Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sadie G. Mays Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with left hand weakness and limited upper-extremity function sustained a hot chocolate burn during Coffee Club when hot liquid was served and spilled, resulting in blisters, ER transfer, and wound care. Staff interviews and observations showed hot coffee, hot chocolate, and hot water were prepared and served as part of the activity, while another resident with severe cognitive impairment and fall risk did not have the ordered floor mats on both sides of the bed; only one mat was observed, and an LPN confirmed the missing mat.
Insufficient Surety Bond for Resident Trust Funds: The facility failed to assure the security of resident personal funds deposited with the facility because the surety bond amount was less than the resident trust fund balances. Review of the policy showed it did not address surety bond review, and bank statements showed multiple months where daily balances exceeded the bond amount. The BOM confirmed the trust fund balances and the reconciliation amount.
Incomplete Water Management Program: The facility failed to maintain an adequate water management program for 129 of 129 residents. The Water Management Program was incomplete and not consistent with current ASHRAE guidelines for Legionella prevention. It lacked a risk assessment and a diagram or written description of the building water system, including where the building connects to the municipal water supply, how water is distributed and used, and the locations of hot tubs, water heaters, cooling towers, and other high-risk areas. The Maintenance Director stated he only had building blueprints and no water system diagram.
A resident with Alzheimer's disease, severe cognitive impairment, limited mobility, and dependence on staff for ADLs had her call button observed under the bed and out of reach on two occasions. The facility policy required the call system to be accessible while the resident was in bed, and an LPN and CNA both confirmed the call button should always be within the resident's reach.
A resident with paranoid schizophrenia, dementia, DM2, COPD, CKD, and encephalopathy repeatedly refused bedtime meds, including insulin glargine-yfgn, mirtazapine, Seroquel, simvastatin, tamsulosin HCl, and trazodone. The record showed no documentation that the physician was notified of the refusals, despite staff stating that repeated refusals should be reported and documented.
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.
Hot liquid burn and missing fall mats
Penalty
Summary
The facility failed to prevent an avoidable accident when a resident with left upper extremity impairment and weakness in her left hand sustained a burn from hot chocolate. The resident was given a cup of hot chocolate during the facility’s Coffee Club activity while she had a private sitter present. The resident spilled the hot chocolate on her left arm, resulting in a burn with blisters, transport to an acute care setting, and subsequent wound treatment. Progress notes documented that the resident was evaluated by the wound team, had drainage from the burn, and later received Silvadene cream to the left arm. During interviews and observation, staff described how hot coffee, hot chocolate, and hot water were prepared and served for the activity. The kitchen staff brought coffee and hot water to the dining room, and temperatures of the hot liquids were observed and measured during the survey. The activity director stated that staff were trained to allow hot chocolate to cool completely before serving it to the resident. The resident’s former sitter stated the resident could not open her entire left hand and had several blisters from the burn. The DON stated she was unsure whether hot liquid assessments existed for residents, and the maintenance director could not locate coffee temperature logs for March 2025. The facility also failed to carry out a fall-prevention intervention for another resident with severe cognitive impairment, limited mobility, and a documented fall risk. The care plan and bedside Kardex directed staff to place floor mats on both sides of the bed, but observations on two separate dates showed only one mat on the right side of the bed. An LPN confirmed there was only one mat and stated there should have been mats on both sides. The DON stated all interventions should be carried out, and the administrator stated both mats should have been on the floor.
Insufficient Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to assure the security of resident personal funds deposited with the facility because the surety bond was not sufficient to cover the resident trust fund deposits. Review of the facility’s policy titled Management of Beneficiary Funds showed it described the process for managing beneficiary funds but did not address surety bond review. The facility’s surety bond document dated 3/26/2025 through 5/26/2025 showed a bond amount of $190,000.00. Review of six months of bank statements from May 2025 through November 2025 showed that five of the six statements had daily balances greater than the surety bond amount, including beginning and ending balances ranging from $187,220.09 to $233,366.33. The total amount of the 123 resident accounts as of 12/19/2025 was $205,144.77. During interview, the Business Office Manager confirmed the amount shown on the resident trust fund bank statements and acknowledged the balance amount listed on the Trust Account Reconciliation document.
Incomplete Water Management Program
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not have an adequate water management program for 129 of 129 residents in the facility. The facility's Water Management Program, dated 11/28/2025, was reviewed and found to be incomplete and not consistent with current ASHRAE Guidelines addressing the potential exposure of Legionnaires' disease within a healthcare facility. The reviewed program did not include a risk assessment or a diagram of the facility's water system, and it did not contain text describing the building water system. The report stated that the description should have included flow diagrams and written details showing where the building connects to the municipal water supply, how water is distributed and used, and the locations of hot tubs, water heaters, cooling towers, and other high-risk areas where water pathogens might develop. During interview, the Maintenance Director stated that he only had blueprints of the building and no diagram of the facility's water system. A request was made to the Administrator for the total number of residents over the age of 65, but no information was provided by the end of the survey.
Call Button Not Kept Within Resident's Reach
Penalty
Summary
The facility failed to ensure the call button was accessible for one resident, R56, whose call button was observed under the bed and out of reach during two separate observations. The facility policy titled Call Lights: Accessibility and Timely Response stated that the call system would be accessible to residents while in their bed or other sleeping accommodations within the resident's room. R56 was admitted with diagnoses including Alzheimer's disease, peripheral vascular disease, and muscle weakness. Her care plan identified her as at risk for falls due to limited mobility and being unaware of safety needs, and noted limited physical mobility due to Alzheimer's disease and weakness. Her annual MDS assessment showed a BIMS score of 2 out of 15, indicating severe cognitive impairment, and documented that she was dependent on staff for toileting hygiene, bathing, dressing, personal hygiene, and transfers. During an observation and interview, an LPN confirmed the call button was not within reach and stated it should be at all times, and a CNA also confirmed that R56 used her call button and it should always be within her reach.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The facility failed to ensure the physician was notified of a change of condition for one resident who refused bedtime medications for multiple days in a row. The resident was admitted with diagnoses including paranoid schizophrenia, dementia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, and encephalopathy. The resident’s care plan identified refusal of medications and care, behavioral concerns related to paranoid schizophrenia, and impaired cognitive function and decision-making due to dementia. The quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment, and also noted rejection of care in the seven-day look-back period. The resident’s MAR showed refusals of insulin glargine-yfgn at bedtime on several dates, and refusals of mirtazapine, Seroquel, simvastatin, tamsulosin HCl, and trazodone at bedtime on multiple dates as well. The clinical record contained no indication that the physician was notified of the medication refusals. During interviews, the resident’s family member stated she was not sure the physician was notified and believed the physician needed to know because the resident had refused medications multiple days in a row. The DON and Administrator stated that the physician and family needed to be notified when a resident refused medications, and staff stated such notifications should be documented in progress notes.
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.
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What surveyors actually found near you
We read the 404 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Atlanta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - West Atlanta | 1.7 mi | ★★★★★ | 10 | 0 |
| Buckhead Center For Nursing And Healing | 4.1 mi | ★★★★★ | 13 | 0 |
| A.g. Rhodes Home, Inc, The | 4.4 mi | ★★★★★ | 8 | 0 |
| Legacy Transitional Care & Rehabilitation | 4.4 mi | — | 9 | 0 |
| Reliable Health & Rehab At Lakewood | 4.6 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.