Sadie G. Mays Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Georgia.
- Location
- 1821 Anderson Avenue Nw, Atlanta, Georgia 30314
- CMS Provider Number
- 115542
- Inspections on file
- 23
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Sadie G. Mays Health & Rehabilitation Center during CMS and state inspections, most recent first.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, resulting in a deficiency related to the delivery of individualized care.
A resident with a physician's order for a condom catheter and drainage bag was instead placed in an adult incontinence brief due to the facility's lack of appropriate urinary drainage bags. The resident, who was cognitively intact and dependent on staff for care, expressed discomfort and dissatisfaction with this arrangement. Staff interviews and observations confirmed the shortage of supplies and the resulting impact on the resident's dignity.
The facility did not timely report allegations of abuse involving two residents with cognitive impairments and complex medical histories. In both cases, required notifications to law enforcement, the facility physician, and the State Agency were either delayed or not completed, and documentation of the incidents and investigations was lacking.
The facility did not complete thorough investigations into alleged abuse involving two residents with cognitive impairments. In both cases, required steps such as notifying law enforcement, obtaining witness statements, and maintaining investigation documentation were not followed, and some staff identified as interviewed were not actually interviewed. Investigation records were also lost after an administrative change.
The facility did not update care plans for several residents after new falls or changes in interventions, despite ongoing fall incidents and changes in condition. For example, a resident with a history of stroke and repeated falls had a care plan that was not revised after a recent fall with injury, and another resident with cognitive impairment had multiple falls that were not addressed in the care plan. Additionally, a resident placed in a Geri chair as a fall prevention measure did not have this intervention documented in the care plan for over a month. Staff interviews confirmed that care plans should have been updated to reflect these changes.
A resident with significant physical and cognitive impairments, including hemiplegia and limited mobility, did not consistently receive staff-assisted showers as required by their care plan. Documentation in both the EMR and bath records was incomplete, and interviews with the UM and DON confirmed that required shower documentation was missing and that showers were not provided as scheduled.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during the inspection.
Two residents with urinary catheters had their drainage bags improperly positioned, including being placed flat on surfaces or on the floor, resulting in urine backing up in the tubing and spillage. Both residents were dependent on staff for care and had significant medical conditions. These actions did not follow facility policy for catheter care, which requires drainage bags to be kept below the bladder and off the floor to ensure proper drainage and reduce infection risk.
The facility failed to follow its infection prevention and control program, with deficiencies including improperly bagged and labeled nebulizers, undated oxygen concentrator tubing, and unbagged bedpans. Additionally, a nurse did not sanitize hands or clean equipment properly during medication administration, violating facility policies.
The facility did not maintain a review of antibiotic prescribing practices or document efforts of its antibiotic stewardship program from January to September 2024. Policies required complete antibiotic orders and specific information when communicating suspected infections, but the facility failed to complete Monthly Healthcare Associated Infection Summary Reports. The Infection Control Preventionist, new to the role, was responsible for monitoring and assessments, yet the antibiotic surveillance tracking form was not used, potentially affecting any resident prescribed antibiotics.
The facility failed to report allegations of sexual abuse involving two residents in a timely manner. An LPN witnessed an incident where a resident was found rubbing on another resident, who was screaming 'stop', but did not notify administration. Another incident involved a resident grabbing another's breast, which was reported to the Social Services Director but not immediately to the state agency. The Administrator confirmed awareness of both incidents but failed to report the first and delayed reporting the second by seven days.
The facility failed to conduct thorough investigations into abuse allegations involving three residents. Incidents included inappropriate touching and physical aggression, but investigations lacked necessary interviews, documentation, and assessments. The facility's administrator and DON confirmed the investigations were incomplete, not adhering to policy requirements.
The facility failed to complete quarterly MDS assessments for two residents. The EMR review showed no updated assessments for these residents, and the MDS Coordinators confirmed the oversight. The DON and Administrator stated that assessments should be done quarterly, annually, and with significant status changes. The facility's policy on MDS assessments was not provided.
A facility failed to develop a baseline care plan for a resident admitted with a supra-pubic catheter, as required within 48 hours of admission. The resident had multiple diagnoses, including bladder dysfunction, necessitating the catheter. Despite physician orders for precautions, the care plan lacked specific instructions for catheter management. Interviews with staff confirmed the oversight, highlighting a lapse in policy adherence.
A resident with multiple diagnoses, including Alzheimer's and diabetes, was not repositioned as frequently as ordered to prevent skin breakdown. Despite having an unstageable pressure ulcer, the resident was only repositioned 59 times out of 96 opportunities. The facility's policy required necessary services for residents unable to perform ADLs independently, but staff failed to adhere to these standards, as confirmed by the DON and Assistant DON.
