Roselane Health Center By Harborview
Inspection history, citations, penalties and survey trends for this long-term care facility in Marietta, Georgia.
- Location
- 613 Roselane Street, Marietta, Georgia 30060
- CMS Provider Number
- 115660
- Inspections on file
- 21
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Roselane Health Center By Harborview during CMS and state inspections, most recent first.
Two residents were not protected from abuse when one, who had moderate cognitive impairment and required extensive ADL assistance, reported that a CNA refused to help her back to bed and twisted her arm, resulting in a skin tear and bruising in a fingerprint pattern, and another nonverbal resident with hemiplegia confirmed by nodding that a CNA had yelled at her to “shut up.” These incidents occurred despite facility policies stating that abuse, neglect, and exploitation are prohibited and that such occurrences will be analyzed to prevent recurrence and reported when there is reasonable suspicion of a crime.
Surveyors found that dietary staff, including a cook and the FSD with facial hair, repeatedly worked in the kitchen without required beard restraints during multiple observations. On several occasions, staff with beards were seen in food preparation and service areas, including while one cook leaned over a steam table to take temperatures on multiple food items, bringing his beard close to hot foods. Facility policy required all dietary staff to wear hair restraints, including beard restraints, and prohibited bare-hand contact with food, but these requirements were not followed, creating a potential for food contamination affecting all residents served.
Surveyors found that pureed foods for eight residents on puree or mechanical diets were not prepared according to the facility’s written puree guidelines and recipes. A cook prepared pureed pulled pork, carrots, and baked beans without using recipes, did not measure ingredients to achieve the required consistency, and described the target texture only as a “peanut butter consistency.” The cook also failed to perform proper hand hygiene before resuming work after retrieving supplies and between preparing different pureed items, and rinsed utensils in a sink during preparation. Policy required specific additives and methods to conserve nutritive value, flavor, and appearance, and leadership confirmed that pureed foods were expected to be prepared per recipe.
A resident who was cognitively intact, morbidly obese, incontinent, and dependent on a mechanical lift consistently received bed baths despite expressing a preference for showers. Over a two‑month period, shower documentation showed only bed baths with no refusals recorded and no evidence the resident was ever assisted with a shower. Staff interviews revealed that a CNA knew the resident was particular about who provided showers, but an RN of three years was unaware of the resident’s preference, despite facility policy and leadership expectations that resident bathing choices be honored and documented on twice‑weekly shower sheets.
The facility did not complete quarterly MDS assessments within the required 92-day timeframe for two residents. Record review showed that the interval between two quarterly MDS ARDs for a resident was 94 days, exceeding regulatory limits and the facility’s MDS 3.0 Completion policy. The RN VP of Clinical Reimbursement confirmed the assessments were late, and leadership acknowledged that assessments are expected to be completed on time to meet regulatory requirements and support timely care planning.
Surveyors identified that multiple residents did not receive or have documented bathing and ADL care according to the facility’s twice-weekly shower schedule and ADL policy. One resident, cognitively intact and dependent for bathing, reported never having a shower since admission despite being scheduled for twice-weekly showers, with records showing only one shower documented for the month. Another cognitively intact resident, fully dependent for bathing and oral hygiene, was observed with oily hair and was reported by family to have unshampooed hair and unbrushed teeth, while bath sheets lacked detail and were fewer than expected, with no refusals documented. A third cognitively intact resident with bilateral above-knee amputations, morbid obesity, heart disease, CKD, and an unstageable sacral ulcer reported inconsistent bed baths and that staff had largely stopped offering them, and review of several months of shower sheets showed far fewer entries than required, despite staff and the DON stating that every resident must be offered and have documented at least two baths per week, including refusals.
A resident with COPD, chronic respiratory failure with hypoxia, and other pulmonary and cardiac conditions was receiving oxygen therapy with orders for weekly and PRN cleaning of the oxygen concentrator filter. Over several observations, the concentrator’s external filter was noted to have gray, fuzzy debris. After the facility transitioned from using an RT to having nursing staff responsible for concentrator maintenance, an LPN reported checking concentrators but not turning the unit to inspect the filter and acknowledged it had likely been more than two weeks since the filter was checked. A CNA confirmed the dirty filter and was unsure of the cleaning schedule. The DON and Administrator stated that filters were expected to be cleaned weekly per facility policy and manufacturer guidance, but this was not done, resulting in the identified deficiency.
