains, scuffed walls, chipped paint, and peeling wallpaper. Specific instances included a dark dried substance on the bathroom floor in room A10 that appeared to be human waste and had been present for approximately five hours, water holding in the bathroom sink in room C18, and multiple rooms with black marks, holes in the walls, food particles on the floor, and stained privacy curtains. These conditions were confirmed by the housekeeping staff and the Environmental Account Manager, who acknowledged that the feces should have been cleaned up by the CNA or nurse on the hall when it happened. Interviews with the Maintenance Director and the Administrator revealed that the facility had a Preventive Maintenance Program in place, but it was not effectively implemented. The Maintenance Director stated that he and his assistant make rounds every morning to identify repairs needed, and there is a system for staff to submit work order sheets. However, the issues identified during the survey had not been addressed in a timely manner. The Administrator confirmed that she expects the facility to be maintained in a clean and homelike environment and that repairs should be done when identified. Despite these expectations, the facility failed to ensure a safe and sanitary environment for its residents, as evidenced by the numerous deficiencies observed during the survey.
Failure to Complete Medication Administration Clinical Skills Checklists
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of practice by not completing the Medication Administration Clinical Skills Checklist for 11 of the 12 certified Medication Aides (CMAs) employed at the facility. The facility's document titled 'Instructions for Completing the Medication Administration Clinical Skills Checklist' indicated that a licensed healthcare professional must validate the unlicensed staff's competency before allowing them to administer medications. However, a review of the facility employee records revealed no evidence that these checklists were completed for the majority of the CMAs. Interviews with the Business Office Manager (BOM), Director of Nursing (DON), and the Administrator confirmed the absence of the required competency checklists. The BOM admitted that the checklists were not in the employee files and could not be located. The DON, who started in December 2023, was unaware of the competency requirements and could not find the checklists. The Administrator stated that the checklists were supposed to be kept in the DON's office but were currently missing. The facility's process for ensuring CMA competency involves the Pharmacy Consultant, DON, or another Registered Nurse completing a check-off tool and demonstration during medication pass, to be done quarterly, but this process was not followed.
Failure to Administer Pneumonia Vaccinations
Penalty
Summary
The facility failed to provide education, offer, or administer pneumonia vaccinations for three residents reviewed for pneumonia vaccinations. The policy titled Pneumococcal Vaccine, dated 12/1/2022, mandates that each resident be assessed for pneumococcal immunization upon admission and be offered the immunization unless medically contraindicated or already immunized. However, the clinical records for three residents (R29, R71, R68) showed no evidence of pneumonia or influenza vaccines being administered, and there were missing consent forms and documentation in the electronic medical records (EMR) and Medication Administration Records (MAR). Resident R29, with severe cognitive impairment and a state-appointed legal guardian, had no documentation of pneumonia or influenza vaccines in the EMR or MAR from January 2024 through April 2024. Resident R71, also with severe cognitive impairment, had a signed consent form for the pneumonia vaccine but no documentation of administration in the May 2023 MAR. Resident R68, who was cognitively intact, also had no evidence of pneumonia or influenza vaccines in the EMR or MAR. The Assistant Director of Nursing confirmed the lack of documentation for these residents' vaccinations.
Violation of Resident Rights and Dignity
Penalty
Summary
The facility failed to ensure residents' rights and dignity were maintained for two residents. For one resident, a sign was posted in the front lobby prohibiting visitation, which was visible to all visitors. This resident, who had moderate cognitive impairment, was unaware of the visitation restrictions and expressed a desire to have visits from former friends. The Social Service Director and Assistant Director of Nursing were unaware of the sign, and the Regional Nurse Consultant admitted to placing it based on a family member's request, acknowledging it was a dignity issue. For another resident, a Certified Nursing Assistant provided perineal care without fully pulling the privacy curtains and with the window blinds open, failing to provide full visual privacy. This resident had severe cognitive impairment and multiple diagnoses, including vascular dementia and COPD. The CNA admitted to being unaware of the need to completely pull the privacy curtains and did not notice the open blinds. The Director of Nursing confirmed that staff are expected to protect resident rights and dignity at all times and was unaware of the posted visitation restrictions for the first resident.
