Rosewood At Tybee Island Of Journey Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Tybee Island, Georgia.
- Location
- 7 Rosewood Avenue, Tybee Island, Georgia 31328
- CMS Provider Number
- 115730
- Inspections on file
- 22
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10 (5 serious)
Citation history
Health deficiencies cited at Rosewood At Tybee Island Of Journey Llc, The during CMS and state inspections, most recent first.
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.
The facility did not ensure licensed nurse coverage on one wing during an evening shift, resulting in no nurse on that wing after about 6:00 PM. Two nurses from the day shift reported that no relief nurse arrived, notified the scheduler, DON, and Administrator, stayed several extra hours, then secured the medication cart keys and left. The scheduler confirmed that no licensed nurses were assigned for that shift and that the DON did not come in. Several cognitively intact residents reported that no nurse was available to administer medications, including a diabetic resident who stated he did not receive his medicine until the next day, and a grievance documented that some residents did not receive their scheduled evening doses.
The facility did not ensure that residents were protected from all forms of abuse and neglect, resulting in a deficiency related to the failure to safeguard residents from harm by others.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as observed and documented by surveyors.
The facility did not manage its operations to ensure effective and efficient use of resources, as observed by surveyors during their review.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
Certified Medication Aides (CMAs) administered medications, including narcotics, without documented annual competency check-offs, and were not certified to give controlled substances. Multiple staff, including RNs and consultants, were unaware that CMAs were administering narcotics, despite facility policy prohibiting this practice. This resulted in unqualified staff administering medications to residents.
A deficiency was identified when clean clothes and linens were found uncovered and coated with dust and debris in the laundry area, with a fan blowing contaminated air onto them. The ceiling, pipes, and equipment were not being cleaned as required, PPE was inadequate and dirty, and there was no proper biohazard container. Staff interviews revealed a lack of awareness and documentation regarding proper laundry sanitation practices.
A resident was taken outside by two CNAs while wearing a hospital gown that was pulled up, leaving the resident's lower body exposed to public view, including construction workers and passing cars. Both CNAs acknowledged they failed to ensure the resident was properly covered, and the DON confirmed this was a dignity issue per facility policy.
A resident with severe cognitive impairment, muscle weakness, and a high fall risk was not provided with fall mats despite a history of falls and repeated attempts to get out of bed or a chair. Staff interviews confirmed that fall mats were not used, and the DON was unaware of their absence, resulting in inadequate supervision and safety measures.
The facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on three medication carts. The policy required documentation and verification of controlled substances by licensed nurses at shift changes. However, reviews of narcotic logs revealed that nurses failed to sign the sheets on multiple dates, indicating a lack of verification. Interviews confirmed the expectation for nurses to sign the logs, and the Nursing Home Administrator acknowledged the deficiency.
A facility failed to create a comprehensive baseline care plan for a newly admitted resident with multiple health conditions. The care plan only addressed nutritional status, neglecting critical needs such as oxygen use, codeine allergy, cognitive deficits, diabetes management, DNR status, and eyeglasses. Staff interviews confirmed the oversight, leading to a deficiency in addressing the resident's immediate needs.
The facility failed to date multi-dose diabetes medications on a medication cart, affecting three residents. During an observation, it was found that three vials of insulin were opened and available for use without being dated, contrary to the facility's policy. An LPN confirmed the oversight, and the Nursing Home Administrator acknowledged the failure to ensure acceptable storage times.
The facility did not adhere to its policy of posting daily nurse staffing information at the beginning of each shift. During a survey, staff could not provide the required postings for certain dates, and a RN admitted to being overwhelmed and unable to organize the files. The Administrator acknowledged the inconsistency in posting the staffing data.
A resident with moderate cognitive impairment was repeatedly observed wearing a hospital gown despite preferring his own clothes, which went missing after a hospital stay. Staff were uncertain about the reason for the gown, and the DON did not see it as an issue, while the Administrator acknowledged the resident's preference for personal attire.
The facility failed to ensure call lights were within reach for four residents, placing them at risk of unmet needs. Observations showed call lights on the floor or out of reach, despite residents having no upper extremity impairments and being dependent on staff for ADLs. Staff interviews confirmed the deficiency, with a CNA and the Administrator acknowledging the issue.