Two residents received antibiotic therapy for presumed UTIs without meeting McGeer criteria, despite the facility’s Antibiotic Stewardship Program requiring use of these criteria and CDC/NHSN definitions to guide treatment decisions. One resident with dementia and multiple comorbidities was given Nitrofurantoin for seven days for confusion and hallucinations with a positive urine culture, even though the facility’s checklist and stewardship binder documented that UTI criteria were not met. Another resident with an indwelling catheter and multiple diagnoses was treated with Ciprofloxacin for five days based on cloudy, foul-smelling urine with sediment, while the McGeer checklist and stewardship documentation again indicated UTI criteria were not met. The DON and an NP acknowledged that stewardship practices, including antibiotic time-outs and accurate tracking, were not being properly followed, and leadership confirmed that provider prescribing did not align with the facility’s established protocol.
Surveyors identified a 24% medication error rate when an LPN crushed and mixed multiple medications together for administration through a GT for a resident, contrary to professional standards, and omitted a scheduled Coreg dose without contacting the pharmacy or checking emergency stock. Review of MARs showed multiple missing documentation entries for three residents, including anticoagulants, analgesics, inhalation treatments, GI medications, topical antifungals, enteral feedings, and related blood pressure checks. The DON acknowledged that mixing crushed medications for GT administration was a deficient practice and confirmed the missing MAR documentation, while the Administrator stated that medications must be administered per policy and professional standards.
The facility failed to follow its Antibiotic Stewardship Program and McGeer criteria when initiating antibiotics for two residents. One resident with dementia, delirium, urinary retention, and other comorbidities was started on nitrofurantoin for a presumed UTI based on confusion, hallucinations, and a positive urine test, even though the McGeer checklist and stewardship documentation showed UTI criteria were not met. Another resident with an indwelling catheter and multiple medical conditions received ciprofloxacin for a UTI after staff noted cloudy, foul-smelling urine with sediment, despite the McGeer checklist and stewardship records indicating UTI criteria were not met. The DON, NP, Administrator, and National Director of Risk Management acknowledged that antibiotics were prescribed and administered without meeting McGeer criteria and that key stewardship practices, including accurate tracking and antibiotic time-outs, were not being properly implemented.
The facility failed to label, date, and ensure food items in storage were not expired, as per their policy. Observations revealed unlabeled and expired items in the freezer, refrigerator, and dry storage. The DM acknowledged these oversights, and the Administrator emphasized the expectation for compliance with food safety protocols.
The facility failed to properly dispose of garbage for two out of three dumpsters, potentially allowing pests and rodents to enter. Observations revealed trash on the ground near the first dumpster, an open side door on dumpster one, and a missing drain plug on dumpster two. The Dietary Manager was unaware of these issues, acknowledging the risk of pest intrusion.
The facility failed to ensure accurate MDS assessments for three residents, leading to incorrect coding of medications and therapy sessions. One resident's Ozempic was coded as insulin, another's therapy days were underreported, and a third's trazodone and Ozempic were misclassified. These errors resulted in inaccurate representations of the residents' health status.
A facility failed to update the PASARR for a resident diagnosed with major depressive disorder. The resident's PASARR Level I Assessment did not reflect this diagnosis, despite a psychiatric evaluation confirming it. The facility's policy requires PASARR updates for diagnosis changes, but this was not done, potentially impacting the resident's psychosocial well-being.
The facility failed to develop comprehensive care plans for two residents, leading to potential unmet care needs. One resident's care plan lacked instructions to notify the physician if insulin was not administered, while another resident's plan was incomplete regarding assistance with ADLs. Interviews confirmed the need for more specific care plans to ensure proper care.
A resident with a history of metabolic encephalopathy and end-stage renal disease experienced altered mental status and refused dialysis. Despite the facility's policy requiring notification of significant condition changes, the resident was sent to dialysis without proper communication or documentation. Upon arrival, the resident was unresponsive, leading to an emergency room transfer. Interviews revealed communication lapses among staff, contributing to the deficiency.
The facility failed to ensure narcotics were signed out before administration for a resident. An LPN obtained pregabalin oxycodone from the controlled substance lock box without verifying the count or signing it out, stating she signs out medications after administration in case of refusal. Another LPN exhibited similar behavior. The DON stated that the expectation is to verify and sign out medications at the time of administration.
