Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
A resident on EBP with a tracheostomy and G-tube received care from nursing staff who did not consistently perform hand hygiene or use PPE. An LPN prepared and administered medications without sanitizing hands between glove changes and did not don a gown, two CNAs provided peri-care without gowns and without hand hygiene between glove changes, and an RN suctioned the resident without the additional PPE required for high-contact care.
Expired and improperly stored meds and supplies were found in a medication cart and in both medication rooms. A CMA kept an insulin pen past its discard date, left an open thickener container unlabeled and of unknown age, and stored electrolyte solution unrefrigerated despite the manufacturer’s 48-hour refrigerated requirement; the CMA also gave residents the orange electrolyte solution with meds. The ADON, Staff Coordinator/Central Supply Clerk, and DON verified multiple expired items in the medication storage areas.
Resident Fed While Staff Stood Over Her: A resident with severe cognitive impairment, Down syndrome, and dementia required meal set-up and cleanup assistance. During lunch in her room, a CNA was observed standing over the resident while feeding her and confirmed she did so because there was no chair in the room. The ADON and DON stated staff should not stand over a resident while feeding and should sit when providing this assistance.
Unrepaired roof leaks affected Shower Room A and the dining room, with observations showing a protruding ceiling and brown stains around a light fixture in the shower room and brown discoloration on the dining room ceiling. A CNA and a kitchen aide stated the leaks occurred when it rained and had been ongoing for over a year, while the Maintenance Director and Administrator confirmed the long-standing issue and noted that outside companies had evaluated the leaks and recommended roof replacement.
Failure to Follow EBP Care Plan Interventions: A resident with a trach, PEG, dysphagia, and dementia had a care plan that included EBP for trach and G-tube status, but staff did not follow those interventions during care. An LPN administered G-tube medication without a gown, two CNAs provided perineal care without gowns, and an RN suctioned the trach without a gown. Staff stated they had not reviewed the care plan or should have checked it before providing care.
A resident’s comprehensive care plan was not updated to reflect a change in code status from full code to DNR. The chart contained a DNR on the admission record, a physician DNR order, and a signed POLST showing DNR, but the care plan still directed staff to provide CPR, call 911, and notify the physician and family if an arrest occurred. Interviews showed the SW, DON, and MDS Coordinator each had roles related to advance directives and care plan updates, yet the care plan remained inconsistent with the resident’s documented DNR status.
Failure to Provide Nail Care for Dependent Residents: The facility did not provide routine nail care for three residents with significant ADL dependence and cognitive impairment. One resident with hemiplegia and diabetes-related nail concerns had extremely long, jagged fingernails and toenails, while two other residents with Parkinson’s disease and other serious diagnoses also had long nails that were not trimmed despite staff and family concerns. Staff interviews showed nail care was deferred to podiatry or other referrals, but the facility had not had an on-site podiatrist for an extended period, and residents’ nails remained untrimmed.
Oxygen Delivered at Incorrect Flow Rate: A resident with SOB and severe cognitive impairment had an order for O2 at 2 LPM via NC every shift, but observations showed the oxygen flow set at 3 LPM. An LPN stated she was unaware of the O2 order and had not checked the flow rate that day, and the DON confirmed the ordered rate was 2 LPM.
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 Follow Hand Hygiene and EBP During Resident Care
Penalty
Summary
The facility failed to ensure nursing staff performed hand hygiene and used PPE while providing care to a resident on enhanced barrier precautions (EBP). The resident had diagnoses including cerebral infarction, acute respiratory failure, paralysis of vocal cords, tracheostomy status, gastrostomy status, dysphagia, failure to thrive, type 2 diabetes, and dementia. The resident’s MDS documented a feeding tube, oxygen, suctioning, and tracheostomy care, and the order summary identified EBP related to the tracheostomy and G-tube every shift. During medication administration, an LPN prepared crushed medications for the resident without sanitizing her hands before donning gloves. When she needed to retrieve a missing medication from another cart, she removed her gloves and walked away without performing hand hygiene, then returned and put on a new pair of gloves without sanitizing her hands. After entering the resident’s room, she placed the medication tray on the bedside table and again donned gloves without sanitizing or washing her hands. She did not don a gown while providing care, and later stated she believed her hands were clean because they had been inside gloves and that she did not think hand hygiene was needed after glove changes. During peri-care, two CNAs provided care to the resident without donning gowns and did not perform hand hygiene between glove changes. During suctioning, an RN entered the resident’s room, sanitized her hands, and donned gloves but did not use additional PPE despite supplies being available. She later acknowledged she should have used PPE but said she was in a rush. The Infection Preventionist and DON stated staff were expected to follow EBP, perform hand hygiene as indicated, and use PPE for high-contact care such as tracheostomy care and tube feeding.
