Seminole Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Donalsonville, Georgia.
- Location
- 100 Florence Street, Donalsonville, Georgia 39845
- CMS Provider Number
- 115712
- Inspections on file
- 12
- Latest survey
- April 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Seminole Manor Nursing Home during CMS and state inspections, most recent first.
Staff failed to properly sanitize a food thermometer probe between measuring different food items, using only a paper napkin instead of a clean probe wipe as required by facility policy. This practice was observed during meal preparation and confirmed by interviews with dietary staff and management, potentially exposing 62 residents to cross-contamination.
Staff did not properly secure confidential medical, financial, and legal records, leaving bins and filing cabinets containing sensitive information unlocked and accessible in multiple areas, including the copy room and behind the Nurse's Station. The storage room containing resident files also used a common entry code and had cabinets with unlocked hasps, increasing the risk of unauthorized access.
Staff did not consistently provide care that promoted dignity and respect, as several residents were observed with food spills on clothing and dirty, jagged fingernails. Despite policies requiring regular checks and assistance with hygiene, residents with cognitive and physical impairments, as well as those on hospice, were not kept clean or neat, and staff did not always intervene to address these issues.
Staff did not ensure that two residents had timely access to their prescribed medications, including Vitamin D3 and Lantus insulin, during medication administration. An LPN found that one resident's Vitamin D3 was not available and another resident's insulin vial was missing an open date and lacked a back-up supply. Facility policy requires medications to be available, properly labeled, and reordered before supplies run out, but these procedures were not followed.
Surveyors found that an LPN left a medication cart unlocked and unattended, and another LPN left a prepared medication unsecured on top of a cart while away. Expired medications and medical supplies, as well as opened and unclean items, were found in storage and treatment areas. A multi-dose insulin vial was also in use without an open or discard date, all in violation of facility policy and accepted standards.
Residents reported that meals were often cold and bland. A test tray sampled by surveyors and the Administrator revealed that food items, including a chicken salad sandwich and green pea salad, were poorly presented, lacked seasoning, and were served at inappropriate temperatures. The green pea salad's liquid caused the sandwich bread to become soggy, and both the soup and salad were bland and not served at the correct temperature.
A resident receiving hospice care for congestive heart failure, who was cognitively intact and required moderate assistance with ADLs, was observed lying in bed with the call bell cord wrapped around the bed rail and not within reach. An LPN confirmed the call device was inaccessible, which was not in accordance with facility policy requiring call systems to be easily accessible to all residents.
A list identifying residents with diabetes was posted in a location visible to visitors and staff, compromising the confidentiality of their medical information. The Activities Director stated the list was used to manage appropriate snacks for these residents but was unaware of the privacy concern.
Staff did not follow facility policies for cleaning, changing, and dating respiratory equipment for four residents receiving nebulizer treatments or oxygen therapy. Nebulizer cups and masks were found assembled and moist, tubing was undated, and there was no documentation of required equipment changes or cleaning. In some cases, oxygen tubing was in contact with the floor or staff were unclear on change frequency.
Surveyors found that the medication error rate exceeded 5% after two residents did not receive scheduled medications due to unavailable supplies and improper labeling. In both cases, LPNs confirmed the omitted doses, and the administrator acknowledged that medications should be reordered before supplies run out.
Improper Sanitization of Food Thermometer Probe During Meal Preparation
Penalty
Summary
The facility failed to ensure sanitary practices were followed during food preparation, as observed during a survey. The Dietary Manager (DM) was seen measuring the temperatures of 11 food items on the steam table and used a paper napkin to wipe the residue from the probe thermometer between each food item, without sanitizing the probe. The DM then used the same unsanitized probe to measure the temperature of a bowl of fruit and a bowl of applesauce. When questioned, the DM placed the probe in a cup of sanitizing solution, stating it was the same solution used in the sanitization buckets, and also provided a box of food probe wipes that appeared tattered and had an illegible date. Interviews with the DM, District Manager, and Registered Dietitian confirmed that the expected practice was to use a clean probe wipe to sanitize the thermometer between each food type to prevent cross-contamination. The failure to follow these procedures was not in accordance with the facility's policy, which required food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical agents. This practice had the potential to affect the 62 residents who received food from the kitchen.
