Sandy Springs Center For Nursing And Healing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Georgia.
- Location
- 1500 S Johnson Ferry Road, Atlanta, Georgia 30319
- CMS Provider Number
- 115504
- Inspections on file
- 19
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Sandy Springs Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
Surveyors found that the facility did not provide adequate housekeeping and maintenance services, resulting in persistent foul odors, stained floors and furniture, and unclean resident rooms and common areas. The EVS director confirmed lapses in cleaning due to broken equipment, and a family member reported repeated observations of dirty, sticky floors and unaddressed spills. The DON acknowledged awareness of these ongoing sanitary issues.
A facility ice machine was found with visible residue, slime-like buildup, and debris, while actively producing ice. Interviews revealed that neither the Maintenance nor Housekeeping Departments had been cleaning the machine, each believing it was the other's responsibility. No cleaning was documented for the past 90 days, and there was no formal policy assigning responsibility for ice machine cleaning.
A medication cart containing oral, PRN, topical, and controlled medications was left unlocked and unattended in the East Wing, with no licensed staff present for approximately 15 minutes. Facility policy requires all medications to be secured in locked compartments accessible only to authorized personnel. The deficiency was confirmed by the ADON, Unit Manager, and DON.
Surveyors identified multiple sanitation and food safety deficiencies, including failure to maintain hot food items above required temperatures, improper use of hairnets, staff with long acrylic nails and nail polish, lack of a foot-pedal trash can, and a dish machine not reaching proper sanitization temperatures. These issues were observed during kitchen operations and confirmed through staff interviews and policy reviews.
Staff failed to provide accessible PPE and follow infection control protocols for multiple residents on Enhanced Barrier Precautions, with PPE not available at the point of care, non-functioning ABHR dispensers, and staff unaware of required precautions. Additionally, CNAs did not follow proper peri-care technique for a resident with immunodeficiency, cleansing from back to front instead of front to back.
The facility did not complete required PASARR assessments for two residents with serious mental health diagnoses. One resident's PASARR I was left blank and not properly completed at admission, while another resident with multiple psychiatric diagnoses did not receive a necessary PASARR Level II evaluation. Both cases involved incomplete or missing documentation at the time of admission.
Two residents experienced significant weight loss, as documented in their medical records and MDS assessments, but their care plans were not updated to address this issue. One resident with severe cognitive impairment and another with multiple chronic conditions and frequent meal refusals both lacked care plan interventions for weight loss, despite staff awareness and facility policy requirements.
A resident with multiple medical conditions did not receive scheduled medications within the required 60-minute window on numerous occasions, with administration times documented as several hours late. The DON could not explain the delays, and the facility's grievance log included several complaints about late medication administration, indicating a failure to meet professional standards for timely medication delivery.
Two residents with significant cognitive and physical impairments did not consistently receive or have documented ADL and incontinence care, as evidenced by blank entries in the POC system, grievances, and staff and family interviews. This resulted in residents being left wet and uncleaned on multiple occasions, with facility leadership unable to account for the lack of care or documentation.
A resident with severe cognitive impairment and a surgically closed wound infection missed three scheduled doses of IV Vancomycin, with no documentation or provider notification regarding the missed doses. Staff interviews confirmed that facility expectations for documenting and reporting missed medications were not followed.
A resident with severe cognitive impairment and multiple medical conditions experienced significant weight loss, but staff failed to perform weekly weights as required by facility policy and did not implement a dietician's recommendation for a nutritional supplement due to an oversight in communicating with the physician. As a result, the resident was not properly monitored or provided with the recommended nutritional intervention.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary, clean, comfortable, and homelike environment for residents, as required by its own housekeeping policy. Observations across multiple units revealed persistent foul odors, stains, spills, and trash on floors, as well as stained furniture and walls. Resident rooms and common areas were noted to have food particles, sticky spills, and unswept debris. The environmental services (EVS) director confirmed that floors had not been mopped in days, cleaning equipment was broken and awaiting repair, and that the facility had not been able to strip and wax the floors. The EVS director also acknowledged the presence of urine odors that had been masked with sprays. Interviews with a resident's family member corroborated these findings, describing frequent visits where floors were dirty and sticky, with spills left uncleaned in resident rooms. The Director of Nursing (DON) was aware of the ongoing sanitary issues and acknowledged that they required attention. These observations and interviews demonstrate a failure to provide necessary housekeeping and maintenance services, resulting in an environment that does not meet standards for cleanliness and comfort.