A resident with severe cognitive and physical impairments was found to have a non-functional call light system, preventing access to staff assistance. The facility's policy requires operational call lights, but the Maintenance Director confirmed the lack of documentation for repairs, and the DON was unsure of routine check frequencies. A specific log for call lights was only created during the survey.
Two residents in an LTC facility experienced deficiencies in pain management and medication administration. One resident was given Fluoxetine (Prozac) for 48 weeks after it was discontinued, leading to behavioral changes and mobility decline. Another resident suffered from inadequate pain management and a gnat infestation on a leg wound. The facility failed to follow its policies on medication administration and pest control, resulting in harm to the residents.
A resident was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued by the psychiatrist, leading to harm. The facility's medication administration policy was not followed, and the pharmacy failed to reconcile the medication orders during a transition. The resident experienced unusual behavior, a low-grade temperature, knee swelling, and a decline in mobility.
A resident was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued, leading to harm including unusual behavior and decreased mobility. The LPN responsible was unaware of the discontinuation due to inadequate training and lack of proper documentation. The facility's medication administration policy was not followed, resulting in this deficiency.
The facility failed to renew certifications for two CNAs, resulting in one working for six months and another for thirty days with expired certifications. The oversight was due to the previous Education Coordinator not performing their duties, as confirmed by the HR Director.
A registered nurse in an LTC facility failed to clean a wrist blood pressure monitor between two residents and did not perform hand hygiene after touching a wheelchair and picking up an item from the floor before administering medication. The facility's policies require cleaning and disinfecting equipment between residents and maintaining hand hygiene to prevent infection spread.
The facility failed to maintain a clean and comfortable environment, with dirt and grime buildup in PTAC units and a large hole under a sink. Additionally, there was an inadequate supply of linen for nine days, affecting multiple units. Interviews revealed that cleaning and linen supply policies were not effectively followed, compromising resident care.
The facility failed to maintain an effective pest control program on Unit B, leading to a black gnat infestation. Observations showed swarms of gnats in several rooms, including one resident's room, where a gnat trapper was ineffective. The Maintenance Director was unaware of the issue until recently, despite the problem persisting for two years. Staff interviews revealed inconsistencies in pest reporting, with some unaware of the pest control logbook.
The facility failed to accommodate the needs of two residents. One resident, with chronic pain and rheumatoid arthritis, was confined to bed without a wheelchair or chair, struggling to use the TV remote due to hand deformities. Another resident, who preferred showers, only received bed baths, with inconsistent documentation of her bathing routine. Staff interviews revealed a lack of awareness and action regarding these issues.
The facility did not conduct criminal background checks for two RNs, violating its policies on abuse prevention and background screening. The HR Director confirmed the oversight, which affected the hiring process for these RNs.
The facility failed to report the misappropriation of Oxycodone involving two residents to the State Survey Agency. An LPN was observed removing narcotics and count sheets from the medication cart. Although the police were notified, the nurse was terminated, and the state board of nursing was informed, the incident was not reported to the SSA as required by facility policy.
The facility failed to develop comprehensive care plans for five residents, impacting their treatment and care. Residents with severe cognitive impairments, fall risks, and specific medical needs such as fractures and oxygen use did not have appropriate care plans. Interviews confirmed the absence of these plans, indicating a systemic issue in care planning.
A resident with severe cognitive impairment and physical limitations did not receive timely assistance with changing food-stained clothes, despite notifying staff. The facility's policy requires assistance for residents unable to perform ADLs independently, but the resident waited over an hour for help, as confirmed by the Unit Manager.
A facility failed to verify the licensure of an RN, resulting in the employment of an unlicensed nurse. The RN worked for one day before quitting, and the lapse in license was not identified by HR staff prior to hire, despite facility policies requiring such verification.
The facility failed to obtain vaccination consent before administering COVID-19 vaccines to two residents, despite their policy requiring documentation of education and signed consent. The Director of Health Services confirmed that consent was not obtained for these vaccinations, indicating a lapse in adherence to the facility's vaccination policy.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Provide Ordered Urinary Drainage Supplies Resulting in Loss of Dignity
Penalty
Summary
A deficiency occurred when the facility failed to maintain the dignity of a resident who was admitted with diagnoses including cerebral infarction with left-sided hemiplegia and hemiparesis, and chronic kidney disease stage three. The resident was cognitively intact, dependent on staff for all activities of daily living, and had a physician's order for a condom catheter with a drainage bag. Despite this order, the facility did not have any large urinary drainage bags available, only leg bags, which were not suitable for the resident's needs. As a result, the resident was placed in an adult incontinence brief instead of the ordered urinary drainage system. The resident expressed dissatisfaction with wearing the adult incontinence brief, stating it caused discomfort and concern for skin breakdown, and made him feel undignified. Staff interviews confirmed that there was a shortage of appropriate urinary drainage bags, and the central supplier acknowledged being recently made aware of the issue. Observations confirmed the resident was wearing an adult incontinence brief due to the lack of proper supplies, and staff were uncertain about when the correct drainage bags would be available.
