Savannah Post Acute Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Savannah, Georgia.
- Location
- 815 East 63 Street, Savannah, Georgia 31405
- CMS Provider Number
- 115120
- Inspections on file
- 21
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Savannah Post Acute Llc during CMS and state inspections, most recent first.
A respiratory nurse technician provided tracheostomy care to a resident with an indwelling medical device without wearing a gown, as required by the facility's Enhanced Barrier Precautions policy. Although the technician wore a mask and gloves, the omission of a gown was inconsistent with posted signage and staff expectations, resulting in a failure to adhere to infection control protocols.
A resident with morbid obesity and muscle weakness, requiring maximal assistance with toileting and always incontinent, was repeatedly provided with incontinence briefs that were too small due to supply shortages. This led to leakage, embarrassment, and the need for additional bathing. Staff and supply personnel confirmed the shortage of the correct size briefs and the use of improperly sized products, resulting in a failure to maintain the resident's dignity.
A resident with significant cognitive and medical impairments reported a sexual abuse allegation to a nurse, who documented the incident in the progress notes but did not notify other staff or the Administrator. This resulted in the allegation not being reported to the State Agency within the required timeframe, contrary to facility policy.
A resident who was transferred to the hospital on two occasions did not receive a written bed hold notice as required by facility policy. Although an LPN included a blank bed hold policy in the transport packet, nothing was given directly to the resident. The DON confirmed that the resident should have received written notification at the time of each transfer, but no documentation was found.
A resident's MDS assessment was not accurately coded to reflect a PASRR Level II evaluation and associated serious mental illness, despite documentation of relevant diagnoses and an existing PASRR Level II approval. The MDS Coordinator was unaware of the resident's PASRR Level II status, leading to the deficiency.
A resident with documented bipolar disorder and anxiety disorder was not referred for a required PASRR Level II assessment. Review of the MDS and EMR confirmed the absence of the assessment, and the administrator verified that the necessary submission had not been made.
The facility did not develop or implement person-centered care plans for oxygen therapy as required, resulting in one resident lacking oxygen interventions in their care plan and two residents receiving oxygen at higher flow rates than ordered. Staff confirmed that care plan interventions were not addressed or followed, despite physician orders and documented care needs.
A resident with significant lower extremity impairment and a care plan requiring leg elevation was repeatedly observed in a wheelchair without a leg rest or footrest, leaving his right leg unsupported. The resident could not attach the device independently and did not receive staff assistance, despite staff acknowledging the necessity of the support due to his medical conditions.
Three residents with respiratory conditions were administered oxygen at flow rates higher than those ordered by their physicians. Staff, including an RT and LPN, acknowledged the discrepancies, and the DON confirmed that oxygen was not provided according to orders. Facility policy required verification and adherence to physician orders for oxygen administration.
Several residents with intact cognition reported not being offered meal choices when eating in their rooms, receiving only the meal provided or a peanut butter and jelly sandwich as an alternative. Observations showed discrepancies between posted menus, tray tickets, and actual meals served, with residents not informed of their options. The Dietary Manager and Administrator confirmed these practices did not align with facility policy.
A resident with dementia and cognitive impairments exhibited wandering and exit-seeking behaviors, but the facility failed to include these issues in the care plan until after the resident eloped. The facility's policy requires comprehensive care plans, but staff confirmed the absence of interventions for elopement prior to the incident.
A resident with dementia and cognitive impairments eloped from the facility and was unaccounted for over an hour due to inadequate supervision and failure to follow the elopement risk policy. The resident exhibited exit-seeking behavior, but no elopement risk assessment or alarm was in place. The front door was not properly secured, and staff were not consistently present to monitor it, allowing the resident to exit unnoticed.
The facility failed to ensure adequate nursing staff for the first quarter of 2024, resulting in a One-Star Staffing Rating due to issues such as failure to submit PBJ data by the deadline and more than four days without RN staffing hours. The deficiency had the potential to adversely affect the care and services provided to the 109 residents.
The facility failed to ensure that three of four Certified Medication Aides (CMAs) completed a Medication Administration Competency Skills Checklist before administering medications to residents. Interviews and document reviews revealed missing competency checklists, and both the Director of Nursing (DON) and Administrator were unaware of the oversight.
The facility failed to maintain kitchen cleanliness and equipment maintenance, with observations of grease buildup, rust, and expired quaternary test strips. Interviews revealed a lack of a cleaning schedule and inadequate deep cleaning. The VP of Clinical Operations confirmed the deficiencies and emphasized the need for proper maintenance.
The facility failed to maintain the outdoor garbage and refuse area in a sanitary manner, with two dumpsters found open and surrounded by uncompressed empty boxes and visible trash bags. The District Manager confirmed that the previous day's dumpster pick-up had not been made, and the kitchen staff was responsible for maintaining the dumpsters.
The facility failed to ensure proper infection control practices were followed during a COVID-19 outbreak. Staff did not change masks when entering and exiting COVID-19 TBP rooms and left TBP room doors open, despite the facility's policies. Interviews revealed a lack of awareness and adherence to these policies.