Failure to Maintain Cleanliness of Ice Machine Due to Lack of Assigned Responsibility
Penalty
Summary
A deficiency was identified when one of two facility ice machines, located in the service hallway of the East Wing Unit, was found to have visible brown/black residue along the interior chute, slime-like buildup on the underside of the ice shield, and loose particulate debris in the ice collection bin. The ice machine was actively producing ice at the time of inspection. Observations and interviews confirmed the presence of a black substance inside the lid and dust particles around the front of the machine. The Director of Maintenance (DM) acknowledged the need for cleaning and confirmed the observations. Further investigation revealed confusion regarding responsibility for cleaning the ice machine. The DM stated that the Housekeeping Department was responsible, while the Housekeeping Supervisor indicated that the Maintenance Department was responsible. Both departments confirmed that neither had been cleaning the ice machines, each believing it was the other's responsibility. Review of the Ice Machine Cleaning Log for the past 90 days showed no documented cleaning, and the Corporate Risk Manager confirmed there was no formal policy specifying responsibility for cleaning the ice machines.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart located on the East Wing Unit, specifically the Middle Cart positioned to the left of the East Wing Nursing Station, was observed to be left unlocked and unattended during a facility tour. The cart contained multiple medications, including oral medications in blister packs, PRN medications, topical treatments, and controlled substances. There were no licensed nurses or other authorized staff present in the hallway at the time, and the cart remained unattended for approximately 15 minutes before staff returned. The facility's Medication Storage Policy requires that all drugs and biologicals be stored in locked compartments, with access limited to authorized personnel. During the observation, both the Assistant Director of Nursing and the Unit Manager confirmed that the cart was unlocked and unattended. The DON also acknowledged that this was a deficient practice, as the expectation is for medication carts to remain locked at all times when not in the direct possession of a licensed nurse.
Multiple Sanitation and Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as evidenced by several observed deficiencies. Hot food items on the steam table were not consistently kept above 135 degrees Fahrenheit, with pureed green beans recorded at 131 degrees Fahrenheit during tray preparation. Staff members were observed not wearing hairnets properly, with some hair not fully covered, and the Dietary Manager was seen with long acrylic nails and nail polish, contrary to facility policy requiring clean, trimmed nails without artificial enhancements. Additionally, the kitchen lacked a foot-pedal trash can, resulting in staff touching the trash can lid after handwashing, which could compromise hand hygiene. The dish machine was also found to be deficient, with its final rinse temperature not reaching the required 180 degrees Fahrenheit for proper sanitization, and the machine's gauges were observed to be stationary and not functioning correctly. Staff interviews confirmed awareness of the temperature and hygiene policies, but also revealed lapses in adherence, such as the Dietary Manager's lack of knowledge regarding the nail policy. The facility's own policies and the manufacturer's guidelines for equipment were not followed, and these practices had the potential to adversely affect all residents receiving an oral diet.
Failure to Provide PPE and Maintain Infection Control Protocols
Penalty
Summary
The facility failed to ensure proper implementation of infection prevention and control protocols for several residents requiring Enhanced Barrier Precautions (EBP). For three residents with significant medical conditions, including dementia, cancer, immunodeficiency, and recent surgical wounds, there was no personal protective equipment (PPE) visibly available at the point of care, despite signage indicating EBP requirements. Alcohol-based hand rub (ABHR) dispensers in these residents' rooms were not functioning, and staff were unaware of the EBP requirements, admitting to not donning PPE during care. PPE was stored in locations inaccessible to direct care staff, and staff had to rely on nurses to access PPE from a storeroom. The Director of Nursing confirmed that PPE was mixed with residents' clothing in wardrobes, and that staff were not using gowns as required. Additionally, the facility failed to maintain infection control during peri-care for a resident with immunodeficiency and end-stage renal disease. Certified Nursing Assistants (CNAs) were observed cleansing the resident's perineal area and buttocks from back to front multiple times, contrary to infection control protocols which require cleansing from front to back. The Director of Nursing confirmed that the correct procedure was not followed during peri-care. These failures were identified through observations, interviews, and record reviews, and were not limited to a single staff member or shift.
Failure to Complete Required PASARR Assessments for Residents with Mental Disorders
Penalty
Summary
The facility failed to complete required Preadmission Screening and Resident Review (PASARR) assessments for two residents with serious mental disorders or intellectual disabilities. For one resident, who was admitted with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and psychosis, the PASARR I form was found to be incomplete, with all fields left blank. Additionally, there was no evidence that a proper PASARR assessment was completed at the time of admission, and the initial PASARR I was only completed years later, after the deficiency was identified. The resident's medical record also included documentation of severe cognitive impairment and the use of psychotropic medications. For another resident, admitted with multiple psychiatric diagnoses such as major depressive disorder, bipolar disorder, and paranoid personality disorder, the facility's records showed that while a PASARR I was present, a required PASARR Level II evaluation was not completed despite the presence of qualifying diagnoses. The medical record indicated that some diagnoses were not included at the time of admission, and the necessary follow-up evaluation was not performed as required by regulation.