Expired and Improperly Stored Medications and Supplies Found in Carts and Medication Rooms
Penalty
Summary
Medications, biologicals, and supplies were not stored according to manufacturers’ recommendations or facility policy in one of four medication carts and in two of two medication rooms. Facility policy required the pharmacy and medication rooms to be routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels, and the medication administration policy required staff to identify expiration dates and notify the nurse manager if expired. The manufacturer’s instructions for the electrolyte bottle stated that once opened, it was good for 48 hours under refrigerated conditions. During observation of a medication cart on Hall A with a CMA, surveyors found one insulin pen with an open date of 7/15/2025 and a discard date of 8/11/2025, which the CMA confirmed should have been discarded. The same cart contained an unlabeled open container of thickener with a date of 6/23, and the CMA stated she was unsure how long it had been opened or what the date meant. The cart also contained two bottles of electrolyte solution that were unrefrigerated, with open dates of 8/20/2025 and 8/25/2025; the CMA stated she was unaware the solution was only good for 48 hours and needed refrigeration, and said she had given residents the orange solution with medications that day. In the front medication storage room, the ADON verified expired saline enema, hemorrhoidal ointment, multi-vite liquid, and bisacodyl suppositories. In the back medication storage room, the ADON verified expired bisacodyl suppositories, adult liquid acetaminophen, lubricating jelly, and glucometer control solutions. The Staff Coordinator/Central Supply Clerk and the DON also verified the expired items were present.
Resident Fed While Staff Stood Over Her
Penalty
Summary
The facility failed to ensure that one resident was treated with dignity during dining. The resident had a BIMS score of 00 on the admission MDS, indicating severe cognitive impairment, and diagnoses included Down syndrome, non-Alzheimer's dementia, and a history of transient ischemic attack without deficit. The MDS also documented that the resident required set-up and cleanup assistance with meals. The care plan identified an ADL self-care performance deficit and risk for not having needs met in a timely manner related to Down syndrome and muscle weakness, with interventions including set-up with meals/eating and extensive assistance with oral hygiene, toileting, dressing, and personal hygiene. During observations in the resident's room, a CNA was seen standing over the resident while assisting with lunch. The CNA confirmed she stood over the resident while feeding her and stated there was no chair in the room to sit in. The ADON and DON stated that staff should not stand over a resident while feeding them and should sit when feeding a resident.
Unrepaired Roof Leaks in Shower Room and Dining Room
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment by not repairing roof leaks in Shower Room A and the dining room. Observation in Shower Room A showed the ceiling protruding downward with visible brown stains around the light fixture, and a CNA stated the ceiling leaked when it rained and had caused the ceiling area to protrude down. In the dining room, brown discolored areas were observed on the ceiling, and a kitchen aide stated the leak in the middle of the dining room had been a known problem for over a year. The Maintenance Director stated the ceiling had leaked for some time and that staff had attempted to repair it themselves by applying silicone, which did not help. He also stated the issue had persisted for over a year and that several local companies had provided estimates. The Administrator confirmed that the dining room and Shower Room A leaked when it rained, stated that several companies evaluated the leaks and recommended replacing the roof, and reported that she had emailed the owner regarding the issue. During the resident council meeting, residents reported ongoing roof leaks in the dining room and Shower Room A.
Failure to Follow EBP Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for one resident who required Enhanced Barrier Precautions (EBP). The resident had diagnoses including cerebral infarction, acute respiratory failure, paralysis of vocal cords, tracheostomy status, gastrostomy status, trach/PEG dependence, dysphagia, failure to thrive, type 2 diabetes, and dementia. The Quarterly MDS dated 8/7/2025 documented a feeding tube, oxygen, suctioning, and tracheostomy care. The care plan, revised 2/24/2025, identified the resident's tracheostomy and included interventions for EBP related to tracheostomy and G-tube status. During observation, an LPN administered medication through the G-tube without wearing a gown, two CNAs provided perineal care without wearing gowns, and an RN suctioned the resident's tracheostomy without wearing a gown. In interviews after the observations, the LPN stated she did not review the care plans daily, the CNAs stated they should have reviewed the care plan to refresh themselves on the resident's required care, and the RN stated she should have put on a gown before suctioning and would look in the orders and care plan to determine whether EBP were required. The IP, DON, and MDS Coordinator all stated that staff were expected to review and follow the resident's care plan, including EBP interventions.