The facility failed to periodically review antibiotic prescribing practices and did not document follow-up measures for infection control data over 12 months. The Antibiotic Stewardship Log lacked documentation, and the Antibiotic Medications Reports did not include necessary details such as organism susceptibility or if infections met McGeers criteria. The DON confirmed that trending, surveillance, and monthly infection control meetings were not conducted.
The facility failed to designate a qualified Infection Control Preventionist (ICP) for two of the last 12 months and did not ensure that the staff assigned to the role had enough time to perform ICP responsibilities for six of the last 12 months. Infection tracking and trending were not completed since November 2023, and monthly infection control meetings were not conducted. The DON admitted to not having enough time to manage the program effectively while performing her dual roles as DON and ICP, and she was not adequately trained in the Infection Control program.
The facility failed to complete 42 out of 101 grievance forms, resulting in unresolved grievances and dissatisfaction among residents. Interviews revealed that residents did not receive follow-up or resolution for their grievances, and some were unaware of the grievance process. The Administrator confirmed the ineffectiveness of the grievance process.
The facility failed to ensure that three residents did not have unsecured and unauthorized medication or medicated treatment products at their bedside. Medications were found unsecured in the rooms of residents who had not been assessed for self-administration, posing potential risks. Staff were unaware of the presence of these medications, and the DON confirmed that no residents had been assessed for safe self-administration.
The facility failed to post a complete listing of how to report abuse, including necessary contact details and instructions. Observations revealed the posted information only included a phone number. Most residents were unaware of what to report or how to report it, and the DON confirmed the posting lacked essential details.
The facility failed to report the misappropriation of property to the State Survey Agency for two residents who were investigated for abuse. Both residents reported missing money, but the grievances were not reported to the State Agency as required by the facility's policy. Interviews revealed that the facility did not follow its reporting process.
The facility failed to thoroughly investigate abuse and misappropriation allegations for four residents. Key personnel were not informed, and proper procedures for investigation and documentation were not followed, leaving residents without resolution or communication regarding their concerns.
The facility failed to develop or implement comprehensive care plans for three residents, leading to potential risks for medical complications and unmet needs. One resident lacked a care plan for contracture management and had undocumented oxygen therapy. Another resident's dialysis care plan was not followed due to missing communication forms. A third resident did not have a care plan for oxygen therapy despite relevant diagnoses. The DON and an LPN confirmed these deficiencies.
The facility failed to provide scheduled baths or showers for a resident with multiple diagnoses, including muscle weakness and bilateral below-the-knee amputations. Despite the resident's care plan indicating the need for supervision with minimal assistance for ADL care, documentation revealed that the resident only received two showers in the past 25 days. Interviews confirmed the resident had not received a shower in two weeks, and the Director of Nursing acknowledged the failure to adhere to the bathing schedule.
A resident readmitted with multifocal pneumonia did not receive prescribed Levaquin due to a failure in transcribing the medication order. The delay in administering the antibiotic was acknowledged by both the LPN and DON, who confirmed the oversight and lapse in care.
A resident with limited ROM did not receive the necessary PROM exercises and splint application as required by her condition. Staff were unaware of the resident's needs, and the facility's policy on contracture management was not followed, resulting in the resident not receiving the necessary care to prevent worsening contracture.
The facility failed to provide proper respiratory care for four residents, including not ensuring current physician's orders for oxygen therapy, not maintaining clean oxygen concentrators and filters, not providing humidification for oxygen therapy, and not documenting daily tracheostomy inner cannula changes. Staff interviews confirmed these deficiencies.
The facility failed to ensure ongoing communication and collaboration with the dialysis center for a resident requiring dialysis services. Despite a policy mandating the completion and submission of dialysis communication forms, the forms were missing and not being sent to the dialysis clinic. Staff interviews confirmed the deficiency, and the dialysis clinic had stopped following up after repeated failures to receive the forms.
Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to ensure that respiratory staff followed infection control practices during tracheostomy care for a resident with a tracheostomy. According to the facility's Enhanced Barrier Precautions (EBP) policy, staff are required to wear gowns and gloves during high-contact care activities, such as tracheostomy care, for residents with indwelling medical devices. Observation revealed that the respiratory nurse technician provided tracheostomy care to a resident who was dependent for activities of daily living and had multiple diagnoses, including respiratory failure, without wearing a gown as required by the EBP protocol. The technician wore only a mask and gloves during the procedure, despite signage on the resident's door indicating the need for both gown and gloves. Interviews with staff confirmed inconsistent understanding and implementation of the EBP requirements. The respiratory nurse technician stated that he wore a gown only for residents on contact isolation precautions, not for those on EBP, while another respiratory nurse technician and the Director of Nursing both indicated that a gown should be worn during tracheostomy care for residents on EBP. This inconsistency in following established infection control protocols led to the deficiency identified during the survey.