A resident with Type 2 Diabetes Mellitus did not receive physician-ordered insulin on multiple occasions, and blood sugar levels were not monitored as required. The facility failed to notify the physician of these lapses. Interviews revealed that the facility occasionally ran out of insulin due to inadequate ordering practices, posing a risk to the resident's health.
A facility failed to properly clean a glucometer after use on a diabetic resident. An LPN used an alcohol wipe instead of the required germicidal wipes, which were not available on the medication cart. The resident was receiving insulin treatment for type two diabetes mellitus. The Unit Manager confirmed the correct procedure, and the DON acknowledged the incident, emphasizing the need for proper supplies on medication carts.
Failure to Protect Residents From Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, resulting in physical harm to one resident and verbal abuse of another. One resident with acute embolism and thrombosis of the right femoral vein, history of pulmonary embolism, fibromyalgia, major depressive disorder, and dementia with agitation had a quarterly MDS showing moderate cognitive impairment and dependence on staff for transfers and significant ADL assistance. Facility documents show that this resident reported asking a CNA for assistance back to bed, and the CNA told her she could put herself in bed and then twisted her arm. A head-to-toe assessment identified a skin tear on the right arm where the resident reported the CNA twisted her arm, and a subsequent skin assessment documented bruising in a fingerprint pattern around the skin tear. During multiple later observations and attempted interviews, the resident either did not answer questions about the incident or refused to discuss it. The deficiency also includes an incident of verbal abuse toward another resident who had been admitted with essential hypertension, GERD, asthma, and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side. The Social Worker District Coordinator reported being informed by staff that a CNA yelled at this resident to “shut up.” The SDC interviewed the resident, who is nonverbal, and the resident confirmed the allegation by nodding yes. The Administrator was notified and also interviewed the resident, who again confirmed the verbal abuse allegation by nodding. The facility’s written policies on Abuse, Neglect and Exploitation and on Reporting Reasonable Suspicion of a Crime state that the facility will prohibit and prevent abuse, neglect, and exploitation of residents and will analyze occurrences to determine why abuse occurred and what changes are needed to prevent further occurrences, as well as report any reasonable suspicion of a crime against a resident.
Failure to Enforce Beard Restraints for Dietary Staff
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to ensure kitchen staff wore appropriate beard restraints in accordance with professional standards and facility policy. During an initial kitchen tour on 2/15/2026 at 11:39 a.m., a cook and the Food Service Director (FSD) were observed to have facial hair without beard nets. On 2/16/2026 at 10:49 a.m., during a comprehensive kitchen tour, another cook and the FSD were again observed with facial hair and no beard nets. Later that day at 12:05 p.m., during a food temperature observation, both cooks and the FSD were observed not wearing beard restraints while one cook took temperature readings for fifteen food items, leaning over the steam table so that his beard came into proximity to hot foods. The facility’s written policy on Dietary Employee Personal Hygiene, revised 9/1/2025, stated that all dietary staff must wear hair restraints, including beard restraints, to prevent hair from contacting food, and that employees should never use bare hand contact with any foods. The facility had a census of 127 residents at the time of the survey, and the surveyors determined that the failure to use beard nets had the potential to contaminate food and cause food-borne illnesses.
Failure to Follow Puree Food Preparation Guidelines and Recipes
Penalty
Summary
Surveyors identified a deficiency in the facility’s preparation of pureed foods for eight residents on puree or mechanical diets. The facility’s policy and guidelines for Puree Food Preparation required that pureed foods be prepared in a manner that conserves nutritive value, palatable flavor, and attractive appearance, and specified the type and amount of ingredients to be added to different food categories (such as broth or gravy for meats and poultry, margarine for noodles and root vegetables, mashed potato flakes for certain vegetables, and thickener for most fruits). During review, it was noted that the policy had been updated, and the Administrator stated that pureed foods should be prepared in accordance with recipes to present food integrity and nutritive value. During an observed puree food preparation session, a cook with five months’ tenure at the facility and five years’ experience as a cook prepared three pureed items: pulled pork, carrots, and baked beans, for eight residents receiving pureed diets. The cook did not have all supplies ready before starting, stopped production to retrieve beef base, and failed to perform hand hygiene before resuming preparation and between preparation of each pureed item. He used a sink to rinse utensils during the process, did not use a recipe, and did not measure ingredients to ensure appropriate consistency. When asked about the expected consistency, he described it as a “peanut butter consistency” and acknowledged he did not know where the recipes were located, while the Food Service Director clarified that recipe books were stored on a shelving unit near the puree preparation area.