A resident with COPD and CHF did not have a comprehensive care plan addressing their significant health needs, such as ADLs, hospice care, and an indwelling urinary catheter. The facility's policy requires a comprehensive care plan within seven days post-MDS assessment, but the plan only included the resident's enjoyment of activities, omitting critical health areas.
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, leading to unmet needs and diminished quality of life. Residents with cognitive impairments and physical limitations were observed with long, dirty fingernails, and one resident was left in a soiled state for several hours. Staff interviews revealed a lack of awareness and prioritization of residents' needs, contributing to the deficiencies in care.
A resident with HIV experienced a five-day delay in obtaining a urine specimen for a urinalysis, culture, and sensitivity test, despite a physician's order. The resident suffered severe pain during this period. Staff interviews revealed confusion and lack of responsibility in collecting the specimen, with the DON and physician acknowledging the delay as unacceptable.
Two residents in a facility shared a single water mug, contrary to infection control policies. One resident, with moderate cognitive impairment, reported not being offered his own mug, while the other confirmed sharing since admission. The DON was unaware of this issue until it was highlighted, and the shared mug was found to be filthy, indicating a lapse in infection control measures.
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.
Lack of Licensed Nurse Coverage on One Wing Leading to Missed Medications
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff on the [NAME] Wing during the 3:00 PM to 11:00 PM shift on December 25, 2025, resulting in no licensed nurse coverage after approximately 6:00 PM. The facility’s daily staffing document for that date showed no licensed nurse scheduled for the [NAME] Wing on the 3:00 PM to 11:00 PM shift. The scheduler confirmed that no licensed nurses were assigned for that shift on the [NAME] Wing and that she was unable to fill the assignments despite using agency staff and being aware of multiple call-outs. She stated that the DON was notified and did not come in to work the shift, and the Administrator later reported being unaware that there was no nurse on the wing after 6:00 PM. On December 25, 2025, two nurses (an LPN and an RN) worked the [NAME] Wing day shift and reported that no nurse arrived to relieve them at 3:00 PM. Both nurses stated they notified the scheduler, DON, and Administrator that there was no relief nurse. One nurse reported that the DON told her there was nothing she could do. Both nurses remained on duty until nearly 6:00 PM, then counted the medication cart together, secured the medication keys in the locked medication room or at the nurse’s station, and left the facility, leaving the [NAME] Wing without licensed nurse coverage for the remainder of the evening shift. A regional nurse consultant later confirmed there was no nurse on the [NAME] Wing after 6:00 PM on that date. Multiple residents with little to no cognitive impairment, as evidenced by BIMS scores of 14 and 15 on their quarterly MDS assessments, reported that there was no nurse available on the [NAME] Wing during the evening of December 25, 2025. One resident stated that there was no nurse after 3:00 PM to give medications, and another resident reported that there had been a couple of days, usually around holidays, when no nurse was available. A resident who returned from an outing with family around 7:00 PM stated there was no nurse working on the [NAME] Wing and that, as a diabetic, he did not receive any medicine until the next day. A grievance/complaint report filed by the DON on December 26, 2025, documented that some residents on the [NAME] Wing reported not receiving their 9:00 PM medications on December 25, 2025, and that the Medical Director was notified.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by anybody. This deficiency indicates that residents were not adequately safeguarded from potential or actual harm caused by others, as required by regulations. The report identifies a lapse in the facility's responsibility to ensure a safe environment free from abuse and neglect for all residents.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on every shift, as observed and documented by surveyors.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of its resources. This deficiency was identified based on observations and findings documented by surveyors, indicating that the facility's management practices did not support optimal resource utilization. Specific actions or inactions leading to this deficiency were not detailed in the report.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
CMAs Administered Medications Without Required Competency and Gave Narcotics
Penalty
Summary
Certified Medication Aides (CMAs) at the facility were permitted to administer medications, including narcotics, without having completed the required skills competency check-offs. Review of facility records showed that six out of seven active CMAs did not have current, signed, and dated annual competency documentation. Additionally, one CMA's skills checklist specifically indicated that she was not certified to administer narcotic medications, yet records showed that she had administered a narcotic medication to a resident. Staff interviews confirmed that CMAs were administering narcotics, and some staff members, including a Registered Nurse, admitted to giving narcotics to CMAs to administer to residents. Multiple facility staff, including the Regional Consultant Nurse, Interim Director of Nursing, Operations Consultant, Medical Director, and Nurse Practitioner, were unaware that CMAs were administering narcotics or controlled substances. The facility's own policy and staff statements indicated that CMAs were not supposed to administer narcotics, yet this practice was occurring. The lack of proper competency verification and unauthorized administration of narcotics by CMAs placed all residents at risk of receiving medication from unqualified personnel.
