Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Sandy Springs Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
Kitchen staff failed to wash hands before putting on gloves, changed gloves without handwashing after wiping a cart, and a staff member with a beard was observed without a beard cover near the serving area. In addition, refrigerator and freezer temperature logs were missing entries for multiple shifts, and the RD and DM confirmed the temperatures should have been recorded.
Infection control practices were not followed during a COVID outbreak on a unit with multiple positive residents. Staff had inconsistent masking practices, outbreak testing and tracking were not clearly documented or communicated, and a CNA moved the same wipes between rooms while carrying clean linen against her uniform. A DH also took an entire dental cart with supplies into resident rooms, including isolation rooms.
Failure to inform a resident’s representative about psychotropic meds: A resident with anxiety disorder, bipolar disorder, and severe cognitive impairment was ordered aripiprazole, buspirone, and paroxetine via feeding tube, but the EMR lacked documentation that the benefits, risks, and alternatives were explained. The family member said they were not informed of the medication changes, and facility leadership confirmed the information had not been provided.
Failure to Provide Written Advance Directive and Treatment Rights Information: The facility did not ensure written information about advance directives and the right to accept or refuse medical and surgical treatment was provided to a resident or the resident representative. The resident had severe cognitive impairment, and review of the EMR plus staff interviews confirmed the admission packet with the required information was not in the record.
Failure to Provide Transfer, Bed-Hold, and Discharge Documentation: The facility did not provide written transfer/discharge notices or bed-hold information to several residents or their representatives when residents were sent to the hospital, despite policies requiring notice of the reason for transfer, appeal rights, and Ombudsman contact information. The DON stated the facility had been sending an eInteract transfer summary instead. The facility also failed to complete required discharge documentation for a resident discharged AMA, including medication reconciliation, final status summary, recapitulation of stay, and Ombudsman notification.
A resident admitted for spinal stenosis and post-surgical care did not receive a completed baseline care plan within 48 hours of admission. The EMR showed the baseline care plan was incomplete, and the resident stated she did not know the plan of care or what to expect. Staff, including an LPN unit manager and the Assistant Administrator, confirmed the baseline care plan was supposed to be completed and printed for the resident within 48 hours, but it was not.
A resident with severe cognitive impairment, incontinence, and total dependence for toileting had a UA, C&S ordered after staff noted a strong odor to the urine. Staff attempted to obtain the specimen by straight cath, but the wife refused the procedure and also would not allow Foley placement. No lab results were found, and staff stated the refusal was not documented or communicated to the CNP, and the order was not discontinued.
Pharmacy recommendations from a monthly med regimen review were not communicated to the physician or documented as addressed for a resident with anxiety disorder, bipolar disorder, and severe cognitive impairment. The review identified that discharge summary medications including metformin, metoprolol tartrate, and prasugrel were not active on the MAR, and the recommendations were only emailed to the DON and ADON without follow-up to the physician.
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.
Kitchen Hand Hygiene, Glove Use, and Temperature Log Deficiencies
Penalty
Summary
The facility failed to ensure kitchen staff washed hands and used gloves appropriately between task changes, and failed to ensure a staff member with a beard wore a beard cover while working near the serving table. During observations in the kitchen, Dietary Aide (DA)2 entered the kitchen and put on gloves without washing hands. DA3 was observed standing near the serving table without a beard cover. Later, DA2 and DA3 re-entered the kitchen, went to the glove box, picked out gloves, and handled wrapped utensils and trays. DA2 also wiped the bottom of a cart with paper towels, removed gloves, reached into another box for new gloves, and put them on without washing hands. When interviewed, both aides stated they should have washed their hands when they came in, and DA2 stated he should have washed his hands before getting new gloves after wiping the cart.