Failure to Provide Correct Size Incontinence Briefs Compromises Resident Dignity
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced the dignity and respect of a resident who required maximal assistance with toileting hygiene and was always incontinent of bladder and bowel. The resident, who had diagnoses including morbid obesity and muscle weakness, reported that the facility often ran out of the correct size incontinence brief, resulting in the use of a smaller size that caused leakage. This situation led the resident to feel embarrassed and to request a bath each time leakage occurred. Staff interviews confirmed that residents were measured for brief size and that there were occasions when the correct size was unavailable, leading to the use of briefs from other residents' supplies, which might not fit properly. The Central Supplies Clerk acknowledged that the facility was running out of the 3x-size briefs, and the Administrator was aware that the resident was receiving a smaller brief than needed. The care plan for the resident included regular checks and provision of incontinence care, but the lack of appropriate supplies resulted in a failure to uphold the resident's dignity.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident. According to the facility's policy, any allegation of neglect, exploitation, mistreatment, or misappropriation of resident property must be reported to the State Regulatory Agency within 24 hours. However, a review of the clinical record and incident report revealed that a resident, who was unable to complete a cognitive interview and had diagnoses including schizophrenia, diabetes mellitus with hyperglycemia, and muscle weakness, reported to the nurse's station that a man was in her room and attempted to sexually assault her. The nurse who received this report only documented the incident in the progress notes and did not notify other staff or the Administrator. As a result, the allegation was not reported to the State Agency within the required timeframe. The Assistant Director of Nursing confirmed that the delay occurred because the nurse failed to follow reporting procedures, and the Administrator acknowledged that the incident was not reported as required by policy. There was no documentation indicating that the abuse allegation was communicated to appropriate personnel or authorities in a timely manner.
Failure to Provide Written Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to one resident during two separate transfers to the hospital. According to the facility's Bed Hold and Returns Policy, residents and their representatives are to receive written information prior to transfer that details their rights and limitations regarding bed holds, the reserve bed payment policy, and the facility per diem rate for holding a bed. Review of the resident's clinical record showed no evidence that such a notice was provided during either transfer. The resident, who was cognitively intact and acted as his own responsible party, confirmed in an interview that he did not receive a written bed hold notice on either occasion. Staff interviews revealed that the process for providing bed hold information was not consistently followed. An LPN stated that while she included a blank bed hold policy in the packet sent with transport, she did not provide anything in writing directly to the resident. The DON confirmed that the resident should have received a written bed hold policy at the time of each transfer and acknowledged that there was no record of this occurring for the resident in question.
Inaccurate MDS Coding for PASRR Level II Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with a Pre-Admission Screening and Resident Review (PASRR) Level II. Review of the resident's annual MDS indicated that Section A did not reflect that the resident had been evaluated by Level II PASRR and determined to have a serious mental illness or related condition, despite Section I documenting diagnoses such as anxiety disorder, depression, and bipolar disorder. Further review of the electronic medical record confirmed the resident's admission and a PASRR Level II approval date. During staff interview, the MDS Coordinator acknowledged being unaware of the PASRR Level II approval for the resident, resulting in the inaccurate coding on the MDS.
Failure to Complete PASRR Level II Assessment for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with diagnoses of bipolar disorder with psychotic features and anxiety disorder received a required Pre-Admission Screening and Resident Review (PASRR) Level II assessment. Review of the resident's Annual Minimum Data Set (MDS) and electronic medical record (EMR) showed no evidence of a PASRR Level II evaluation, despite documentation of serious mental illness. The resident was not included on the facility's list of individuals with PASRR Level II, and the administrator confirmed that no submission for the assessment had been made, even though it was required based on the resident's diagnoses.
Failure to Develop and Implement Person-Centered Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for residents receiving oxygen therapy, as required by their own policy. For one resident with diagnoses including COPD and acute respiratory failure with hypoxia, the care plan did not include any interventions for the use of oxygen, despite a physician's order for continuous oxygen at 2 liters per minute (LPM) via nasal cannula. Observations showed this resident was receiving oxygen at a higher flow rate of 3.5 LPM. For two other residents with similar respiratory diagnoses and physician orders for oxygen at 2 LPM, care plans did include interventions for oxygen use, but staff did not follow these interventions, as both residents were observed receiving oxygen at 3.5 LPM instead of the ordered rate. Staff interviews confirmed that the care plan interventions were not addressed or followed for these residents, and the MDS Coordinator acknowledged that the care plan serves as a blueprint for nursing care. The failure to develop and implement appropriate, individualized care plans for oxygen therapy was identified through review of medical records, care plans, physician orders, and direct observation of care.