Failure to Maintain Sanitary Laundry Conditions Resulting in Cross-Contamination Risk
Penalty
Summary
The facility failed to maintain the laundry area in a sanitary manner, resulting in the potential for cross-contamination of residents' clothing and linens. Observations revealed a thick, dark greyish substance coating the ceiling, pipes, and a large industrial fan in the laundry room. Clean clothes, blankets, sheets, and pillowcases were found uncovered and coated with dust and debris. The fan, also covered in dust, was blowing directly onto clean laundry. Additionally, a window in the laundry room was covered with dust and broken glass, further exposing clean laundry to contamination. There was only one apron available as PPE, which was itself coated with dust and debris, and no other PPE was present. No separate designated hazardous container was available; instead, a trash can was being used for biohazardous materials. Interviews with staff revealed a lack of awareness regarding the need to cover clean laundry and the proper use of PPE. The Housekeeping Manager and Laundry Aide both confirmed that cleaning of the ceiling and pipes was not being performed as required, and the Laundry Aide reported never seeing these areas cleaned. The Director of Nursing/Infection Preventionist stated she was unaware of the laundry room's condition. Requested cleaning logs for the laundry room were not provided, indicating a lack of documentation and oversight in maintaining sanitation standards in the laundry area.
Resident Exposed While Outside, Dignity Not Maintained
Penalty
Summary
Certified Nursing Assistants (CNA) II and CNA JJ were observed pushing a resident in a geriatric chair outside of the facility. The resident was wearing a hospital gown that was pulled up above his stomach, with a blanket folded across his chest, leaving his legs and lower torso exposed. This exposure revealed the resident's brief and bandages on his right leg stump. The observation took place in an area visible to construction workers and passing cars on a nearby street. During concurrent interviews at the time of the observation, both CNAs confirmed that they did not ensure the resident's body was properly covered and acknowledged that they should have done so. The Director of Nursing (DON) later confirmed that staff are expected to ensure residents are properly dressed and not exposed, and agreed that this incident constituted a dignity issue. The facility's policy on promoting and maintaining resident dignity requires all staff to provide care in a manner that maintains or enhances each resident's quality of life and respects their rights.
Failure to Provide Fall Prevention Measures for High-Risk Resident
Penalty
Summary
A deficiency was identified when the facility failed to implement appropriate safety measures for a resident with multiple risk factors for falls, including muscle weakness, epilepsy, unsteadiness on feet, and severe cognitive impairment. The resident was assessed as a high fall risk, with a history of falls documented in progress notes, including incidents where the resident was found on the floor or observed attempting to get out of bed or a chair. Despite these risk factors and repeated fall incidents, observations revealed that no fall mats were placed around the resident's bed or chair during multiple checks, and the bed was only placed in the lowest position. Interviews with staff confirmed that the resident was capable of moving in bed and often attempted to get out of bed or the geriatric chair. Staff reported they were not instructed to use fall mats, and the DON was unaware that fall mats were not in place, despite knowing the resident was a high fall risk. These actions and inactions resulted in the facility failing to ensure adequate supervision and safety measures to prevent accidents for this resident.