Failure to Honor Resident Choice for Showering Versus Bed Bath
Penalty
Summary
The facility failed to honor a cognitively intact resident’s right to choose their preferred method of personal hygiene, specifically bathing versus showering. During an observation and interview, a malodorous smell was noted in the resident’s room, and the resident reported that he is always given a bed bath because he requires a mechanical lift, but that he would prefer a shower. In a follow-up interview, the resident reiterated his preference for showers but stated he felt it was too much work for staff, so he did not insist. Review of the EMR showed the resident was admitted with morbid obesity, systolic heart failure, atrophic skin disorder, xerosis cutis, bipolar disorder, and major depressive disorder, and the most recent MDS reflected a BIMS score of 14, indicating he was cognitively intact, required two staff for care, used a mechanical lift for transfers, and was incontinent of bowel and bladder. Record review of shower sheets for December and January showed only five entries in December and three in January, all documented as bed baths, with no documentation of refusals and no indication that the resident was ever assisted with a shower. Staff interviews revealed that a CNA stated the resident is particular about who showers him and that this usually occurs on second shift, while an RN who had worked at the facility for three years was unaware that the resident preferred showers over bed baths. The RN described the facility’s process that CNAs should document refusals on shower sheets and notify the charge nurse, who then confirms refusals and signs the sheet. The DON and Administrator both stated that residents should have two shower sheets per week documenting type of bath, refusals, and skin issues, and that resident choice and accommodations for those choices are expected. The facility’s Residents’ Rights policy stated that residents have the right to choose schedules and health care, including aspects of life in the facility that are significant to them, but this was not implemented for this resident’s bathing preference.
Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required regulatory timeframe for two of three sampled residents. For one resident, the Electronic Health Record showed an admission date followed by a series of MDS assessments with Assessment Reference Dates (ARDs) including quarterly and annual assessments. Review of these ARDs revealed that the interval between the quarterly assessment dated 12/21/2024 and the subsequent quarterly assessment dated 3/25/2025 was 94 days, which exceeded the 92-day regulatory limit for OBRA-required assessments. This delay meant the quarterly assessment was not completed within the timeframe specified by regulation and the facility’s own policy. During interviews, the RN Vice President of Clinical Reimbursement confirmed that the quarterly assessments were late by two days, acknowledging there were 94 days between the ARDs instead of the required maximum of 92 days. The Administrator and the National Director of Risk Management stated that the facility’s expectation is that assessments are completed on time and referenced the potential negative outcomes of failing to meet regulatory requirements and ensuring appropriate care planning within required timeframes. Review of the facility’s policy titled “MDS 3.0 Completion” showed that annual assessments must use an ARD no more than 366 days from the most recent comprehensive assessment and no more than 92 days from the most recent quarterly assessment, and that quarterly assessments must use an ARD no more than 92 days from the most recent prior quarterly or comprehensive assessment, confirming that the 94-day interval was out of compliance.
Failure to Provide and Document Scheduled Bathing and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing and ADL care according to residents’ needs and the facility’s own shower schedule and policy. One resident, R15, reported during an interview that she had not received a shower since admission, although she had received bed baths and preferred showers. Her admission MDS showed she was cognitively intact, dependent for bathing, and had impaired lower extremity mobility, with a care plan indicating she required assistance of two staff for bath/shower and transfers, and noted a preference for bed baths. The bath schedule assigned her room showers twice weekly on the evening shift, but review of February bath sheets showed only one shower documented out of four scheduled dates, and no bath sheet for a specific scheduled date, while she stated that staff did not ask her about taking a shower when a new roommate was offered one. A second resident, R46, also did not receive showers and related ADL care as scheduled and documented. She was cognitively intact, dependent on staff for oral hygiene, toileting hygiene, and showering/bathing, with a care plan identifying ADL self-care deficits and requiring two staff for bathing/showering, including provision of sponge baths if a full bath or shower could not be tolerated. Observation found her in bed with oily hair, and she stated she had not had a shower. Her family representative reported that her hair appeared never shampooed and her teeth appeared caked with debris, and that leadership, including the DON and Social Worker Director, had been informed. The bath schedule assigned her room showers twice weekly on day shift, but February bath sheets only showed dates without indicating what type of bathing was provided, and an LPN confirmed that only two shower sheets were present when six should have been, with no documentation of refusals. A third resident, R125, similarly did not receive or have documented twice-weekly bathing as required. He was cognitively intact with multiple significant diagnoses, including bilateral above-knee amputations, morbid obesity, heart disease, chronic kidney disease, and an unstageable sacral pressure ulcer, and was dependent on staff for oral hygiene, toileting, showers, dressing, and personal hygiene. Review of shower sheets over three months showed very few bath sheets compared to the expected number based on a twice-weekly schedule. During observation and interview, there was a very strong body odor noted, and both he and his roommate reported that baths were not provided consistently and less than twice weekly; he stated he only takes bed baths due to orthostatic hypotension and feeling unsafe sitting up, that he occasionally refuses when not feeling well, and that staff had stopped offering baths regularly. Staff interviews with a CNA, an LPN, and the DON confirmed that all residents are scheduled for two baths per week, that a bath/shower sheet should be completed for every scheduled bath including refusals, and that this documentation was not present for R125, indicating that required offers and/or provision of bathing were not consistently carried out or recorded for these residents.