Failure to Provide Wheelchair Leg Rest Support for Resident with Lower Extremity Impairment
Penalty
Summary
A resident with multiple medical conditions, including peripheral vascular disease, a stage four pressure ulcer, contracture of the right knee, hemiplegia, and an above-knee amputation, was observed on several occasions sitting in a wheelchair without a supportive leg rest or footrest. The resident was seen propelling himself in the hallway and sitting in various areas of the facility with his right lower extremity elevated and unsupported, despite having a care plan intervention to elevate his legs when sitting. The resident reported that he had a leg rest with an attached footrest but was unable to attach it himself and did not receive assistance from staff. Staff interviews confirmed that the resident should not be positioned in his wheelchair without the leg rest/footrest due to his medical conditions, including an ankle ulcer and contracture. The DON stated she was unaware that the device was not attached and that it was the responsibility of nursing staff to ensure the leg rest/footrest was applied daily. The failure to provide and secure the supportive device as required resulted in the resident repeatedly being left without necessary support for his lower extremity.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
Staff failed to administer oxygen therapy to three residents in accordance with physician orders. For one resident with COPD and acute respiratory failure, observations showed oxygen was delivered at 3.5 LPM via nasal cannula, despite a physician order for 2 LPM continuously. Another resident with COPD was observed receiving oxygen at 4.5 LPM, while the physician order specified 2 LPM. The respiratory therapist acknowledged increasing the flow rate due to a low oxygen saturation reading but confirmed this was not per the physician's order. The Director of Nursing confirmed that both residents were receiving oxygen at incorrect flow rates and stated that staff should not alter oxygen flow without a physician's order. A third resident, with COPD and chronic respiratory failure, was observed receiving oxygen at 3.5 LPM, though the physician order was for 2 LPM. The resident reported that the oxygen had been set at 3.5 LPM since admission, and a nurse confirmed the discrepancy between the order and the administered flow rate. The nurse also stated that it was the responsibility of nursing staff to ensure the correct oxygen flow rate. These findings were based on observations, staff interviews, and review of medical records and facility policy.
Failure to Offer Meal Choices and Follow Menus
Penalty
Summary
The facility failed to ensure that residents were offered meal choices and that menus were followed as required by policy. Multiple residents with little to no cognitive impairment reported that when they received meals in their rooms, they were not given a choice of food, and the only alternative offered was a peanut butter and jelly sandwich. Residents stated they received whatever the facility provided without being informed of the menu or given an opportunity to select their meals. This lack of choice was specifically noted for residents who ate in their rooms, while those who ate in the dining room were able to make meal selections. Additionally, there were discrepancies between the meals listed on the posted menus, the meal tray tickets, and the actual food served to residents. For example, one resident was served meals that did not match either the tray ticket or the posted menu on two separate occasions. The Dietary Manager confirmed that residents receiving meals in their rooms were not informed of their meal options and could not explain the inconsistencies between the posted menus, tray tickets, and meals served. The Administrator acknowledged that all residents should be informed of the menu and offered alternatives, and that the posted meals should be served as written.
Failure to Develop Care Plan for Wandering Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of wandering and exit-seeking behaviors, which increased the potential for the resident not to receive appropriate treatment and care. The facility's policy on Person Centered Care Plans mandates that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and implemented for each resident, addressing their physical, psychosocial, and functional needs. However, the resident's care plan lacked focus areas, goals, or interventions for wandering or elopement until after an incident occurred. The resident, diagnosed with dementia and other cognitive impairments, exhibited wandering behavior and exit-seeking tendencies, as documented in the clinical records and staff interviews. Despite these behaviors being noted, the care plan did not include interventions for elopement until after the resident was found outside the facility. Interviews with the Director of Nursing, the Administrator, and the MDS Coordinator confirmed the absence of a care plan addressing these behaviors prior to the incident, highlighting a delay in assessing the resident for elopement risks.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and protective oversight to prevent the elopement of a resident diagnosed with dementia and other cognitive impairments. The resident, identified as R1, was able to exit the facility and remain unaccounted for by staff for over an hour. The facility's policy on elopement risk and prevention was not followed, as no elopement risk assessment was completed for R1 prior to the incident, despite documented behaviors indicating a risk of wandering and exit-seeking. On the day of the incident, R1 exhibited increased agitation and confusion, expressing a desire to leave the facility and return home. Staff interviews revealed that R1 had a history of asking to go home and had been confused for several months. Despite these behaviors, no wander or elopement alarm was used for R1, and the resident was able to leave the facility through the front door, which was not properly secured. The front exit door had a delay in latching, and staff were not consistently present to monitor the door, allowing R1 to exit unnoticed. Interviews with staff indicated a lack of training and awareness regarding elopement prevention. The receptionist, who was responsible for monitoring the front door, was not present at the time of R1's exit, and the door was not locked. Maintenance staff were unaware of the door's malfunction until after the incident. The Director of Nursing confirmed the delay in assessing R1 for elopement risk, and the facility's failure to ensure staff presence at the front door contributed to the resident's unsupervised departure.