Failure to Secure Confidential Resident Records
Penalty
Summary
Staff failed to safeguard resident-identifiable information and maintain medical, financial, and legal records in accordance with accepted professional standards. Observations revealed that a bin for storage of medical records to be destroyed was left unlocked in the copy room, and the door to this room was also unlocked. Additionally, a shred bin behind the Nurse's Station was found unlocked with the door slightly ajar, and the Nurse's Station itself had an open floor plan with no barriers to restrict access to the area where the bin was located. Multiple staff members were present in and around the area at the time of observation. Further observations showed that the storage room on [NAME] Hall, which contained multiple filing cabinets labeled with sensitive information such as financial, social service, business office, and resident files, used the same entry code as the restroom. Several cabinets labeled as Resident Files had unlocked hasps attached, making them accessible. These findings indicate that confidential records were not stored securely, allowing for potential unauthorized access.
Failure to Maintain Resident Dignity and Personal Hygiene
Penalty
Summary
Staff failed to provide care in a manner that promoted dignity and respect for five residents, as evidenced by multiple observations of food spills on clothing and dirty, jagged fingernails. Facility policies on dignity and routine resident checks required staff to ensure residents' well-being and maintain a clean, neat appearance, but these were not consistently followed. For example, one resident with diabetes and impaired vision was observed with food on his hospital gown after breakfast, despite being dependent on staff for personal hygiene and requiring assistance with eating. Another resident with multiple sclerosis, who was dependent on staff for all ADLs, was seen with food on his shirt and overbed table after breakfast, with no meal tray present, indicating the meal had already been completed. A third resident with vascular dementia and intellectual disabilities was repeatedly observed throughout the day and on multiple days wearing T-shirts with visible orange stains, and staff interviews confirmed that he would only change his shirt if prompted. Additional residents, including those on hospice care, were observed with dirty, jagged, or untrimmed fingernails and dried food on their hands, face, and clothing, with no evidence that staff had addressed these hygiene needs. Interviews with staff and the administrator confirmed expectations for regular rounding and personal hygiene assistance, but the observations indicated these expectations were not met. The failure to provide timely and adequate assistance with personal hygiene and clothing cleanliness had the potential to diminish the quality of life for the affected residents, contrary to facility policy and regulatory requirements for dignity and respect.
Failure to Ensure Timely Availability and Proper Labeling of Routine Medications
Penalty
Summary
Staff failed to ensure that routine medications were available for two residents during medication administration. One resident did not receive a scheduled dose of Vitamin D3 1000 units because the medication was not present in the resident's supply, and the LPN confirmed it was not available in the medication storage room. The LPN stated she would order the medication from the pharmacy. In another instance, a resident with an order for Lantus insulin did not have a properly labeled multi-dose vial, as neither the box nor the vial was marked with an open date, and there was no back-up supply available. The LPN confirmed the absence of a back-up supply and reordered the insulin from the pharmacy. Facility policy requires that pharmacy services be available 24/7, that residents have a sufficient supply of prescribed medications, and that medications are labeled and stored according to standards. The policy also prohibits borrowing medications due to failure to order or reorder in time. The administrator stated that her expectation was for a back-up container of insulin to be available for each resident prescribed insulin and for medications to be available as ordered. These observations and interviews demonstrate that the facility did not follow its own policies regarding medication availability and labeling.
Medication Storage, Security, and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and security of drugs and biologicals. One medication cart was observed unlocked and unattended in a hallway, accessible to unauthorized individuals, while the responsible LPN was not in direct line of sight. Additionally, a prepared cup of MiraLax was left unsecured on top of a medication cart while the nurse left the area, leaving the medication unattended and accessible. Expired medications and medical supplies were found in both the central supply storeroom and the treatment cart. Items such as gastrostomy feeding tubes, dressing change trays, infusion sets, IV start kits, suction catheters, packing strip dressings, and various wound care supplies were all past their expiration dates. Some items were also found opened, compromising their sterility and cleanliness, including dressings and cotton-tipped applicators spilling from open packaging. A multi-dose vial of Lantus insulin was found in use without an open or discard date, contrary to facility policy and accepted pharmaceutical practices. The DON and Administrator confirmed that these practices did not meet facility expectations, as expired and opened items should have been removed from use, and multi-dose vials should have been properly dated.