Failure to Timely Report Allegations of Abuse to Required Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the required agencies and physician within the state-mandated reporting time frame for two residents. For one resident with metabolic encephalopathy, end stage renal disease, major depressive disorder, and anxiety disorder, a concern of abuse by a CNA was reported by a dialysis center director to the facility. The grievance was forwarded to the Interim DON for investigation, but the local law enforcement and the facility’s physician were not notified, and the Day One report to the State Agency was submitted 24 hours after the incident was reported to the facility, exceeding the required two-hour window for abuse allegations. The Interim DON confirmed that the incident was not reported within the required time frame and that not all required parties were notified. For another resident with vascular dementia, a stroke, and seizures, the resident reported to surveyors that he had been physically abused about six months prior and had informed a nurse at the time. However, a review of nursing progress notes showed no documentation of this allegation, and the current Administrator could not find any investigation or evidence that the allegation was reported to the State. The incident was listed on the reportable list, but there was no documentation of follow-up or reporting as required by policy.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into alleged abuse involving two residents out of a sample of 21. For one resident with moderately impaired cognition and dependent on staff for ADLs and dialysis, an allegation was made that a CNA placed a hand near the resident’s vaginal area. The incident was reported to the facility and documented, but the investigation was incomplete: local law enforcement and the facility physician were not notified, and the facility could not provide documentation of witness statements or resident interviews regarding safety. Interviews with staff revealed that some CNAs who were identified as being interviewed had not actually been interviewed or asked for statements. Additionally, the documentation related to the investigation was reportedly lost after the interim administrator resigned and the abuse manual disappeared. In a separate case, another resident with severe cognitive impairment reported being physically abused by a staff member, stating that he had informed a nurse and that the staff member was subsequently let go. However, when the administrator was asked to provide the facility’s investigation into this alleged abuse, no documentation was available. These failures to follow the facility’s abuse and neglect policy and to complete required investigative steps resulted in incomplete investigations of alleged abuse.
Failure to Revise Care Plans After Falls
Penalty
Summary
The facility failed to revise and update care plans related to falls for four residents, as required by their own policy and federal regulations. The policy states that care plans must be reviewed and updated when there is a significant change in a resident's condition, when desired outcomes are not met, or at least quarterly. However, for several residents with a history of falls and high fall risk, care plans were not updated to reflect new fall incidents or changes in interventions. One resident was re-admitted with a history of stroke and repeated falls, and experienced multiple falls, including one that resulted in shoulder pain. Despite these incidents, the care plan was not updated to include the most recent fall. Another resident with cerebrovascular disease and impaired cognition had multiple falls, including one with injury, but the care plan did not document these events or address them with new interventions. The Director of Nursing confirmed that care plans should have been updated as falls occurred. A third resident with vascular dementia and moderate cognitive impairment had two non-injury falls during the assessment period. Although the resident was placed in a Geri chair as a new intervention to address fall risk, this change was not reflected in the care plan for over 30 days. Staff interviews confirmed that the Geri chair was a therapy intervention and should have been included in the care plan, but it was not. These omissions demonstrate a failure to ensure care plans were current and reflective of residents' needs and conditions.
Failure to Provide and Document Required ADL Assistance for Dependent Resident
Penalty
Summary
A resident with vascular dementia, a history of stroke, and right-sided paralysis was dependent on staff for assistance with activities of daily living (ADLs), including bathing and showering. The resident's care plan specified that two staff members were required to assist with bathing or showering three times weekly and as necessary. Documentation in the electronic medical record (EMR) and the June Bath Book showed that showers were not consistently provided according to the care plan schedule, with significant gaps in documentation for May and June. The available records indicated only a few showers were given, and there were instances of resident refusal, but overall, the required frequency of showers was not met. Interviews with the Unit Manager and DON revealed uncertainty and inconsistency regarding documentation practices for showers. The Unit Manager was unsure if CNAs were required to document showers in the EMR, and the DON confirmed that CNAs had not completed any shower sheets for the resident. No additional documentation was provided to account for the missing showers, indicating a failure to ensure that the resident received the necessary assistance with ADLs as outlined in the care plan.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Improper Positioning of Urinary Drainage Bags
Penalty
Summary
The facility failed to properly position urinary drainage bags for two residents, resulting in inadequate drainage and the potential for urine to flow back toward the bladder. For one resident with multiple sclerosis, hemiplegia, and neuromuscular bladder dysfunction, observations revealed the urinary drainage bag was placed flat on a stretcher and later on the floor, with urine backing up in the tubing and a strong urine odor present. The drainage port was also found to be improperly clamped, leading to urine spillage on the floor. The resident was dependent on staff for all activities of daily living and required an indwelling catheter. Another resident with cerebral infarction, hemiplegia, and chronic kidney disease, who was also dependent on staff for all ADLs and used an external catheter, was observed with the urinary drainage bag resting on the floor. The drainage bag remained in this position during subsequent observations, and the tubing was not adjusted to promote adequate urinary drainage. These actions were inconsistent with the facility's urinary catheter care policy, which requires drainage bags to be positioned below the bladder and off the floor to prevent backflow and potential infection.