Failure to Maintain Clean Oxygen Concentrator Filter for Resident on Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean oxygen concentrator filter for a resident receiving oxygen therapy. The resident had diagnoses including COPD, chronic respiratory failure with hypoxia, interstitial pulmonary disease, and paroxysmal atrial fibrillation, and the MDS documented ongoing oxygen therapy. Physician orders directed that the oxygen concentrator filter be cleaned once weekly and as needed, and the resident’s care plan included oxygen therapy with monitoring for signs and symptoms of acute respiratory insufficiency. Multiple observations over several days showed the oxygen concentrator filter contained gray, fuzzy debris. Staff interviews revealed that responsibility for concentrator maintenance had recently shifted from a respiratory therapist, who previously checked concentrators twice weekly, to nursing staff, who were expected to clean filters weekly. A CNA stated that another nurse specialized in oxygen concentrators and changed them but was unsure of the schedule, and confirmed the presence of gray, fuzzy debris on the filter. An LPN-Unit Manager reported checking concentrators on a prior date but acknowledged not turning the concentrator around to inspect the filter and stated it had likely been over two weeks since the filter had been checked. The DON confirmed there was no respiratory therapist currently and that external filters were expected to be cleaned weekly, and the Administrator stated that concentrators were expected to be cleaned weekly, monitored, and audited. The facility’s Oxygen Administration policy required following manufacturer recommendations for cleaning equipment filters and providing care of equipment in accordance with facility policies, which was not followed in this instance.
Failure to Follow Antibiotic Stewardship and McGeer Criteria for UTI Treatment
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary antibiotics, contrary to its Antibiotic Stewardship Program policy and use of McGeer criteria. For one resident (R92) with vascular dementia, delirium, urinary retention, cerebrovascular disease, metabolic encephalopathy, and major depressive disorder, a urinalysis with culture and sensitivity was ordered due to increased confusion and hallucinations. The practitioner documented a positive urinary tract infection (UTI) and ordered Nitrofurantoin 100 mg by mouth twice daily for seven days, which was administered from 1/13/2026 through 1/19/2026. However, the facility’s Antibiotic Stewardship Binder and the revised McGeer Criteria for Infection Surveillance Checklist dated 1/8/2026 documented that UTI criteria were not met, and that the resident did not meet McGeer criteria for antibiotic initiation. For another resident (R10) with an indwelling catheter and diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, neuromuscular bladder dysfunction, urinary retention, acute cystitis without hematuria, Type 2 diabetes with hyperglycemia, unspecified psychosis, and recurrent major depressive disorder, staff documented cloudy, foul-smelling urine with sediment and notified the practitioner with a request for urine testing. The practitioner subsequently ordered Ciprofloxacin 250 mg by mouth every 12 hours for five days for a UTI, and the medication was administered from 1/20/2026 through 1/26/2026. The revised McGeer Criteria checklist for this resident, dated 1/13/2026, documented foul smell, cloudy urine, and sediments but indicated that UTI criteria were not met, and the Antibiotic Stewardship Binder recorded that McGeer criteria for antibiotic initiation were not met. Interviews with the DON and NP II confirmed that antibiotics were prescribed and administered based on the clinical picture and positive urine culture results rather than adherence to McGeer criteria and the facility’s stewardship policy. The DON acknowledged that the facility had not been appropriately following antibiotic stewardship practices, had not been conducting antibiotic time-outs, and that the stewardship data tracking tool had not been properly implemented, resulting in inaccurate antibiotic stewardship data. The Administrator and National Director of Risk Management stated that providers were expected to follow McGeer criteria and acknowledged that the prescribing patterns in these cases did not meet the facility’s protocol.