Meals Served Lacked Palatability, Proper Temperature, and Presentation
Penalty
Summary
The facility failed to provide meals that were palatable, attractive, and served at an appropriate temperature, as evidenced by resident complaints and direct observations. During a Resident Council meeting, residents reported that meals were often cold and lacked flavor. A test tray was later prepared and delivered to the Activity Room, where it was sampled by two surveyors and the Administrator. The tray included a chicken salad sandwich, green pea salad, broccoli and cheese soup, and barbeque potato chips. Observations revealed that the green pea salad's liquid had spread across the plate, causing the sandwich bread to become soggy. The chicken salad was described as bland and lacking seasoning, while the soup was lumpy, bland, and of an inappropriate consistency. Both the soup and the pea salad were served at temperatures that were neither hot nor cold, and the pea salad lacked seasoning and was not served cold as expected. All participants agreed that the presentation and taste of the food items were unsatisfactory, with the Administrator acknowledging that most resident complaints were about the supper meal. The improper plating, lack of seasoning, and failure to maintain appropriate food temperatures contributed to the deficiency, affecting the quality and palatability of meals served to residents. No specific resident medical histories or conditions were mentioned in relation to the deficiency.
Call Device Not Accessible to Resident
Penalty
Summary
A deficiency occurred when a resident's call device was not placed within reach, contrary to the facility's policy requiring that each resident have access to a functional call system at all times. During an observation, the resident was found lying in bed with the call bell cord wrapped around the right upper half bed rail, with the pendant dangling below the rail and not accessible to the resident. The resident's left hand was free, but the call device was not within reach, and this was confirmed by an LPN during the observation. The resident involved had been readmitted to the facility and was on hospice care for congestive heart failure. Assessment records indicated the resident was cognitively intact and required partial to moderate assistance with eating and activities of daily living. The care plan documented the need for limited assistance with ADLs due to debility. The facility's policy specifically states that cords are to be placed easily in reach of the resident, and if a resident cannot use the call system, an alternative must be provided and documented. However, in this instance, the call device was not accessible, resulting in noncompliance with the policy.
Resident Medical Information Posted Publicly
Penalty
Summary
A handwritten list titled 'Diabetics' containing the names of four residents with diabetes was posted on the wall in the activity room, which was visible through a window from the lobby. This allowed anyone visiting the facility to see the list, compromising the privacy and confidentiality of the residents' medical diagnoses. The activity room was used daily by both residents and staff. During an interview, the Activities Director stated that the list was intended to help ensure residents with diabetes received appropriate snacks, but she was unaware that posting the list constituted a privacy and confidentiality issue.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for four residents who required nebulizer treatments or oxygen therapy. Facility policies required staff to clean nebulizer equipment after each use, disassemble and air-dry components, and change and date tubing and masks every 14 days. However, observations and record reviews revealed that nebulizer cups, masks, and tubing were not dated, and there was no documentation of routine changing or cleaning of these items as required. In several cases, nebulizer equipment was found assembled and moist after use, indicating it had not been properly disassembled and air-dried. For one resident with scheduled nebulizer treatments for shortness of breath, the equipment was found on the floor, attached to the compressor, and undated, with no documentation of tubing or mask changes despite multiple treatments administered. Another resident receiving frequent nebulizer treatments for COPD had equipment resting on paper towels, with visible moisture inside the cup and no dates on the tubing, cup, or mask. The MARs for both residents lacked documentation of required cleaning or equipment changes. Two additional residents using oxygen therapy also had deficiencies in equipment maintenance. One resident receiving oxygen via nasal cannula had undated tubing, and staff were unclear on the required frequency for changing it. Another resident's oxygen tubing was found in direct contact with the floor, undated, and not in use at the time of observation. In all cases, the facility failed to follow its own policies and physician orders regarding the cleaning, changing, and dating of respiratory equipment.