Infection Control and Equipment Handling Deficiencies
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, as evidenced by several deficiencies observed during the survey. For two residents, nebulizers were not properly bagged, dated, or labeled, which is a violation of the facility's policy on standard precautions. One resident's oxygen concentrator tubing was undated, and the filter was found to be covered with a white fuzzy substance, indicating a lack of proper maintenance and sanitation. Additionally, the nebulizer equipment was found unbagged and undated on the residents' nightstands, with tangled tubing cords attached. In another instance, bedpans in a shared bathroom were found on the floor, unbagged, and unlabeled, which is contrary to the facility's infection control policies. The bedpans were observed in various states of disarray over multiple days, and staff interviews revealed that they should have been properly bagged and labeled to prevent potential infection control issues. The DON, who had recently started working at the facility, acknowledged the importance of proper handling and storage of such equipment to prevent the spread of infections. Furthermore, during a medication administration observation, a nurse failed to sanitize her hands, prepare a clean barrier for an Accu check, and properly clean the glucometer before and after use. The nurse also mishandled medication by dropping pills on the cart and sweeping them into a cup without ensuring a clean surface. These actions were not in line with the facility's policies for medication administration and infection control, as confirmed by the DON during an interview.
Failure in Antibiotic Stewardship Program Documentation
Penalty
Summary
The facility failed to maintain a comprehensive review of antibiotic prescribing practices and documentation of the antibiotic stewardship program's efforts from January 2024 to September 2024. The policies in place required that antibiotics be prescribed and administered under the guidance of the facility's antibiotic stewardship program, with complete orders including drug name, dose, frequency, duration, route, and indications of use. Additionally, when a nurse communicated a suspected infection to a prescriber, specific information was to be provided, such as signs and symptoms, hydration status, and current medication list. However, the facility did not complete the required tracking and trending of antibiotic use, as evidenced by the absence of completed Monthly Healthcare Associated Infection Summary Reports for each month in 2024. The Infection Control Preventionist, who started working at the facility on October 1, 2024, indicated that her duties included monitoring personal protective equipment and conducting infection control assessments. Despite these responsibilities, the facility's antibiotic surveillance tracking form was not utilized to document antibiotic regimens, including details such as resident name, unit, date symptoms appeared, and antibiotic start and stop dates. This lack of documentation and review of antibiotic use had the potential to affect any resident prescribed antibiotics, as the facility did not adhere to its own policies for antibiotic stewardship and surveillance.
Failure to Timely Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse involving two residents, R10 and R108, in a timely manner as required by their policy and state regulations. The policy mandates that any suspicion of abuse must be reported immediately to the administrator and relevant authorities within two hours if it involves abuse or results in serious bodily injury. However, the incident on 8/5/2024, where R98 was found rubbing on another resident who was screaming 'stop', was not reported to administration or authorities. The LPN involved did not notify anyone in administration but only passed the information during the shift report. Another incident on 8/20/2024 involved R98 grabbing R10's breast, which was reported to the Social Services Director but not immediately to the state agency. The Administrator, who is the abuse coordinator, confirmed awareness of both incidents but failed to report the first incident and delayed reporting the second incident by seven days. The facility's failure to adhere to their policy and regulatory requirements for timely reporting of abuse allegations resulted in a deficiency.