Infection Control Failures During COVID Outbreak
Penalty
Summary
The facility failed to implement infection prevention and control practices during an active COVID outbreak on the [NAME] unit. The facility had 144 residents and had already identified multiple COVID-positive residents, with the first positive resident tested on 03/30/2026 and additional positives identified on 04/07/2026, 04/09/2026, and 04/12/2026. During entrance observations, a COVID outbreak sign was posted at the check-in desk, but there was no hand sanitizer at the front desk. The Assistant Administrator confirmed COVID was in the building with two new positive cases and stated N95 masks were being provided to staff. The DON did not know the masking policy during a COVID outbreak, and the IP was off work for the week, with the DON covering in her absence. The outbreak response was not clearly documented or consistently communicated. The DON later confirmed there were three positive COVID cases and eight new cases identified on 04/12/2026, for a total of 11 positive residents, 10 of whom were in the facility in isolation. The Administrator provided testing documentation for positive residents on the affected unit, but testing results for all residents on the [NAME] unit were not provided, and no testing information was provided for housekeeping staff or physical therapy staff who regularly entered resident rooms on that unit. During observation, RN1 had a mask dangling off one ear and LPN4 was standing at the medication cart in the hallway with no mask. RN1 stated LPN4 did not need to wear a mask in the hallway, only when entering an isolation room with airborne precautions. In addition, staff did not follow infection control practices while moving between resident rooms. CNA1 was observed taking the same package of wipes from one room to another and carrying clean unbagged linen to a resident room while holding it against her uniform. CNA1 stated she should not take wipes from one room to another, but she only had one package of wipes for the unit, and she did not know how clean linen was supposed to be transported. The Dental Hygienist was observed taking her entire dental cart into resident rooms, including rooms on the affected unit, and stated she took the cart into every room including isolation rooms because she could not leave it unattended. The cart contained mouth wash, toothbrushes, Cavi wipes, toothpaste, cleaning tools in plastic bins, paper dental drapes, and hand sanitizer.
Failure to Inform Resident Representative About Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the risks, benefits, and alternatives related to psychotropic medications were communicated to the resident or resident representative for one resident reviewed for unnecessary medications. The resident had diagnoses including anxiety disorder and bipolar disorder, and the comprehensive MDS indicated severe cognitive impairment with a BIMS score unable to be determined. Physician orders in the EMR included aripiprazole 10 mg via G-tube in the morning for manic behavior, buspirone 5 mg via G-tube twice daily for anxiety, and Paxil 10 mg via PEG-tube in the morning. Review of the EMR did not show documentation that information about the benefits, risks, and alternatives for aripiprazole, buspirone, and paroxetine had been communicated to the resident or resident representative. The resident’s family member stated they had not been informed by the facility or physician about the medication changes since readmission. The Quality Coordinator confirmed the facility did not inform the family about the benefits versus risks or alternatives for the psychotropic medications, and the Assistant Administrator confirmed the expectation that residents receiving psychotropic medications need to be informed of the benefits, risks, and possible alternative interventions before administration.
Failure to Provide Written Advance Directive and Treatment Rights Information
Penalty
Summary
The facility failed to ensure written information about the right to formulate an advance directive, change an advance directive, and accept and/or refuse medical and surgical treatment was provided to one resident or the resident representative. The deficiency was identified through staff interviews, record review, and facility policy review, which showed the facility policy required residents or resident representatives to be given information in an easy-to-understand manner about the right to refuse medical or surgical treatment and to formulate an advance directive. Resident 10 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, unspecified dementia, unspecified protein calorie malnutrition, and major depressive disorder. The quarterly MDS showed a BIMS score of 3 out of 15, indicating severely impaired cognition. Review of the EMR and interviews with the Social Service Director and Admissions Coordinator confirmed there was no evidence that written advance directive information or information about the right to accept or refuse medical and surgical treatment was provided to the resident or resident representative, and the admission packet containing that information was not present in the EMR.
Failure to Provide Transfer, Bed-Hold, and Discharge Documentation
Penalty
Summary
The facility failed to provide written transfer/discharge documentation and bed-hold information to residents and/or their representatives for four residents who were sent to the hospital. R27, who had diagnoses including atherosclerotic heart disease, unsteadiness on feet, urinary retention, manic episode, anemia, and pulmonary embolism without acute cor pulmonale, had a BIMS score of 9 and was transferred for severe toe pain and concern for osteomyelitis. R5, with diagnoses including hemiplegia and hemiparesis following cerebral infarction, COPD, and chronic systolic CHF, had a BIMS score of 10 and called 911 stating he was hurting and wanted to go to the hospital. R12, who had a BIMS score of 14 and intact cognition, was sent to the hospital for respiratory distress, and R4, who had a BIMS score of 15 and intact cognition, was sent to the hospital for right side abdominal pain. Review of each resident’s EMR did not reveal evidence that the resident or representative received written transfer/discharge notice or bed-hold notice. The facility policy titled, Bed Hold Prior to Transfer, stated written information regarding bed-hold practices is to be provided well in advance and at the time of transfer for hospitalization or therapeutic leave. The facility policy titled, Transfer and Discharge (including AMA), stated the transfer/discharge notice is to be provided in a language and manner the resident and representative can understand and include the reason for transfer or discharge, effective date, location, appeal rights, state appeal contact information, appeal form information, assistance information, Ombudsman contact information, and, when applicable, protection and advocacy contact information. During interview, the DON stated the facility had not been providing bed-hold notifications or transfer/discharge notices to residents or representatives when residents were sent to the hospital, and that the facility sent an eInteract transfer summary with the resident instead. The facility also failed to complete required discharge documentation for R158, who was discharged against medical advice. The EMR documented that R158 had diagnoses including CHF, panic disorder, and kidney failure, and that the resident left the facility AMA. Review of the record showed the resident departed with belongings, but there was no information regarding the disposition of medications. The record also lacked a recapitulation of the stay, a final summary of status, reconciliation of pre- and post-discharge medications, and notification of the Ombudsman of the discharge. The Corporate Compliance Officer stated the facility policy was to discharge residents with their medications or document destruction if the medications were not taken by the resident upon discharge.