Failure to Reconcile Controlled Drugs
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs across three medication carts. The facility's policy required that all controlled substances obtained from a non-automated medication cart or cabinet be recorded on a designated usage form, with a daily visual audit conducted by the charge nurse or designee. Additionally, two licensed nurses were expected to account for all controlled substances and access keys at the end of each shift. However, the review of the Change of Shift Narcotic Logs for the West Medication Cart One, [NAME] Medication Cart Two, and East Medication Cart revealed that the on-coming and/or off-going nurses failed to sign the sheets during shift changes on multiple dates, indicating a lack of verification for the completion of the controlled drug count. Interviews with LPNs AA, BB, and CC confirmed the observations and acknowledged that licensed nurses were expected to sign the count verification at the change of shift. The Nursing Home Administrator also confirmed the lack of additional documentation and stated that it was her expectation for nursing staff to sign the Control Substance logs at shift changes to identify any discrepancies. The failure to adhere to these procedures resulted in the facility's inability to properly reconcile controlled drugs, as required by their policy.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a comprehensive baseline care plan for a resident within 48 hours of admission, as required. The resident, who was admitted with multiple diagnoses including acute respiratory failure with hypoxia, dysphagia, cognitive communication deficit, essential hypertension, type 2 diabetes mellitus, restless legs syndrome, and insomnia, had a baseline care plan that only addressed nutritional status. Critical care needs such as the use of oxygen, an allergy to codeine, cognitive communication deficits, diabetes management, DNR code status, and the use of eyeglasses were not documented or addressed in the baseline care plan. Interviews with facility staff, including an LPN/MDS Coordinator and the Nursing Home Administrator, confirmed the oversight. The LPN acknowledged the single entry in the care plan and the failure to include essential healthcare information. The Nursing Home Administrator also confirmed that the facility did not adequately address the resident's care and management needs in the baseline care plan, leading to a deficiency in meeting the resident's immediate needs upon admission.
Failure to Date Multi-Dose Diabetes Medications
Penalty
Summary
The facility failed to adhere to acceptable storage requirements and use-by dates for multi-dose diabetes medications on one of the medication carts, specifically West Cart Two. During an observation, it was found that three vials of insulin, belonging to three different residents, were opened and available for use without being dated when initially opened. This is contrary to the facility's policy, which requires multi-dose vials to be re-labeled with a beyond-use date 28 days after being opened, unless otherwise specified by the manufacturer. The policy also mandates that the medication label should include the initials of the nurse who opened the vial, and that staff should visually inspect the vial before each use to check the expiration date and ensure there is no visible contamination. The observation was confirmed by an LPN present at the time, who acknowledged that the medications should have been dated when opened. Additionally, the Nursing Home Administrator confirmed that the facility failed to date multi-dose medications when opened, which is necessary to assure acceptable storage times. This deficiency affected three residents who were using the diabetes medications stored on the cart.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nursing staffing data, as observed during a four-day survey. The facility's policy mandates that the Nurse Staffing Sheet be posted at the beginning of each shift daily. However, upon request, the staff was unable to provide the postings for certain dates. During an interview, a Registered Nurse admitted to being unable to locate the nurse staffing data, citing an overwhelming workload and difficulty in organizing files. The Administrator later acknowledged the inconsistency in posting the Daily Nurse Staffing information.
Resident Dignity Compromised by Inappropriate Attire
Penalty
Summary
The facility failed to ensure that a resident, identified as R2, was treated with dignity, which potentially diminished his quality of life. R2, who has moderate cognitive impairment as indicated by a BIMS score of 10, was observed multiple times wearing a hospital gown despite having brought his own clothes to the facility. R2 expressed a preference for wearing his own clothes and mentioned that his clothing went missing after a hospital stay, although he could not recall if this was reported. Staff interviews revealed uncertainty about why R2 was consistently in a hospital gown, with one CNA stating she would change his clothes and another mentioning that R2 is dressed in sweatpants and a shirt for dialysis. The Director of Nursing stated that residents who do not get out of bed typically wear hospital gowns and did not identify this as an issue for R2. However, the Administrator confirmed that R2 was particular about his appearance and should not be in a hospital gown unless he desired it. This lack of attention to R2's preferences and the failure to address the missing clothing contributed to the deficiency in maintaining the resident's dignity and quality of life.
Call Lights Not Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, which placed them at risk of accident, injury, and/or unmet needs due to their inability to call for staff assistance. Observations revealed that the call lights for these residents were either on the floor, coiled around bed rails, or positioned over the headboard, making them inaccessible. Each of these residents was documented as having no impairment of the upper extremities and was dependent on staff for activities of daily living (ADLs). Interviews with staff confirmed the deficiency, with a Certified Nursing Assistant (CNA) acknowledging that the call lights were not within reach and should not be on the floor. The facility's Administrator also stated that call lights should always be within the residents' reach. These observations and interviews highlight a failure in the facility's responsibility to reasonably accommodate the needs and preferences of each resident, as required.