Inadequate Investigations into Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving three residents. For the first resident, who has severe cognitive impairment, incidents were documented where the resident was found inappropriately touching another resident. Despite the incidents being reported, the facility did not conduct interviews with other residents or perform skin assessments to identify potential additional victims. The facility's administrator, who is also the abuse coordinator, confirmed that the investigation was incomplete and lacked necessary documentation. In the second case, a resident with moderate cognitive impairment was involved in a sexual abuse allegation. The facility's investigation was insufficient, as it only included one staff statement and a review of video footage. There were no interviews with other residents or additional staff statements, and no skin assessments were conducted for cognitively impaired residents. The Director of Nursing confirmed that the investigation process was not fully executed as per the facility's policy. The third incident involved a resident with intact cognition who reported hitting his roommate with a cane after the roommate made sexual comments. The facility's investigation into this incident was also inadequate, with only one witness statement recorded and no further documentation provided. These deficiencies highlight a pattern of incomplete investigations into abuse allegations, failing to meet the facility's policy requirements for thorough investigations.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed quarterly for two residents, R33 and R405, out of a sample of 58 residents. A review of the Electronic Medical Records (EMR) revealed that both residents were admitted on unspecified dates, but there were no updated MDS assessments in their clinical records. During interviews, the MDS Coordinators, who have been working at the facility for several years, confirmed that they had overlooked completing the assessments for these residents. The Director of Nursing and the Administrator both stated that MDS assessments should be completed quarterly, annually, and when there is a significant change in a resident's status. The facility's policy related to MDS assessments was requested but not provided.
Failure to Develop Baseline Care Plan for Resident with Catheter
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed for a resident admitted with a supra-pubic catheter. According to the facility's policy, a baseline plan of care should be developed within 48 hours of admission to address the resident's immediate health and safety needs. However, upon review, it was found that the baseline care plan for the resident did not include instructions necessary for effective and person-centered care related to the supra-pubic catheter. The resident was admitted with multiple diagnoses, including neuromuscular dysfunction of the bladder and retention of urine, which necessitated the use of a supra-pubic catheter. Despite the physician's order for Enhanced Barrier Precautions due to the catheter, the baseline care plan lacked specific guidance for managing this condition. Interviews with the MDS Coordinator/LPN and the DON confirmed the absence of a baseline care plan addressing the supra-pubic catheter, indicating a lapse in the facility's adherence to its care planning policy.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide preventative care consistent with professional standards of practice for a resident at risk for skin breakdown. The resident, identified as R455, was admitted with multiple diagnoses including Alzheimer's Disease, diabetes, and severe vascular dementia. The resident had an unstageable pressure ulcer on the sacral area and was ordered to be turned and repositioned every two hours to prevent further skin breakdown. However, documentation revealed that the resident was only repositioned 59 times out of 96 opportunities over a specified period. The facility's policy on Activities of Daily Living (ADL) indicated that residents unable to carry out ADLs independently should receive necessary services to maintain their health. Despite this, the facility's staff did not adhere to the physician's orders for repositioning the resident, as confirmed by the Director of Nurses and the Assistant DON. They were unable to access the Dependent Turning Schedule on the computer, which further highlighted the deficiency in care provided to the resident.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that a resident had a functioning call light system, which is essential for residents to gain access to staff assistance. The facility's policy mandates that each resident should have a call light and that these should be answered promptly. However, during an observation, it was found that the call light for a resident with severe cognitive impairment and significant physical limitations was not operational. This resident, who requires substantial assistance for daily activities, was unable to activate the call light system, as confirmed by the assigned Certified Nursing Assistant. Further investigation revealed that the Maintenance Director was aware of the issue but noted that repairs are often communicated verbally and not documented in the electronic maintenance system. The Director of Nursing had previously conducted an in-service to ensure call lights were functioning, but was unsure of the frequency of routine checks by maintenance. The Maintenance Director stated that call lights were checked bi-weekly, but there was no prior documentation to verify this, as a specific log for call lights was only created during the survey.