Inadequate Nursing Staff for Q1 2024
Penalty
Summary
The facility failed to ensure adequate nursing staff for the first quarter of 2024, as evidenced by a review of the Payroll-Based Journal (PBJ) Staffing Data Report and the Facility Assessment Tool 2024. The PBJ Staffing Data Report for Quarter 1 2024 revealed that the facility triggered a One-Star Staffing Rating due to several issues, including failure to submit PBJ data by the deadline, more than four days in the quarter without Registered Nurse (RN) staffing hours, and failure to respond to or pass a CMS audit designed to discover discrepancies in PBJ data. The Facility Assessment Tool 2024 indicated that the average daily census was 106 to 109 residents, and the staffing plan documented the number of staff available to meet residents' needs, which included eight licensed nurses for days and four for evenings, 12 CNAs for days and eight for evenings, four to six CNAs for nights, and one to two CMTs available for care during those shifts. Interviews with the Director of Nursing (DON) and the Nursing Scheduler (NS) III revealed that they were aware of the facility's one-star staffing rating for the first quarter of 2024, attributing it to the facility's high turnover rate and reliance on staffing agencies. The Administrator also acknowledged awareness of the one-star staffing rating. The deficient practice had the potential to adversely affect the care and services provided to the 109 residents residing in the facility.
Failure to Ensure Medication Administration Competency for CMAs
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) met professional standards of quality by not providing evidence that three of four CMAs completed a Medication Administration Competency Skills Checklist before being allowed to administer medications to residents. This deficiency was identified through staff interviews and a review of facility documents, which revealed that the required competency checklists were missing for the majority of the CMAs employed at the facility. The facility's document titled Certified Medication Aide Bi-Annual Checklist indicated that an RN or Pharmacist should conduct an annual competency assessment, but this was not adhered to for three of the four CMAs reviewed. Interviews with the CMAs and the Director of Nursing (DON) confirmed the lack of completed competency checklists. One CMA stated she had only been observed once by a consultant pharmacist since being hired, while another CMA reported not having completed any medication administration skills checkoff. The DON acknowledged awareness of the requirement but could not provide additional information or documentation to confirm the completion of the checklists. The Administrator was also unaware that the CMAs had not completed the required checkoffs, indicating a lapse in oversight and adherence to the facility's own policies and procedures.
Kitchen Cleanliness and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure that the kitchen walls, floors, and equipment were clean and free of rust, debris, and grease buildup, and also failed to use un-expired quaternary test strips in the three-compartment sink. Observations revealed a sticky, brown, greasy substance and debris behind the oven and surrounding area, a dusty ventilation unit on the juice machine, and a build-up of rust and dust on the fire extinguisher located next to the handwashing sink. Additionally, water puddles were observed on the floor near the three-compartment sink, and the water from the handwashing sink would not turn off completely. The Food Service Manager (FSM) confirmed these observations. Expired quaternary test strips were also found in use at the three-compartment sink, which was confirmed by the FSM. Interviews with dietary aides revealed a lack of a cleaning list or schedule, and it was noted that water was usually present on the floor around the sinks. The FSM stated that although staff did a lot of scrubbing and cleaning, the grease and grime buildup was due to the old building. Dietary aides confirmed that they had never seen anyone clean the ventilation units or filters, nor had they observed deep cleaning or repairs in the kitchen. During a walk-through, the VP of Clinical Operations confirmed that the kitchen was not clean and needed deep cleaning, and that the fire extinguisher near the hand-washing sink needed cleaning. The VP expressed expectations that dietary staff should maintain cleanliness in the kitchen and ensure all equipment is in good working condition.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure the outdoor garbage and refuse area was free of litter and maintained in a sanitary manner for two of two dumpsters. During an initial observation, the Food Service Manager and the District Manager verified that the dumpsters were open and filled with visible black trash bags and boxes. Additionally, uncompressed empty boxes were found surrounding the dumpsters. The District Manager and FSM confirmed that the dumpsters should have been closed and free of trash or boxes on the ground around them. In an interview, the District Manager confirmed that the previous day's dumpster pick-up had not been made, and the Maintenance Director had called for an alternative pick-up. The District Manager also confirmed that maintaining the dumpsters was the kitchen staff's responsibility. The facility's policies on garbage disposal and environmental maintenance were reviewed, revealing that the procedures were not followed as required, leading to the observed deficiencies.