Deficient Care Planning for Resident
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident, identified as R4, which is a deficiency in their care planning process. The facility's policy on Comprehensive Care Plans requires that a comprehensive care plan be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS) assessment. This care plan should consider all Care Assessment Areas triggered by the MDS and describe the services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. However, the review of R4's care plan, dated August 14, 2023, revealed that it only included a focus area on the resident's enjoyment of activities such as TV, music, and arts and crafts, without addressing critical areas such as activities of daily living (ADLs), chronic obstructive pulmonary disease (COPD), hospice care, or the management of an indwelling urinary catheter. R4 was admitted with diagnoses including chronic obstructive pulmonary edema (COPD) and congestive heart failure (CHF), and the MDS indicated that R4 required assistance with ADLs, had an indwelling urinary catheter, and was receiving hospice services. Despite these significant health needs, the care plan did not include focus areas for these conditions, which are essential for providing appropriate care. An interview with the Director of Nursing (DON) confirmed that baseline care plans are created upon admission, and a comprehensive person-centered care plan should be developed by the 14th day. The DON acknowledged that the care plan is used by nurses to determine the type of care a resident requires, highlighting the importance of having a comprehensive plan in place for R4's care needs.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, leading to unmet needs and diminished quality of life. Resident 18, with cognitive communication deficit and muscle weakness, was observed with long, dirty fingernails and reported that staff rarely offered to trim them. Resident 20, diagnosed with hemiplegia and muscle weakness, also had untrimmed, dirty nails and stated that staff were too busy to assist. Resident 16, with severe cognitive impairment and muscle weakness, had not had his nails trimmed in six months, as confirmed by staff interviews. Certified Nursing Assistant (CNA) HH admitted to not having time to trim residents' nails, and Licensed Practical Nurse (LPN) CC was unaware of the need for nail care. Resident 15, with severe cognitive impairment and incontinence, was found lying in bed with a strong odor of bowel movement, indicating a lack of timely incontinent care. Despite being aware of the situation, CNA FF prioritized passing out meal trays over providing immediate care to Resident 15. The Director of Nursing (DON) and the Administrator acknowledged that staff should have checked on Resident 15 every two hours and provided necessary care promptly. The failure to provide timely ADL care for these residents highlights significant deficiencies in the facility's care practices.
Delayed Urine Specimen Collection for Resident
Penalty
Summary
The facility failed to obtain a critical laboratory test for a resident in a timely manner, specifically a urine specimen, which was delayed for five days after the physician's order. The resident, who has a diagnosis of Human Immunodeficiency Virus (HIV) and a BIMS score indicating little to no cognitive impairment, experienced urinary discomfort and severe pain. Despite the physician's order for a urinalysis, culture, and sensitivity test on 8/8/2024, the specimen was not collected until 8/13/2024. The delay in obtaining the urine sample was noted in the resident's progress notes, and the resident reported relief and decreased pain once the sample was finally collected. Interviews with staff revealed a lack of clarity and responsibility in collecting the urine specimen. An LPN acknowledged the order but did not attempt to collect the sample, passing the information to another nurse whose identity was not recalled. Another LPN confirmed the procedure for collecting a specimen but was unsure why it was delayed. The Director of Nursing verified the order and stated it should have been collected promptly, expressing unawareness of the delay. The physician emphasized that such orders should be executed within 12 to 24 hours, deeming the five-day delay unacceptable.
Failure to Provide Individual Water Mugs for Residents
Penalty
Summary
The facility failed to implement proper infection control precautions by not providing individual water mugs for two residents, R19 and R33, who shared a single water mug in their room. This oversight was identified through observations, resident interviews, and staff interviews. R19, who had moderate cognitive impairment and required minimal assistance with ADLs, reported that staff did not offer him his own water mug, leading to him and R33 sharing the same mug. R33, who had little to no cognitive impairment and also required minimal assistance with ADLs, confirmed that he had been sharing the water mug with R19 since his admission. The facility's policy on infection control, dated 4/1/2024, mandates the establishment and maintenance of an infection prevention and control program to prevent the transmission of communicable diseases. However, the Director of Nursing (DON) was unaware of the shared water mug situation until it was brought to her attention. Upon inspection, the DON found the shared mug to be filthy and acknowledged the infection control concern. The Administrator also confirmed that residents should not share water mugs, indicating a lapse in adherence to the facility's infection control policy.
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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