Deficiencies in Pain Management and Medication Administration
Penalty
Summary
The facility failed to provide adequate nursing care and services to meet the medical needs of two residents, R6 and R15, particularly in the areas of pain management and medication administration. R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued, leading to increased unusual behavior, a low-grade temperature, swelling in bilateral knees, and a decline in mobility. The facility's policy on administering medications was not followed, as there was no physician order for the continued administration of Fluoxetine. Additionally, R15's pain management was inadequate, as the resident was observed in pain with swollen knees, and the facility failed to notify the physician or provide appropriate pain relief in a timely manner. R6 experienced inadequate pain management and a pest infestation issue. The resident, who had a vascular wound on the left leg, was observed with gnats on the wound dressing, which was saturated with drainage. Despite the presence of gnats being a known issue, it was not reported or addressed until brought to the attention of the facility by surveyors. R6 also reported having to request pain medication, as it was not regularly scheduled, and there was no documentation of the physician being notified about the frequency of pain and administration of as-needed medication. The facility's failure to adhere to its policies and procedures regarding medication administration, pain management, and pest control resulted in harm to the residents. The lack of communication and documentation regarding changes in residents' conditions and medication orders contributed to the deficiencies observed. The facility's staff did not adequately assess, document, or report the residents' needs and changes in their conditions, leading to a decline in the quality of care provided.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R15, was receiving medications as prescribed by the psychiatrist. Despite the psychiatrist's order to discontinue Fluoxetine (Prozac) on 6/29/2023, the pharmacy continued to dispense the medication, and it was administered to R15 for forty-eight weeks. This oversight resulted in harm to R15, who exhibited increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and a decline in mobility from ambulating independently to being unable to ambulate. The facility's policy on administering medications, dated April 2019, mandates that medications be administered safely, timely, and as prescribed. The policy also requires that any concerns about medication dosages or potential adverse consequences be communicated to the prescriber or medical director. However, during an observation on 6/20/2024, it was noted that R15 was still receiving Fluoxetine, despite the absence of a physician order for it. The psychiatrist's progress note from 6/28/2023 had recommended stopping Fluoxetine and starting Lexapro, but this change was not reflected in the medication administration. The facility underwent a transition between pharmacies around June 2023, during which the current pharmacy was supposed to reconcile all resident physician orders. However, the Executive Director acknowledged that the order to discontinue Fluoxetine for R15 was not properly communicated to the pharmacy. Additionally, the Pharmacy Nurse Consultant, responsible for medication cart audits, did not conduct an audit for R15, and the pharmacy continued to dispense the discontinued medication without any recommendations or interventions noted in the monthly reviews from July 2023 to May 2024.
Failure to Discontinue Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Resident R15, who was admitted with diagnoses including major depressive disorder and severe unspecified dementia, was administered Fluoxetine (Prozac) for forty-eight weeks after it had been discontinued. This administration led to harm, as evidenced by increasing unusual behavior, a low-grade temperature, swelling in the knees, and a decline in mobility from ambulating independently to being unable to ambulate. During a medication observation, it was noted that Fluoxetine was not listed on R15's Medication Administration Record (MAR), indicating a lack of proper documentation and oversight. Interviews with the LPN responsible for administering the medication revealed that she was unaware of the discontinuation and continued to administer Fluoxetine as it was included in the resident's strip pack. The LPN confirmed that she had not been adequately trained in medication administration and had not completed a medication pass with the Pharmacy Nurse Consultant. The facility's policy on administering medications requires verification of the right medication and dosage, which was not adhered to in this case. The Director of Health Services acknowledged the oversight and the need for improved training and supervision of medication administration processes.
Failure to Renew CNA Certifications
Penalty
Summary
The facility failed to ensure the timely renewal of certifications for two Certified Nursing Assistants (CNAs), leading to a deficiency in compliance with state regulations. CNA TT worked for six months with an expired certification, while CNA UU worked for thirty days without a valid certification. The lapse in certification was identified through a review of employee files and confirmed by staff interviews. The facility's Human Resources Director acknowledged the oversight, attributing it to the previous Education Coordinator's failure to perform their duties in monitoring and updating certifications. The deficiency was discovered during a review of the State of Georgia Nurse Aide Registry Nurse Aide Certification Renewal records, which require CNAs to maintain current certifications to work in licensed Medicaid and Medicare facilities. Both CNAs continued to work with expired certifications until the issue was identified by the facility. Interviews with the CNAs revealed that they were not reminded of their certification expiration, a task typically managed by the facility. Once the lapse was discovered, the facility took steps to address the issue, but the deficiency had already occurred.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain infection control standards as observed during a medication administration session. A registered nurse (RN) used a wrist blood pressure monitor on two different residents without cleaning and disinfecting it between uses, which is against the facility's policy. The policy, revised in September 2022, mandates that resident-care equipment, including reusable items, must be cleaned and disinfected according to CDC recommendations and OSHA standards. Additionally, the RN did not perform hand hygiene after assisting a resident by touching their wheelchair and picking up an item from the floor before administering medication to another resident. During interviews, the RN acknowledged the failure to clean the equipment and perform hand hygiene, confirming the breach of infection control procedures. The Director of Health Services also stated that staff should always clean and disinfect equipment between residents and perform hand hygiene to prevent the spread of germs. These actions and inactions led to the deficiency in infection prevention and control within the facility.