Care Plan Not Updated for Changed Code Status
Penalty
Summary
The facility failed to ensure the comprehensive person-centered care plan was updated for a resident whose code status changed from full code to DNR. The resident, admitted with a documented DNR in the admission record, had a BIMS score of 13 on the admission MDS, indicating little to no cognitive impairment. The care plan, revised later, still identified the resident as having a physician’s order for full code and included interventions for CPR, calling 911, and notifying the physician and family/responsible party if an arrest occurred. Record review also showed a physician order for DNR and a signed Georgia POLST form indicating DNR status, signed by the resident and physician. During interviews, the Admission/Social Worker stated she provided the POLST form at admission, sent the completed form to the physician, and notified department heads of the resident’s code status, while the DON stated the MDS Coordinator was responsible for updating the care plan and that she communicated daily with the MDS Coordinator. The MDS Coordinator stated the Social Worker completed advance directive care plans, that care plans should be updated immediately when code status changes, and confirmed the care plan still listed the resident as full code despite the POLST and physician order showing DNR.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide nail care for three sampled residents, including residents with significant functional dependence and cognitive impairment. The facility policy titled Nail Care stated that routine cleaning and inspection of nails would be provided during ADL care, with routine nail care including trimming and filing on a regular schedule and as needed. A June 9, 2023 letter from a podiatrist stated the podiatrist would no longer provide services to the facility effective immediately. Resident R66 was admitted with diagnoses including lack of coordination, muscle weakness, and hemiplegia/hemiparesis following cerebral infarction affecting the left side. The resident’s MDS showed moderate cognitive impairment and dependence for all ADLs. During interviews and observations, R66 stated his fingernails and toenails were awfully long and that he had asked for them to be trimmed. Observations showed extremely long and jagged fingernails and toenails on multiple occasions. Staff interviews indicated bath sheets were reviewed by the wound care nurse, nail abnormalities were referred to podiatry, and nurse aides were not allowed to cut diabetic residents’ nails. The DON stated the facility had not had a podiatrist to provide nail care since at least April 2024, and the Administrator stated residents were sent to an outside appointment when there was a dire need. Resident R50 had severe cognitive impairment, Parkinson’s disease, dyskinesia, muscle weakness, and required staff for personal care. Her care plan identified an ADL self-care performance deficit and extensive assistance with hygiene, bathing, and dressing. Her resident representative observed long fingernails and toenails and stated the facility painted nails but did not cut them, and that the fingernails were so long and dirty that she had to cut them herself. Resident R81 had severe cognitive impairment, required maximal assistance for personal care including nail grooming, and had care plan interventions for assistance with grooming and podiatry care as ordered. Observations showed long fingernails and toenails, and both the resident and resident representative stated the nails had not been trimmed for months. The physician orders showed no podiatry order for R81, and staff including the hospice RN case manager and NP stated they did not cut nails and referred residents back to the facility or to podiatry for nail care.
Oxygen Delivered at Incorrect Flow Rate
Penalty
Summary
The facility failed to deliver oxygen per physician order for R74, a resident with diagnoses including shortness of breath and severe cognitive impairment. The quarterly MDS dated 6/5/2025 documented a BIMS score of 1 and indicated that oxygen was not administered while the resident. An order dated 8/18/2025 directed oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath, but observations on 8/25/2025 at 11:29 am and 8/26/2025 at 9:17 am showed R74 receiving oxygen via nasal cannula with the flow rate set at 3 liters per minute. During an observation and interview on 8/26/2025 at 4:08 pm, an LPN stated she was unaware of the oxygen order for R74 and had not checked the oxygen flow rate that day. The DON later confirmed the ordered oxygen rate was 2 liters per minute and stated the flow rate should be checked every shift and oxygen should be administered as ordered by the physician.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Appling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mccormick Post Acute | 13.6 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Evans, Llc | 15.5 mi | ★★★★★ | 0 | 0 |
| Pavilion At Brandon Wilde | 16 mi | ★★★★★ | 9 | 0 |
| Thomson Health And Rehabilitation | 18.1 mi | ★★★★★ | 8 | 0 |
| Harrington Park Health And Rehabilitation | 19 mi | ★★★★★ | 8 | 0 |
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