Baseline Care Plan Not Completed or Shared Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was completed and shared with the resident within 48 hours of admission for one resident. The resident was admitted on 03/31/2026 with diagnoses including spinal stenosis of the lumbar region with neurogenic claudication and post surgical care. Review of the resident’s comprehensive MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Review of the resident’s EMR showed the baseline care plan was incomplete, with the general information section started but the Functional Status, Health Conditions, Dietary-Therapy-Social Services, and Care plan summary-signatures sections not completed. During interview, the resident stated she did not know what the plan of care was, what care to expect, and that no one had spoken to her about what to expect. Staff interviews confirmed that each new resident was to have a baseline care plan completed within 48 hours of admission and printed for the resident, and the Assistant Administrator confirmed that expectation, but the resident’s baseline care plan had not been completed within that timeframe.
Failure to Complete Ordered UA, C&S
Penalty
Summary
The facility failed to follow a physician's order for a UA, C&S for one resident. The resident was admitted with diagnoses including traumatic subdural hemorrhage with loss of consciousness, malignant neoplasm of the prostate, and diabetes mellitus. The resident's MDS assessment showed severe cognitive impairment, bilateral lower extremity impairment, and incontinence of both bladder and bowel. The care plan stated the resident was totally dependent on staff for toileting and required two staff with a mechanical lift for transfers. A progress note documented that the CNA reported the resident's urine had a strong odor, and the CNP then entered an order for a UA, C&S, with straight catheterization permitted. Review of the EMR showed no lab results for the ordered test. During interviews, staff stated the DON and another nurse attempted to obtain the specimen, but the resident's wife would not allow the straight catheter or Foley placement. Staff also stated there was no documentation or communication to the CNP that the specimen was not obtained, and the order was not discontinued. The CNP stated results were checked daily and that there should have been communication from staff so another plan could be made. The DON and RN also stated the refusal should have been documented and communicated.
Pharmacy Recommendations Not Communicated to Physician
Penalty
Summary
The facility failed to ensure that the March 2026 pharmacist medication regimen review recommendations were communicated to the resident's physician and that the results of that communication were documented in the medical record for one of five residents reviewed for unnecessary medications. The facility policy titled, Medication Regimen Review, required the pharmacist to communicate irregularities through verbal communication for urgent needs and written communication to the attending physician, Medical Director, and DON. In this case, the pharmacist's recommendations were emailed to the DON and ADON, but they were not followed up. Resident 1 was admitted on 04/25/2024 and readmitted on 02/10/2026 with diagnoses including anxiety disorder and bipolar disorder. The resident's MDS with an ARD of 02/25/2026 showed a BIMS score unable to be determined due to severe cognitive impairment. The March 2026 pharmacy review identified that the discharge summary recommended metformin 500 mg twice daily, metoprolol tartrate 25 mg twice daily, and prasugrel 10 mg daily, but these medications were not active on the MAR. During interviews, the DRC confirmed the pharmacy recommendations were not communicated to the physician, and the Assistant Administrator confirmed the expectation was that the recommendations were to be communicated to the physician for a response.
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.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Pruitthealth - Brookhaven | 1.8 mi | ★★★★★ | 19 | 0 |
| Perimeter Rehabilitation Suites By Harborview | 2.1 mi | — | 25 | 1 |
| Lenbrook | 3.1 mi | ★★★★★ | 2 | 0 |
| William Breman Jewish Home, The | 5.1 mi | ★★★★★ | 0 | 0 |
| Nurse Care Of Buckhead | 5.1 mi | ★★★★★ | 6 | 0 |
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