Medication Error Rate Exceeds 5% Due to Omitted Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required by policy, resulting in an observed error rate of 6.67 percent during the survey. Out of 30 medication administration opportunities, two errors were identified involving two residents. In the first instance, an LPN was unable to administer a scheduled dose of Vitamin D3 1000 units to a resident because the medication was not available in either the resident's medication supply or the back-up supply. The LPN confirmed the omission of the dose. In the second instance, another LPN was preparing to administer Lantus insulin to a resident as ordered, but the multidose vial of insulin did not have an open date labeled, and there was no way to determine when it had been opened. Due to the lack of an open date and the absence of a back-up or emergency supply, the medication was not administered. The LPN confirmed this as an omitted dose. The administrator stated that her expectation was for medications to be available for each resident and that medications should be reordered before the supply is exhausted.
Latest citations in Georgia
The facility failed to follow its abuse investigation policy when responding to an allegation that a male resident wandered into a female shared room, allegedly sat on a resident’s bed, inappropriately touched her leg, stared at another resident, and opened the bathroom door to watch a third resident brushing her teeth. The allegation was reported by a cognitively intact resident and involved residents with varying levels of cognitive impairment. The investigation, conducted by the Administrator and former DON, relied only on interviews with a RN and a CNA, did not obtain required written, signed, and dated witness statements, and did not include interviews with other residents to assess their sense of safety. Despite these omissions and incomplete documentation, the facility’s final report concluded the allegation was unsubstantiated.
A resident with protein calorie malnutrition and a terminal prognosis was admitted on hospice with corresponding physician orders and a care plan, but hospice services were not coded on either the admission or quarterly MDS assessments. The MDS Coordinator and two MDS LPNs confirmed that, despite the resident receiving hospice care, Section O of both MDS assessments incorrectly indicated the resident was not on hospice, which the Administrator and DON acknowledged resulted in inaccurate MDS data.
Surveyors found that PTAC unit filters in two resident rooms on one hallway were not maintained free of visible grey, fuzzy debris, despite facility policy requiring regular inspection and cleaning or replacement at least every three months. Across multiple observations on different days, the condition of the dirty filters remained unchanged. The Maintenance Director reported he is responsible for monthly cleaning and checks, including spot checks and inspections in construction areas, and did not dispute the observed dust accumulation when shown. The Administrator confirmed that maintenance staff are responsible for monthly PTAC filter cleaning as part of preventative maintenance and acknowledged that this issue could negatively affect residents’ health and well-being.
A resident with intact cognition and known skin integrity risks reported being left on a bedpan for an extended period and not being adequately cleaned by a CNA. The following shift, another CNA found the resident on soiled linens with a blister on the left upper thigh but did not report this new skin issue to the charge nurse or DON. Subsequent documentation showed development of an open area on the thigh associated with pain, and later NP evaluation identified a larger wound requiring sharp excisional debridement. These events show failure to provide adequate incontinent care and to promptly assess and report a new wound, contrary to the facility’s abuse/neglect prevention policy and CNA responsibilities.
A cognitively intact resident with skin-related diagnoses reported delayed and inadequate incontinent care after using a bedpan, describing prolonged waits for staff response and feeling not properly cleaned by a CNA. The next morning, another CNA found feces-soiled linen and a blister on the resident’s left upper thigh, later documented as a new open area. The resident texted the Administrator stating that a CNA had left feces on her and that she had developed a painful blister, but the Administrator did not report this allegation of neglect to the State Survey Agency as required by facility policy.
A resident with lymphedema and identified risk for pressure ulcers developed a new open wound on the upper thigh, documented by a NP with specific wound measurements. Although the existing care plan included interventions to observe and document skin changes, the care plan was not updated to include this new wound. The Wound Care Nurse and the resident confirmed the wound location, while the MDS Coordinator reported not receiving recent weekly wound reports and only recently learning of the wound. The MDS Coordinator confirmed that the care plan had not been revised in real time as required by facility procedures, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
The facility did not complete a required Georgia Criminal History Check System (GCHEXS) fingerprint background check for a CNA, as identified during review of ten employee files with a census of eighty residents. The facility’s abuse-prevention policy required criminal background checks for all employment candidates, but there was no documentation of a fingerprint records check for this CNA. The HR manager, who is responsible for background and fingerprint checks and maintaining employee files, confirmed that the GCHEXS fingerprint check had not been conducted, resulting in a deficiency under F-Tag 600.