Failure to Follow Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper infection control practices were followed to prevent the transmission and spread of COVID-19. Specifically, staff did not change their masks when entering and exiting COVID-19 Transmission-Based Precaution (TBP) rooms and did not close the doors of two COVID-19 TBP rooms during care. Observations revealed that staff, including a Restorative Aide, Certified Nursing Assistants (CNAs), and a housekeeper, repeatedly left TBP room doors open and did not change their masks as required by the facility's policies. These actions occurred despite the facility being in an outbreak status, with 31 residents and 11 staff members testing positive for COVID-19. Interviews with staff indicated a lack of awareness and adherence to the facility's infection control policies. For instance, a Restorative Aide admitted she did not realize the TBP room doors were open and acknowledged that they should remain closed. Additionally, a CNA revealed she had not received updated COVID-19 or infection control education since the current outbreak began. The Director of Nursing (DON) confirmed that she was only recently made aware of the issue with the TBP room doors being left open and stated that staff were re-educated on the importance of containing the spread of infections and illness.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices and did not document follow-up measures in response to the data for 12 of 12 months of infection control data reviewed. The facility's policy titled Antibiotic Stewardship, dated 2/1/2024, stated that antibiotics would be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program. However, the facility's Antibiotic Stewardship Log lacked documentation for several months, and there was no testing data to determine if infections met the McGeers criteria or were facility or community-acquired. Additionally, the Antibiotic Medications Reports from the pharmacy did not document the organism, if a culture was performed, or the organism's susceptibility to the prescribed antibiotic, nor did it indicate if the McGeers criteria were met or if the infection was a true infection. The facility's calculated infection rate was the only documented data for April 2023 through March 2024. The Director of Nursing (DON) confirmed that the program's trending, surveillance, and monthly calculation rates were not being monitored, and monthly infection control meetings were not conducted in the facility. The President of Clinical Services revealed that the Infection Control Program, particularly the Antibiotic Stewardship Program, did not utilize floor plan mapping effectively or track organisms and perform surveillance. She had educated the DON on the process but had not followed up to see if it was implemented. The DON stated that there had not been a specific person monitoring the Antibiotic Stewardship Program since December 2023.
Failure to Designate and Support Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to the role of Infection Control Preventionist (ICP) for two of the last 12 months and did not ensure that the staff assigned to the role had enough time to perform ICP responsibilities for six of the last 12 months. This deficiency was identified through record reviews, staff interviews, and a review of the facility document titled Healthcare Center Infection Preventionist. The facility's infection surveillance documentation was missing from November 2023 to April 2024, and there were no line listings for infectious illnesses for January, February, and March 2024. The Director of Nursing (DON) and the newly appointed ICP confirmed that infection tracking and trending had not been completed since November 2023, and monthly infection control meetings were not conducted during this period. The DON admitted to not having enough time to manage the program effectively while performing her dual roles as DON and ICP, and she was not adequately trained in the Infection Control program. The DON stated that she was responsible for infection control from March 2023 through December 2023, and a staff member who is no longer employed by the facility was responsible for infection control in January 2024. No one was responsible for infection control from February 2024 through March 2024, and the new ICP began the position in April 2024. The DON also mentioned that she had requested help from the Corporation's President but did not receive adequate support. The lack of proper infection surveillance and documentation, along with the absence of a designated and trained ICP, contributed to the facility's failure to maintain an effective Infection Prevention program, potentially putting all residents at risk of infectious diseases. The facility had a census of 109 residents at the time of the survey.
Incomplete Grievance Forms and Lack of Follow-Up
Penalty
Summary
The facility failed to thoroughly complete resident grievance forms, resulting in unresolved grievances and dissatisfaction among residents. A review of 101 grievance forms revealed that 42 were incomplete, lacking evidence of thorough investigation, resolution, and follow-up to ensure resident satisfaction. During a Resident Council Meeting, several residents reported that they had filed grievances but did not receive any follow-up or resolution. Some residents were unaware of the grievance process altogether. Interviews with staff, including the Activity Director and the Administrator, confirmed that the grievance process was ineffective. The Activity Director mentioned that she would submit complaints to the Administrator if residents reported no follow-up. The Administrator, who started working at the facility on 2/5/2024, acknowledged the problem with the grievance process and confirmed that no effective process was in place when she began her tenure. The deficiency had the potential to adversely affect any resident who filed a grievance.
Unsecured and Unauthorized Medications at Bedside
Penalty
Summary
The facility failed to ensure that three residents (R30, R32, and R71) did not have unsecured and unauthorized medication or medicated treatment products at their bedside. For R30, a bottle of fluticasone was found unsecured on the bedside table, and the resident had not been assessed for self-administration of medication. The Infection Control Preventionist confirmed the presence of the medication but did not remove it, and the Director of Nursing confirmed that R30 was not assessed for self-administration. Licensed Practical Nurses were unaware of the medication at the bedside and confirmed that R30 was not assessed for self-administration. For R32, a container of Alka Seltzer Cold Medicine and a jar of Zinc Oxide Skin Protectant cream were found unsecured on the bedside table. R32 had a moderate cognitive impairment and had not been assessed for self-administration of medication. The medications were removed by an LPN who confirmed that the resident was not assessed for self-administration and that the zinc oxide ointment was not ordered. For R71, a bottle of rubbing alcohol and a bottle of hydrogen peroxide were found unsecured on the bedside nightstand. The resident had not been assessed for self-administration of medication, and the LPN confirmed the unsecured medications and removed them. The DON stated that no residents in the facility had been assessed for safe self-administration of medications.