Failure to Address Weight Loss in Resident Care Plans
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement comprehensive care plans addressing significant weight loss for two residents. For one resident with severe cognitive impairment and multiple diagnoses, including dementia and anemia, the medical record and MDS documented a weight loss of over 5% in the last month. Despite this, the resident's care plan, last revised after the weight loss was identified, did not include interventions or goals related to the weight loss. Staff interviews confirmed that the weight loss was recognized and coded in the MDS, but the care plan was not updated as required by facility policy. Similarly, another resident with multiple diagnoses, including cancer and chronic kidney disease, and who was cognitively intact, experienced a weight loss of over 5% in the last month as documented in the MDS. This resident also frequently refused meals and medications, as noted in progress notes. However, the care plan did not address the resident's refusal to eat or the risk for weight loss. Staff confirmed that the issue was identified in the MDS but not incorporated into the care plan, indicating a failure to ensure that all identified needs were addressed in accordance with facility policy.
Failure to Administer Medications Within Required Timeframe
Penalty
Summary
The facility failed to administer scheduled medications within the required 60-minute window before or after the scheduled time for one resident. According to the facility's Medication Administration policy, medications are to be administered by licensed nurses or authorized staff as ordered by the physician and in accordance with professional standards. Record review showed that a resident with multiple diagnoses, including sepsis cystitis, urinary tract infection, depression, and dysphagia, had several medications ordered to be given at specific times in the evening. However, the Medication Administration Audit Report documented repeated instances where these medications were administered several hours past the scheduled time, with administration times ranging from over an hour to several hours late on multiple dates. The resident was noted to be cognitively intact but dependent on nursing staff for personal hygiene and was frequently incontinent. The Director of Nursing was unable to provide an explanation for the late administration of medications during an interview. Additionally, a review of the facility's Grievance Log revealed several complaints from residents regarding late receipt of medications, further supporting the finding that the facility did not consistently meet professional standards for timely medication administration.
Failure to Provide and Document Required ADL and Incontinence Care
Penalty
Summary
The facility failed to provide necessary Activities of Daily Living (ADL) care, including peri-care and incontinence care, for two residents who required extensive to total assistance. One resident, admitted with diagnoses such as immunodeficiency, end stage renal disease, dementia, and osteoarthritis, was care planned as incontinent and in need of peri-care with each episode. However, multiple days across three months showed blank documentation in the Point of Care (POC) system, indicating care may not have been provided. Grievance reports and family interviews confirmed repeated instances where the resident was found soaked in urine and not properly cleaned, with the Assistant Director of Nursing unable to explain the lack of documentation. Another resident, with severe cognitive impairment and multiple diagnoses including dementia and depression, also had significant gaps in POC documentation for peri-care across several shifts over three months. Staff interviews corroborated that the resident was found wet and that care was inconsistently documented. The Director of Nursing acknowledged that blanks in the POC were unacceptable and should have been marked as Not Applicable if care was not provided, but this was not done. These findings demonstrate a failure to consistently provide and document required ADL care for residents dependent on staff assistance.
Missed IV Vancomycin Doses and Lack of Documentation
Penalty
Summary
A resident with multiple complex medical conditions, including Alzheimer's disease, dementia, contractures, muscle weakness, and a surgically closed wound infection of the left hip, was admitted with a physician's order for daily intravenous Vancomycin to treat the wound infection. The resident was severely cognitively impaired and required extensive assistance with activities of daily living. According to the medication administration record, the resident missed three scheduled doses of Vancomycin on separate days, with no documentation provided for the missed doses. There was no evidence that the physician was notified about the missed doses or that any laboratory tests were drawn as a result. Staff interviews confirmed that the expectation was to document any missed medication doses and notify the provider, but this did not occur. The lack of documentation and provider notification for the missed antibiotic doses constituted a failure to provide treatment and care according to physician orders and facility policy.
Failure to Monitor Weight and Implement Dietician Recommendations After Significant Weight Loss
Penalty
Summary
The facility failed to follow its own weight monitoring policy and did not implement a dietician's recommendation for a resident with significant weight loss. According to the facility's policy, residents with weight loss are to be weighed weekly, but records showed that after two separate episodes of significant weight loss, weekly weights were not consistently documented for the resident. The resident, who was severely cognitively impaired and had multiple diagnoses including dementia, depression, and anemia, experienced a 5.2% weight loss in less than a month and an 8.48% weight loss in one month. Staff interviews confirmed that weekly weights were not always performed after weight loss, and the Assistant Director of Nursing acknowledged that weekly weights were infrequent for both new admissions and residents with weight loss. Additionally, the dietician recommended a nutritional supplement to be given three times daily to address the resident's weight loss, but this recommendation was not communicated to the physician, and no corresponding physician's order was found in the medical record. The only supplement order present was for a different dosing schedule and duration. The dietician confirmed that the lack of a physician's order for the recommended supplement was due to an oversight. These failures resulted in the resident not receiving the recommended nutritional intervention and not being monitored according to policy after significant weight loss.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