Surveyors found that four of six resident shower rooms were not kept free of hazards or adequately cleaned. On one floor, razors were on the floor, dirty gloves and a comb were on a shower bed, floors were stained, an opened gallon of bath soap and a bottle of chemical-resistant spray were present, and a razor and hair clippers were in a bag on the floor along with a shower cap and toothbrush. On other floors, surveyors observed multiple opened containers of skin and hair cleaner, conditioner, and skin ointment, along with a strong urine odor. Unit managers and the Environmental Senior Director stated that CNAs were responsible for cleaning after each resident and that environmental services cleaned shower rooms daily, and acknowledged that items should not be left on the floor and that product containers should be closed.
Surveyors found that staff did not follow standard and transmission-based precautions when handling ice on two floors. On one floor, the ice scoop cover on top of the ice machine had visible black specks near the end of the scoop used to dispense ice. On another floor, the ice scoop was observed submerged in ice and water inside the cooler used to serve residents, despite the unit manager acknowledging that the scoop should not be left in the cooler. The Maintenance Director reported that maintenance cleaned and checked ice machines regularly, while nursing staff were responsible for cleaning scoops and covers. The SDC/Infection Control nurse stated that all staff had been in-serviced on hand hygiene and ice scoop protocol, including that scoops should be stored in a holder after use and never left in the ice.
A resident with multiple serious conditions, moderate cognitive impairment, and total dependence for ADLs was placed in bed with side rails intended to assist with positioning, despite the MDS indicating no bed rail use. Facility records showed no evidence of safe rail spacing or regular inspection of the bed and rails. The assigned CNA, who came on duty late in the evening, last saw the resident around the start of the shift and did not check on him again for several hours, relying on the resident to use a call light. In the early morning, the CNA and an RN found the resident partially out of bed, entrapped in the half side rail, requiring multiple staff to free and reposition him. The resident was unresponsive except for moaning, with altered mental status and respiratory failure documented by EMS and the ER, and later expired at the hospital. The facility’s failure to provide required monitoring and to ensure safe side rail use resulted in neglect and Immediate Jeopardy.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of sexual abuse in accordance with its policy titled “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating.” The policy required that all allegations be thoroughly investigated, including reviewing documentation and evidence, interviewing any witnesses, interviewing staff on all shifts who had contact with the resident, and completely documenting the investigation, with written, signed, and dated witness statements. A facility-reported incident documented that a male resident was wandering into a female three-bed room, allegedly inappropriately touching one resident, staring at another for a length of time, and then opening the bathroom door and staring at a third female resident while she was brushing her teeth. The allegation was initially reported by a cognitively intact resident (BIMS score 15) and involved another resident with moderate cognitive impairment (BIMS score 8) and a resident with severe cognitive impairment (BIMS score 99). The Administrator reported that the investigation of this incident was conducted by the former DON and herself after the allegation was reported by a RN. She stated that this was not the first time the alleged male resident had wandered into other residents’ rooms and described the allegation as the male resident entering a resident’s room, sitting on the resident’s bed, and allegedly touching the resident’s leg. Staff interviews for the investigation were limited to the RN and a CNA, and the Administrator acknowledged that no written witness statements were obtained, contrary to facility policy. She also confirmed that no additional residents were interviewed to assess their sense of safety following the incident. The facility’s final investigation report concluded that the allegation was unsubstantiated, despite the lack of comprehensive interviews, written statements, and full documentation required by the facility’s abuse investigation policy.
Failure to Accurately Code Hospice Services on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for a resident receiving hospice services. The facility’s policy on Certification of Accuracy of the MDS requires that appropriate health professionals correctly document residents’ medical, functional, and psychosocial problems using the Resident Assessment Instrument. The resident in question was admitted with diagnoses including protein calorie malnutrition and had a care plan dated 01/09/2026 indicating a terminal prognosis and admission to hospice, with a goal to honor advance directives and provide comfort with dignity. Physician’s orders dated 12/09/2025 also included an order to admit the resident to hospice. Despite this, review of the admission MDS and a subsequent quarterly MDS showed that hospice services were not coded in Section O (Special Treatments, Procedures and Programs), even though both assessments documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. Interviews with the MDS Coordinator and two MDS LPNs confirmed that the resident had been on hospice since admission and that both the admission and quarterly MDS assessments were incorrectly coded as not on hospice. The MDS Coordinator acknowledged that the MDS should present an accurate clinical picture for a given period and stated that this was a clerical error, resulting in CMS not receiving correct hospice coding for the resident. The Administrator and DON stated their expectation that MDS assessments accurately reflect residents’ services and confirmed that failure to code hospice in the MDS results in an inaccurate reflection of the data.