Incomplete Abuse Reporting Information
Penalty
Summary
The facility failed to post a complete listing of how to report abuse and the types of abuse, including a mailing address, email address, and information on how to report to the State Agency in a manner accessible to residents and visitors. During the initial tour and daily walks throughout the building, it was observed that the posted information only included a phone number for the Georgia Department of Community Services. During a Resident Council Meeting, the majority of residents did not know what information to report or how to report it, and none could identify the location of the posting. The Director of Nursing confirmed the posting lacked the correct agency name, address, telephone number, and detailed instructions on reporting different types of abuse. The Administrator also confirmed the incomplete information on the sign and acknowledged the issue.
Failure to Report Misappropriation of Property
Penalty
Summary
The facility failed to report the misappropriation of property to the State Survey Agency (SSA) for two residents who were investigated for abuse. Resident 41 reported missing six hundred dollars, which he claimed to have handed to the receptionist upon admission. The Social Service Assistant (SSA) documented the grievance but did not report it to the Social Services Director (SSD) or the State Agency. Similarly, Resident 45 reported missing $7.80, which she had placed in her bra. The SSA documented this grievance but also failed to report it to the State Agency. Both grievances were not signed or dated by the Administrator, indicating a lapse in the reporting process. Interviews with the residents, SSA, Director of Nursing (DON), and the Administrator revealed that the facility did not follow its policy for reporting allegations of misappropriation of property. The DON was unaware of the missing money incidents, and the Administrator did not recall being informed about them. The facility's policy required that such allegations be reported to the State Agency within 24 hours, but this was not done. The Administrator acknowledged that the initial report should have been filed with the State Agency, the police notified, and a five-day follow-up report sent to the State office after the investigation.
Failure to Investigate Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to ensure that abuse allegations, specifically an allegation of physical abuse and allegations of misappropriation of resident property, were thoroughly investigated for four residents. The facility's policy required that all allegations be investigated and documented, but this was not done in several instances. For example, a resident with severe cognitive impairment reported physical abuse, but the investigation was not documented, and key personnel were not informed. The Director of Nursing (DON) and the Administrator were unaware of the incident, and the Social Services Director (SSD) admitted to not following proper procedures for investigation and documentation. Another resident with moderate cognitive impairment reported missing $600, but the investigation was incomplete. The Social Service Assistant (SSA) checked the facility's safe but did not follow up further or inform the resident about the investigation's outcome. The grievance form was not signed by the Administrator, and the resident was left without any resolution or communication regarding the missing money. Two other residents also reported missing money, but their allegations were not thoroughly investigated. One resident reported $7.80 missing, and the SSA did not document interviews with other residents or staff. Another resident reported $36 missing, and the SSD did not document the investigation or interview staff who had access to the resident's room. The DON and the Administrator were unaware of these incidents, and the facility did not follow its policy for investigating and documenting such allegations.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop or implement comprehensive, person-centered care plans for three residents, leading to potential risks for medical complications and unmet needs. For one resident, the facility did not develop a care plan for contracture management despite the resident's diagnoses of hemiplegia, hemiparesis, and functional quadriplegia. Additionally, the care plan for oxygen therapy was not followed, as evidenced by the lack of documentation for oxygen administration and oxygen saturation checks. The Director of Nursing (DON) confirmed these deficiencies during an interview, acknowledging the absence of a contracture management care plan and the failure to document respiratory care interventions. Another resident's care plan for dialysis was not properly implemented, as there were no current dialysis communication forms in the electronic medical record (EMR), with the last one filed several months prior. The DON confirmed that the care plan interventions were not being followed due to the lack of communication with the dialysis center. Additionally, a third resident did not have a care plan for oxygen therapy despite having diagnoses of acute respiratory failure and pneumonia. The DON and a Licensed Practical Nurse (LPN) both verified the absence of the care plan, and the Administrator was unaware of this deficiency. These failures indicate a lack of adherence to the facility's policy on developing and implementing individualized care plans.
Failure to Provide Scheduled Baths or Showers
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADL), specifically baths or showers, for one resident (R5) out of 54 sampled residents. The facility's policy titled Bathing-Shower, effective 2/1/2024, outlines the purpose and procedure for bathing residents, including providing the opportunity to bathe according to preference and revising the bathing plan as needed. Despite this policy, R5, who has multiple diagnoses including muscle weakness, type 2 diabetes mellitus, and bilateral below-the-knee amputations, did not receive the required assistance with bathing. R5's care plan, revised on 3/7/2024, indicated the need for supervision with minimal assistance for ADL care, including bathing. However, documentation revealed that R5 only received two showers in the past 25 days, and there was no record of any baths from April 1, 2024, to April 6, 2024. Interviews with R5 confirmed that he had not received a shower in two weeks, despite being scheduled for showers twice a week. The Director of Nursing (DON) confirmed that bath sheets, which track when showers or baths are given, were completed for all residents, and any refusals were to be documented and reported for care plan revisions. However, the DON acknowledged that only two bath sheets were completed for R5 in the last 25 days, indicating a failure to provide the scheduled baths or showers. Interviews with Certified Nursing Assistants (CNAs) revealed that staff generally followed the bath schedule, but if a bath sheet was not completed, it meant the shower or bath was not provided. This failure to adhere to the bathing schedule and properly document care placed R5 at risk for unmet needs and a diminished quality of life.