High Medication Error Rate and Improper GT Medication Administration with Missing MAR Documentation
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5 percent, with surveyors identifying a 24 percent error rate based on 25 medication observations. During a medication pass, an LPN administered medications via a gastrostomy tube (GT) to a resident by crushing multiple medications together in one envelope, mixing them in water, and giving them through the GT, contrary to professional standards that require medications to be crushed and administered separately. In the same observation, a scheduled dose of Coreg 6.25 mg was omitted because it was not available on the medication cart, and the LPN did not contact the pharmacy or check emergency stock for the medication. The LPN later stated she had limited experience with GT medication administration, had been informally shown the process by another LPN, and was unaware of the proper method and potential harm of the practice. In addition, review of the electronic medical record and MARs revealed multiple instances of missing medication administration documentation for three residents on specific dates. For one resident, there was missing documentation for enoxaparin, diazepam, Micatin cream, albuterol inhalation solution, and oxycodone at various scheduled times. For another resident with a GT, there were missing entries for blood pressure checks and administration of amlodipine, Coreg, clonidine patch, MiraLax, Nexium, vitamin B1, amantadine, enteral feedings, and a change of feeding syringe on the night shift. A third resident’s MAR showed missing documentation for Protonix, methocarbamol, acetaminophen, and oxycodone at scheduled early morning times. The DON confirmed that mixing crushed medications for GT administration was a deficient practice and acknowledged the missing MAR documentation for the three residents, and the Administrator stated that medications should be given per policy and professional standards.
Failure to Follow McGeer Criteria in Antibiotic Stewardship
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required by its policy and nationally recognized infection surveillance criteria, specifically the McGeer criteria, when initiating antibiotics for two residents. For one resident, R92, who had vascular dementia with psychotic disturbance, delirium due to a known physiological condition, urinary retention, cerebrovascular disease, metabolic encephalopathy, and major depressive disorder, a urinalysis with culture and sensitivity was ordered due to increased confusion and hallucinations. The practitioner documented that the urinalysis was positive for a urinary tract infection and ordered Nitrofurantoin 100 mg twice daily for seven days, which was administered as ordered. However, the facility’s Antibiotic Stewardship Binder documented that R92 did not meet McGeer criteria for antibiotic initiation. The Revised McGeer Criteria for Infection Surveillance Checklist dated 1/8/2026 for this resident recorded increased confusion and visual hallucinations, and specifically indicated that urinary tract infection criteria were not met. Despite this, antibiotic therapy was started and completed. This showed that the decision to treat was made and carried out without adherence to the established McGeer criteria that the facility’s policy required for determining when to initiate antibiotics. For another resident, R10, who had an indwelling urethral catheter and diagnoses including infection and inflammatory reaction due to an indwelling catheter, neuromuscular dysfunction of the bladder, urinary retention, acute cystitis without hematuria, Type 2 diabetes mellitus with hyperglycemia, unspecified psychosis, and recurrent major depressive disorder, staff documented cloudy, foul-smelling urine with sediment and notified the practitioner with a request for urine testing. The practitioner ordered Ciprofloxacin 250 mg every 12 hours for five days for a urinary tract infection, and the medication was administered as ordered. The Revised McGeer Criteria Checklist for this resident documented foul smell, cloudy urine, and sediments, and indicated that urinary tract infection criteria were not met. The Antibiotic Stewardship Binder also documented that this resident did not meet McGeer criteria for antibiotic initiation. Interviews with the DON, NP, Administrator, and National Director of Risk Management confirmed that antibiotics were prescribed and administered when McGeer criteria were not met and that antibiotic stewardship practices, including antibiotic time-outs and accurate data tracking, were not being properly followed per facility policy.