Facility Fails to Maintain Cleanliness and Adequate Linen Supply
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in several resident rooms, as evidenced by observations of dirt and grime buildup inside the air discharge grilles of the PTAC units in multiple rooms. The facility's policy titled '7 Step Cleaning Process' was intended to guide staff in daily cleaning procedures, including dusting all surfaces and correcting deficiencies immediately. However, interviews with the Environmental Service Director (EVSD) and the Maintenance Director revealed that the PTAC units were only cleaned every three months, and the buildup of dirt and grime was confirmed in rooms B09, B22, and B29. Additionally, a large hole was observed under the sink in the bathroom shared by rooms B14 and B16, which was not addressed promptly despite being acknowledged by the Executive Director. The facility also failed to ensure an adequate supply of linen for nine days, as observed in multiple units. Linen carts and closets on Units A, B, B/C, and C/D were found to be lacking essential items such as washcloths, towels, and blankets. Interviews with the Laundry Aide and the Environmental Services Director confirmed the insufficient amount of linen available, and the Environmental Services Director stated that he was not responsible for ordering linen but only alerted the Assistant Executive Director of the department's needs. The Laundry Aide mentioned that the department washed what was received and divided it among the linen closets, but the quantity was insufficient for the number of residents. These deficiencies highlight the facility's failure to adhere to its own cleaning and maintenance policies and to provide necessary supplies for resident care. The lack of cleanliness in the PTAC units and the inadequate linen supply compromised the residents' right to a safe, clean, and comfortable environment. The facility's inaction in addressing these issues promptly contributed to the ongoing deficiencies observed during the survey.
Pest Control Deficiency Due to Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program on Unit B, resulting in an infestation of black gnats. Observations revealed swarms of live black gnats in multiple rooms, including R6's room, where gnats were seen flying around the resident's leg. Despite the presence of a gnat trapper installed by the Maintenance Department, the resident expressed concerns about its effectiveness. The facility's pest control policy, dated May 2008, mandates an ongoing program to keep the building free of insects and rodents, with maintenance services assisting as necessary. However, the Maintenance Director, who oversees the pest control program, was unaware of the gnat issue until 5/2/2024, despite the problem being ongoing for two years according to LPN OO. Interviews with staff revealed inconsistencies in the reporting and awareness of pest issues. The Maintenance Director stated that pest control services are provided weekly, and staff are required to log pest sightings in a pest control logbook. However, LPN LL was unaware of such a logbook and reported maintenance concerns through an electronic system. The Executive Director, Assistant Executive Director, and Environmental Service Director confirmed the presence of gnats on Unit B. Despite the Maintenance Director's claim of no pest issues, the observations and staff interviews indicate a significant lapse in the facility's pest control measures, leading to the infestation.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs of two residents, R6 and R8, as observed during a survey. R6, who was admitted with chronic pain, gout, and rheumatoid arthritis, was found to be lying in bed without a wheelchair or any sitting chair in his room. Despite being cognitively intact, R6 had not been out of bed since October 2023 due to the removal of his wheelchair after an incident where he slipped out of it. The facility did not provide an alternative solution for R6 to sit out of bed, and he struggled to use the television remote due to deformities in his hands. The facility's offer to move his bed to improve remote access was not implemented, and R6 remained in bed during multiple observations. R8, another resident, expressed dissatisfaction with her bathing routine, as she was only receiving bed baths instead of showers on her designated days. Despite her preference for showers being documented in her assessment, R8 reported that she had not received a shower for a week, and her grievance was noted in the facility's records. The CNA Bath Skin Sheets, which should document each shower or bath, were inconsistently completed, indicating a lack of adherence to the resident's bathing schedule. Interviews with facility staff, including the social worker and executive director, revealed a lack of awareness and action regarding the residents' needs. The social worker described R6 as aggressive and verbally abusive, which may have influenced the facility's response to his needs. The executive director was unaware of R6's lack of a chair and his confinement to bed. Similarly, the LPN confirmed R8's bath schedule but acknowledged the incomplete documentation of her bathing routine. These deficiencies highlight the facility's failure to accommodate the residents' needs and preferences adequately.
Failure to Conduct Required Background Checks for RNs
Penalty
Summary
The facility failed to conduct criminal background checks for two Registered Nurses (RNs) out of ten employee files reviewed, which is a violation of their own policies and procedures. The facility's policy on Abuse, Neglect, Exploitation, or Misappropriation mandates that background checks be conducted to ensure that no individual with a history of abuse, neglect, exploitation, or misappropriation is employed. Additionally, the policy on Background Screening Investigations requires that background checks, including criminal conviction checks and fingerprinting, be completed before employment for all direct access team members. Upon review, it was found that RN GG, hired as a full-time RN Supervisor, and RN HH, also hired as a full-time RN Supervisor, did not have documented criminal background checks in their employee files. The Human Resources Director confirmed during an interview that these checks were not conducted for RN GG and RN HH, despite the facility's policy requiring such checks to be completed before the commencement of employment.