Failure to Maintain Clean PTAC Unit Filters in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain Packaged Terminal Air Conditioner (PTAC) unit filters in a safe, clean condition in two resident rooms on the Sapphire Hallway. The facility’s written policy titled "Instructions" requires that air filters be removed and inspected for cleanliness, washed or replaced if dirty, and at a minimum replaced or thoroughly cleaned every three months. During multiple observations in one room on 3/22/2026, 3/24/2026, and 3/25/2026, the PTAC unit filter was noted to have visible grey, fuzzy debris accumulation, with no change in condition across all three observations. Similar repeated observations on those same dates in another room showed the PTAC unit filter also contained visible grey, fuzzy debris accumulation that remained unchanged. In an interview, the Maintenance Director stated he is responsible for cleaning and checking the PTAC filters monthly, including conducting monthly checks and random inspections in areas where construction is occurring, and confirmed that the maintenance department is responsible for ensuring filters are clean and functioning properly. He also stated that expectations include spot checks of PTAC units. However, during an observation of one of the affected rooms in his presence, dust accumulation was again observed on the PTAC unit filter, and he did not dispute the finding. In a separate interview, the Administrator stated that the maintenance department is responsible for cleaning PTAC filters, which are supposed to be cleaned monthly, and that her expectation is for preventative maintenance to be completed monthly and as needed, noting that a potential negative outcome is the impact on residents’ health and well-being.
Neglect of Incontinent Care and Delayed Wound Reporting Leading to Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to prevent neglect and to assess and provide timely wound and incontinent care to a cognitively intact resident with known skin integrity risks. The resident, who had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema, was care planned as being at risk for pressure ulcer development and skin integrity issues, with interventions directing staff to observe, document, and report any changes in skin status. On a night shift, the resident reported being left on a bedpan for approximately an hour and a half. When the CNA on that shift (CNA BB) assisted with post-toileting care, the resident told her she did not feel adequately cleaned; CNA BB did not recheck or further clean the resident and left the room. The next morning, the resident reported burning in the left upper thigh and informed another CNA (CNA EE) that she had not been cleaned well. During morning care, CNA EE found the pad under the resident soiled with feces and wet with urine and observed a blister on the resident’s left upper thigh, but did not report the new blister to the charge nurse or DON. A subsequent Skin Wound Note documented a new open area on the left posterior thigh with the resident reporting pain while sitting on the bedpan. Later, an NP wound care consult documented that the thigh wound had been present for approximately two weeks per nursing report and measured 3.5 cm x 4.0 cm x 0.2 cm, requiring sharp excisional debridement to remove necrotic tissue and decrease bacterial burden. On observation by the surveyor with the Wound Care Nurse, the left upper thigh area was open to air, shiny pink and granular, about the size of a half dollar. These findings demonstrate that the facility did not follow its abuse/neglect prevention policy and CNA job responsibilities to provide necessary care and to report changes in condition, resulting in neglect of incontinent care and delayed wound assessment and treatment for this resident.
Failure to Report Allegation of Neglect to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the State Survey Agency (SSA) as required by its own abuse and neglect reporting policy. The facility’s policy, dated 1/2025, states that any complaint, allegation, observation, or suspicion of resident neglect must be immediately communicated to the Abuse Coordinator and promptly investigated and documented, and that all alleged violations involving mistreatment, abuse, or neglect will be thoroughly investigated under the direction of the Administrator in accordance with state and federal law. Despite this, the Administrator acknowledged that an allegation of neglect reported by a resident was not reported to the SSA. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. The resident reported that during a night shift she requested assistance for incontinent care after using a bedpan and experienced multiple delays before a CNA assisted her. She stated that when the CNA finally provided care, she did not feel adequately cleaned, and the CNA did not verify cleanliness before leaving. The next morning, another CNA found soiled linen with feces and a blister on the resident’s left upper thigh, which the resident reported as burning. A subsequent skin/wound note documented a new open area on the left posterior thigh. The resident texted the Administrator describing that a CNA had left feces on her and that she had developed a painful blister. The Administrator confirmed receiving this text but did not report the allegation of neglect to the SSA, despite being aware it should have been reported.