Failure to Label and Date Food Items in Storage
Penalty
Summary
The facility failed to ensure that all food items in the freezer, refrigerator, and dry storage were properly labeled, dated, and not expired, as per their policy titled 'Date Marking for Food Safety.' During an observation, it was found that the walk-in freezer contained a bag of turkey and a bag of hot dogs, both opened without a use-by-date. Additionally, the walk-in refrigerator had a bag of pork with an expired date, and the dry storage room contained two bowls of cereal and a bag of cake mix, all without labeling or dating. An opened bag of Jell-O was also found with an expired date. The Dietary Manager (DM) acknowledged these oversights during an interview, admitting that these items should have been caught. The facility's policy requires the head cook or designee to check the refrigerator daily for expiring food items and discard them accordingly, with the dietary manager or designee conducting weekly spot checks for compliance. The Administrator expressed that the expectation is for all kitchen items to be labeled, dated, and not expired, indicating a lapse in adherence to the established food safety protocols.
Improper Garbage Disposal in Facility Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse for two out of three dumpsters, which could potentially allow pests and rodents to enter. During an observation of the dumpster area behind the kitchen, it was noted that a small amount of trash was on the ground near the first dumpster. Additionally, the side door of dumpster number one was open, and dumpster number two was missing a drain plug, leaving an opening. During an interview, the Dietary Manager admitted to being unaware of the missing plug and the open door, acknowledging the risk of pest intrusion.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their recorded health status. For one resident, Ozempic was incorrectly coded as insulin, despite the resident's diabetes being controlled by diet and having no orders for insulin. Another resident's therapy sessions were inaccurately recorded, with the MDS indicating only one day of occupational and physical therapy, while the resident actually received six and five days, respectively, during the observation period. The MDS Coordinator acknowledged the error, attributing it to a failure to update the system daily. Additionally, a third resident's MDS inaccurately coded trazodone as an antianxiety medication and Ozempic as insulin. The resident had orders for trazodone for generalized anxiety disorder and Ozempic for severe morbid obesity. The MDS Coordinator explained that the trazodone was used for anxiety, and Ozempic was an antidiabetic medication, indicating a misunderstanding in the coding process. These inaccuracies in the MDS assessments did not accurately reflect the residents' health status during the specified observation periods.
Failure to Update PASARR for Resident with Major Depressive Disorder
Penalty
Summary
The facility failed to ensure that a resident, identified as R70, had an updated Level I Preadmission Screening and Resident Review (PASARR) following a new diagnosis of major depressive disorder. The facility's policy requires coordination with the PASARR program to ensure residents with mental disorders receive appropriate care. However, R70's PASARR Level I Assessment did not reflect the diagnosis of major depressive disorder, despite the psychiatric evaluation confirming this diagnosis. R70 was admitted to the facility with a diagnosis that included major depressive disorder, but the quarterly Minimum Data Set (MDS) assessment did not identify this diagnosis. The Social Services Director and the Administrator acknowledged that the PASARR should have been updated following the diagnosis change. This oversight has the potential to negatively impact R70's psychosocial well-being by not providing the necessary treatment for major depressive disorder.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R65 and R97, which led to potential unmet care needs. For R65, who was diagnosed with quadriplegia and type two diabetes mellitus, the care plan did not include instructions to notify the physician if the resident did not receive their prescribed insulin or if blood sugar levels were not obtained. Despite the resident being cognitively intact and receiving insulin regularly, the facility's records showed that the physician was not notified when the medication was not administered. Interviews with the Staff Development Coordinator and the Director of Nursing confirmed that the physician should have been notified and that this should have been included in the care plan. For R97, who was admitted with a stroke and osteoarthritis, the care plan was incomplete regarding the resident's needs for assistance with activities of daily living (ADLs). Although the resident was cognitively intact and required substantial assistance with ADLs, the care plan lacked specific details about the assistance needed for toileting, transfers, and the number of staff required for assistance. The MDS Coordinator indicated that the person responsible for developing the care plan was no longer with the facility, and the Director of Nursing acknowledged that the care plan needed to be more specific to ensure staff were aware of the resident's needs.