Failure to Report Misappropriation of Controlled Drugs
Penalty
Summary
The facility failed to report a situation involving the misappropriation of a controlled drug, Oxycodone, to the State Survey Agency (SSA) for two residents. The facility's policy requires that all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property be reported to local, state, and federal agencies as required by current regulations. The policy also mandates that suspicions of such incidents be reported immediately to the administrator and other officials according to state law. However, in this case, the misappropriation was not reported to the SSA. The incident involved a Licensed Practical Nurse (LPN) who was observed on camera removing narcotics and narcotic count sheets from the medication cart. The Director of Health Services (DHS) stated that the police were notified, the nurse was terminated, and the state board of nursing was informed. The pharmacy was also notified, and the medication for the affected residents was replaced. Despite these actions, the DHS was unaware that the misappropriation needed to be reported to the SSA, leading to the deficiency noted in the report.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for five residents, which had the potential to impact their treatment and care. The facility's policy requires that care plans be developed within seven days of the completion of the required Minimum Data Set (MDS) assessment and no more than 21 days after admission. However, for residents R3, R7, R8, R9, and R16, the facility did not document care plans addressing their specific needs, such as activities of daily living (ADLs), fall risks, and medical conditions like fractures and oxygen use. Resident R3, who was readmitted with a severe cognitive impairment and a right arm fracture, did not have a care plan addressing her ADLs, fall risk, or fracture. Despite a history of falls and a significant change in her condition, the care plan was not updated to reflect these concerns. Similarly, resident R7, with severe cognitive impairment and a history of falls, lacked a care plan for ADLs and fall prevention, even after experiencing falls within the facility. Resident R8, who required oxygen and BiPAP/CPAP for chronic obstructive pulmonary disease and sleep apnea, did not have a care plan for these needs. Resident R9, with severe cognitive impairment and requiring assistance with dressing, also lacked an ADL care plan. Lastly, resident R16, who needed extensive assistance with ADLs, did not have a documented care plan addressing these needs. Interviews with MDS Coordinators confirmed the absence of these care plans, highlighting a systemic issue in the facility's care planning process.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to a resident, identified as R9, who was unable to perform these tasks independently. R9, who was readmitted to the facility with conditions including hemiplegia, hemiparesis, and vascular dementia, required partial to maximal assistance with dressing. Observations revealed that R9 had remnants of food on his clothing and was unable to change without assistance. Despite notifying charge nurses, R9 did not receive the needed help for over an hour. The facility's policy on ADLs, revised in March 2018, mandates that residents unable to perform ADLs independently should receive appropriate care to maintain hygiene and grooming. However, on the day of the observation, R9 was seen propelling himself in a wheelchair with food-stained clothes and was not assisted promptly, as confirmed by the Unit Manager. This delay in assistance was acknowledged by the Unit Manager, who confirmed that the charge nurses should have helped R9 change his clothes sooner.
Failure to Verify RN Licensure
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) had the required licensure to provide nursing care to residents. The RN, identified as HH, was hired on November 3, 2023, but her professional licensing status had lapsed, which was not identified by the Human Resources (HR) staff prior to her hire. The facility's policy on Background Screening Investigations requires contacting the respective licensing board to check for any sanctions against an applicant's license, and the Hiring Process policy mandates verification of licenses or certifications before making an offer. However, these procedures were not followed, resulting in the employment of an unlicensed RN. The RN worked for 7.67 hours on November 2, 2023, before quitting without notice. During an interview, the Executive Director, Assistant Executive Director, and HR Director revealed that they were unaware of the lapsed license at the time of the interview and hire. The HR Director admitted responsibility for verifying the completeness of applications, including license verification, but acknowledged that the final check was not conducted. The Executive Director noted that there were insufficient controls in place, which allowed staff to circumvent the system, leading to the hiring of the current HR Director to implement necessary policies and procedures.
Failure to Obtain COVID-19 Vaccination Consent
Penalty
Summary
The facility failed to obtain vaccination consent before administering COVID-19 vaccines to two residents, R1 and R10, as required by their policy. The policy, revised in May 2023, mandates that each resident is offered the COVID-19 vaccine unless medically contraindicated or fully vaccinated, and that the resident's medical record must include documentation of education provided and signed consent. However, a review of R1's electronic medical record (EMR) showed that while R1 received COVID-19 vaccines on three occasions, there was no documentation of consent obtained prior to these vaccinations. Similarly, R10's EMR indicated that the resident received COVID-19 vaccines on three separate occasions, yet there was no documentation of consent obtained before these vaccinations. During an interview, the Director of Health Services confirmed that education should be provided and consent obtained before administering any vaccine, acknowledging that R1 and R10 did not have signed consent forms for the COVID-19 vaccines administered. This oversight represents a failure to adhere to the facility's vaccination policy, as documented in the report.
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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