Failure to Conduct Care Plan Meetings and Involve Family
Penalty
Summary
The facility failed to conduct care plan meetings and ensure that residents and/or their families were invited to participate in care planning for one of the sampled residents, R5. The facility's policy titled Care Planning-Resident Participation, dated 12/1/2022, mandates that residents be informed of and participate in their care planning and treatment. However, a review of R5's clinical record revealed no documentation indicating that R5's family had been invited to care plan meetings or that such meetings were held. Additionally, there were no signatures from the resident representative indicating participation in care plan meetings. Interviews with the MDS Coordinator and the Regional Nurse Consultant confirmed that care plan meetings had not been taking place. The MDS Coordinator, who works remotely, stated that she has not been conducting care plan meetings with each department or with families. The Regional Nurse Consultant revealed that the facility has experienced high turnover in MDS Coordinators over the past year, contributing to the lack of care plan meetings. R5's Power of Attorney also indicated that he had not been contacted for care plan meetings in a long time, despite having no concerns about his mother's care.
Failure to Complete PASRR Level II Assessments
Penalty
Summary
The facility failed to ensure that two residents were assessed for Level II Pre-Admission Screening/Resident Review (PASRR) and coordinate services as needed. Resident 29 was admitted with diagnoses including schizoaffective disorder and Moderate Intellectual Disabilities (ID). The admission Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a diagnosis of schizophrenia, but there was no evidence of a completed PASRR Level II assessment. The PASRR Level 1 Assessment for Resident 29 indicated bipolar disorder but did not mention schizoaffective disorder or ID, and the facility did not contact the screening authority upon discovering this discrepancy. Resident 85 was admitted with diagnoses including schizoaffective disorder-bipolar type and anxiety disorder. The admission MDS assessment indicated no cognitive impairment and a diagnosis of schizophrenia, with routine psychotic medications received. However, there was no evidence of a completed PASRR Level II assessment. The PASRR Level 1 Assessment for Resident 85 did not mention bipolar disorder, schizoaffective disorder, or ID, and the facility did not contact the screening authority upon discovering this discrepancy. The Social Service Director confirmed the lack of PASRR Level II assessments for both residents, citing an inability to access the GAMMIS website.
Failure to Update Resident's Code Status in Care Plan
Penalty
Summary
The facility failed to revise the care plan to reflect the current code status for one resident, identified as R5. The comprehensive care plan, which was last updated on 7/3/2023, did not reflect the resident's Do Not Resuscitate (DNR) status as indicated in the Physician Orders for Life Sustaining Treatment (POLST) form signed on 6/28/2023 and the physician's order dated 6/30/2023. Instead, the care plan still listed the resident as Full Code. This discrepancy was confirmed during interviews with the MDS Coordinator and the Regional Nurse Consultant (RNC), who acknowledged that the care plan should have been updated to reflect the current DNR status during the last MDS update. The MDS Coordinator, who works remotely and occasionally visits the facility, admitted that she has not been updating the residents' care plans. The RNC also revealed that the facility has experienced high turnover among MDS Coordinators in the past year, which may have contributed to the oversight. Despite the resident's Power of Attorney (POA) expressing no concerns about the care provided, the failure to update the care plan to reflect the resident's current DNR status represents a significant deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Document and Administer COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure proper documentation regarding the education, offering, and administration of the COVID-19 vaccine for one resident, identified as R29. The resident was admitted with severe cognitive impairment and had a state-appointed legal guardian responsible for healthcare decisions. Despite the facility's policy requiring the offering and documentation of COVID-19 vaccinations, there was no evidence in R29's records that the vaccine was offered or administered. The Infection Control Preventionist (ICP) confirmed the absence of documentation and noted that she did not have access to the Georgia Immunization Registry (GRITS) to verify the resident's immunization history. The Social Service Director (SSD) and the Director of Nursing (DON) both acknowledged that the legal guardian had not submitted the necessary consent forms for the COVID-19 vaccine, as well as for influenza and pneumococcal vaccines, and that the SSD was responsible for obtaining these consents upon admission. Interviews with facility staff revealed a breakdown in the process of obtaining and documenting vaccination consents. The SSD was responsible for including immunization consent forms in the resident's admission package and uploading them into the system for the ICP's access. However, this process was not completed for R29, resulting in the resident not receiving the COVID-19 vaccine. The DON was unaware of the lapse in vaccination for R29, indicating a lack of communication and oversight within the facility's vaccination protocol. Additionally, R29 tested positive for COVID-19 during their stay, further highlighting the importance of the missed vaccination opportunity.
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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