Failure to Transcribe and Administer Antibiotic Medication Order
Penalty
Summary
The facility failed to transcribe and administer an antibiotic medication order for a resident (R49) as prescribed by the physician, resulting in a delay in treatment. R49 was readmitted to the facility from an acute care hospital with a diagnosis of multifocal pneumonia and a discharge medication list that included Levaquin 750 mg daily for five days starting on 4/5/2024. However, the medication order was not transcribed into the electronic medical record (EMR) upon the resident's return, and the medication was not administered until 4/10/2024, five days after the prescribed start date. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) revealed that the floor nurses were responsible for transcribing physician orders when residents returned from hospital stays. The LPN acknowledged the oversight and confirmed that the order for Levaquin was not entered into the EMR until 4/10/2024. The DON also acknowledged the lapse in care due to the delay in transcribing the medication order, which resulted in the resident not receiving the necessary antibiotic treatment in a timely manner.
Failure to Provide Necessary PROM and Splinting for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received the necessary passive range of motion (PROM) exercises and splint application to address her condition. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed multiple times without any splint or device in her hands to prevent contracture. The facility's policy on contracture management was not followed, as the resident was not on the restorative caseload and did not receive the required PROM or splinting services as indicated by her condition and previous therapy recommendations. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for PROM and splinting. The Restorative Aides and Licensed Practical Nurse (LPN) responsible for the Restorative Nursing Program were unaware that the resident required these services. The Certified Nursing Assistants (CNAs) assigned to the resident did not perform or document the necessary exercises and splint application. The Rehabilitation Manager confirmed that the resident would benefit from therapy services and needed ROM for her left hand and an orthotic device for her right hand, but no referrals for screening had been made by the nursing department. The Director of Nursing (DON) acknowledged that the resident should have remained on the Restorative Nursing Program if a splint was required and that nursing staff should have informed her of any changes in the resident's condition. The DON was unaware that the resident no longer received PROM and splinting for her right hand or that her left hand had limited ROM. This lack of communication and adherence to the facility's policy resulted in the resident not receiving the necessary care to maintain or improve her ROM, potentially leading to worsening contracture, pain, or skin breakdown.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for four residents receiving respiratory services. Specifically, the facility did not ensure there was a current physician's order for oxygen therapy and oxygen saturation checks before administering oxygen, did not maintain clean oxygen concentrators and filters, and did not provide humidification for oxygen therapy for one resident. Additionally, the facility failed to document daily tracheostomy inner cannula changes for another resident, and did not clarify a physician's order for oxygen for a third resident. The facility also failed to follow physician's orders for oxygen, ensure the oxygen concentrator had a filter, and label and store respiratory equipment in a sanitary manner for a fourth resident. One resident with acute and chronic respiratory failure was observed receiving oxygen via nasal cannula at 4 liters per minute, but the oxygen concentrator's filter was dirty, and the humidification container was empty. The electronic medical record revealed no current order for oxygen therapy or oxygen saturation checks, and the Medication Administration Record did not document oxygen administration or saturation checks for the current month. Interviews with staff confirmed the deficiencies in maintaining the oxygen equipment and ensuring proper documentation and orders. Another resident with a tracheostomy had a physician's order to change the inner cannula daily, but there was no documentation that this was done for several days. Staff interviews confirmed the lack of documentation and adherence to the physician's order. A third resident's oxygen concentrator filter was found to be dirty, and the physician's order for oxygen therapy was not clearly defined. The fourth resident's oxygen concentrator did not have a filter, and the nasal cannula was not stored properly, with observations showing it lying on the floor and not in a protective bag. Staff interviews confirmed these deficiencies and the failure to follow physician's orders for oxygen therapy.
Failure to Ensure Ongoing Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis center for a resident (R60) who required dialysis services. The facility's policy titled Dialysis Care, effective 2/1/2024, mandated pre and post care for dialysis residents, including the completion and submission of dialysis communication forms to the dialysis center. However, a review of R60's electronic medical record revealed that the only dialysis communication form documented was dated 10/2023, despite a physician's order for dialysis services three times a week. Interviews with staff, including the Registered Nurse (RN), Director of Nursing (DON), and Central Supply/Medical Record Licensed Practical Nurse (LPN), confirmed that the dialysis communication forms were missing and not being sent to the dialysis clinic as required. The dialysis clinic had contacted the facility to request the forms but eventually stopped following up after the facility continued to fail to submit them. The deficiency was further corroborated by the Dialysis RN, who confirmed that the facility was not submitting R60's dialysis communication forms to the dialysis clinic at the time of the resident's dialysis appointments. The Administrator was also unaware of the issue and stated that her expectations were for the nursing staff to send the dialysis communication form to each dialysis appointment. This failure to adhere to the facility's policy and ensure proper communication with the dialysis center had the potential to place R60 at risk for medical complications, unmet needs, and a diminished quality of life.
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.