Failure to Transfer Resident with Altered Mental Status to Hospital
Penalty
Summary
The facility failed to identify a resident's need to transfer to the hospital after a change in condition, specifically altered mental status, for one of the residents reviewed. The facility's policy requires notifying the attending physician or physician on call when there is a significant change in a resident's condition, which includes the need to transfer to a hospital. However, this protocol was not followed for the resident in question, who had a history of metabolic encephalopathy, chronic pain, end-stage renal disease, and dependence on hemodialysis. The resident, who had been readmitted from the hospital with altered mental status, refused dialysis due to not feeling well. Despite being alert and talkative during a follow-up visit, the resident continued to experience pain and refused dialysis. The facility's records indicated that the resident's condition was monitored, but there was a lack of communication and documentation regarding the resident's declining condition and the need for hospital transfer. The resident was eventually sent to dialysis, where they arrived unresponsive, prompting the dialysis center to refuse responsibility and the facility to direct the transport to take the resident to the emergency room. Interviews with facility staff, including the Unit Manager, Nurse Practitioner, and Director of Nursing, revealed inconsistencies in communication and awareness of the resident's condition. The Unit Manager admitted there was likely no note communicating the resident's condition to the dialysis center, and the Nurse Practitioner did not recall being aware of the resident's decline. The Medical Director was also not informed of the resident's condition changes, highlighting a breakdown in communication and adherence to the facility's policy for managing significant changes in a resident's condition.
Failure to Sign Out Narcotics Before Administration
Penalty
Summary
The facility failed to ensure that narcotics were signed out for one of the 36 sampled residents, specifically Resident 99. During a medication administration observation, an LPN obtained pregabalin oxycodone from the locked controlled substance lock box and placed it in a medication cup with the resident's other scheduled medications. The LPN did not verify the remaining amount of pregabalin on the medication card against the controlled substance book or sign the medications out prior to administering them. The LPN stated that she administers the medications first and signs them out afterward to allow for the possibility of the resident refusing the medication, which would then be destroyed. A similar observation was made with another LPN who removed pregabalin, oxycodone, and trazadone from the controlled substance lock box without signing them out or verifying the count. The LPN also stated that she administers the medications first and signs them out afterward. The Director of Nursing (DON) stated that the expectation is for nurses to verify the medication against the MAR and label, and to sign the narcotic book at the same time as administering the medication, which is a standard of nursing practice.
Failure to Administer Insulin to Resident
Penalty
Summary
The facility failed to administer physician-ordered insulin to a resident, identified as R65, who was dependent on insulin for managing Type 2 Diabetes Mellitus. The resident's electronic medical record (EMR) indicated that insulin was not administered on multiple occasions, specifically on 10/04/24, 10/09/24, 10/22/24, 10/26/24, 10/28/24, 11/13/24, 11/15/24, and 11/30/24. Additionally, the resident's blood sugar levels were not obtained as required, and the physician was not notified of these lapses in medication administration. R65's care plan, which was intended to manage diabetes and prevent complications, did not include instructions to notify the physician if insulin was not administered or if blood sugar levels were not monitored. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and had been receiving insulin consistently prior to the noted deficiencies. Despite the care plan's goal to prevent diabetes-related complications, the facility's failure to administer insulin and monitor blood sugar levels posed a risk to the resident's health. Interviews with the resident and facility staff revealed that the facility occasionally ran out of insulin due to inadequate ordering practices. The resident expressed concerns about the facility's failure to order medications in a timely manner, leading to missed doses. Staff members acknowledged that the resident's insulin requirements were high, which sometimes resulted in running out of insulin pens. However, there was no evidence that the facility took appropriate steps to address these shortages or notify the physician of the missed doses.
Improper Cleaning of Glucometer After Use
Penalty
Summary
The facility failed to ensure proper cleaning of a glucometer after blood glucose testing for one of the residents observed. During an observation, a Licensed Practical Nurse (LPN) used an alcohol wipe instead of the required germicidal wipes to clean the glucometer after testing a resident's blood glucose levels. The LPN admitted to not having the appropriate wipes on the medication cart and mentioned that they would need to go to Central Supply to obtain them. This action was contrary to the facility's policy and the manufacturer's instructions, which specify the use of EPA-registered germicidal wipes for disinfecting the glucometer. The resident involved in the incident was admitted to the facility with a diagnosis of type two diabetes mellitus and was receiving insulin treatment as per a sliding scale. The Unit Manager confirmed that each diabetic resident has their own glucometer and that alcohol wipes are not to be used for cleaning. The Director of Nursing (DON) acknowledged awareness of the incident and emphasized that all medication carts should be stocked with the proper cleaning supplies, and nurses should inform their managers if supplies are missing.
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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