Failure to Update and Implement Care Plan for Newly Developed Pressure Ulcer
Penalty
Summary
Surveyors identified a failure to implement and update the care plan for a newly developed pressure ulcer for one resident. The facility’s policy "RAI Care Planning Management" requires a comprehensive, accurate assessment and real-time modification of the care plan when changes occur. The resident was admitted with diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. A recent MDS quarterly assessment showed the resident was cognitively intact (BIMS 15), at risk for pressure ulcer development, and had no unhealed pressure ulcers at that time. The existing care plan, dated 6/6/2024, identified potential for pressure ulcer development and skin integrity issues related to immobility and lymphedema, with interventions to observe, document, and report changes in skin status, including wound size, stage, and signs of infection. Subsequently, a NP wound report documented a new open wound on the resident’s thigh that had been present for approximately two weeks, with specific measurements recorded. During observation and interview, the Wound Care Nurse and the resident confirmed the wound was on the left upper thigh, which differed from the NP report that referenced the right thigh. The MDS Coordinator reported she previously received weekly wound sheets from the Wound Care Nurse but had not received one in about a month, and that the DON was now responsible for emailing the weekly wound report. She verified that the last wound report she received did not include this resident and stated that new wounds should be discussed in the morning management meeting and the care plan updated in real time. The MDS Coordinator confirmed she only recently became aware of the upper left thigh wound and that the resident’s care plan had not been updated to reflect this new wound, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
Failure to Complete Required GCHEXS Fingerprint Check for CNA
Penalty
Summary
The facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for one CNA among ten employee files reviewed, despite a census of eighty residents and a written policy requiring criminal background checks for all employment candidates. The policy titled "Freedom of Abuse Abuse Prevention Fast Alert" dated 1/2025 states that, as part of pre-employment screening, all candidates must authorize a criminal background check for conviction of crimes. During record review with the Human Resources Manager (HRM), there was no documentation of a fingerprint records check for CNA BB, and the HRM confirmed that this CNA did not have a GCHEXS fingerprint check conducted. The HRM also stated that she is responsible for background checks, fingerprint checks, reference checks, and maintaining employee files. This failure to complete the required fingerprint background check for CNA BB resulted in noncompliance cited under F-Tag 600. No resident-specific medical histories, conditions, or direct resident care events were described in the report related to this deficiency.
Failure to Maintain Safe and Clean Conditions in Multiple Resident Shower Rooms
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate environmental controls in multiple resident shower rooms. On the 4th floor, observation with the Unit Manager showed four razors on the floor, dirty gloves and a dirty comb on a shower bed, stained/dirty floors, an opened gallon bottle of complete bath soap, and a bottle of chemical resistant spray in the shower room. A razor and hair clippers were found in a black bag on the floor, and a shower cap and toothbrush were lying on the floor. The 4th floor Unit Manager stated that CNAs were supposed to clean up before showering residents and acknowledged that the items found should not be on the floor. The Environmental Senior Director reported that shower rooms were cleaned daily, with responsibilities including cleaning high-touch areas, sweeping and mopping floors, removing linen, and cleaning the area, and stated there had been no complaints about showers not being cleaned. On the 3rd floor, observation with the Unit Manager revealed an open bottle of skin and hair cleaner, an open bottle of conditioner, and an open bottle of skin ointment in the resident shower room. The 3rd floor Unit Manager stated that items in the shower room should be closed and that CNAs were to clean after each resident. On the 2nd floor, observation with the Unit Manager revealed two opened gallon containers of skin and hair cleaner and a strong urine odor in the shower room. The 2nd floor Unit Manager stated that the soap should have a top on it and that CNAs were responsible for cleaning after each resident. These observations and interviews showed that four of six resident shower rooms were not maintained free of hazards and were not cleaned as expected by facility staff, creating the potential for injury and spread of infection as stated in the report.
Improper Ice Scoop Handling and Storage Breaches Infection Control Protocol
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper handling and storage of ice scoops on two of four floors. On the 4th floor, observation of the ice scoop and scoop cover showed black specks near the end of the scoop used to put ice in cups, and the scoop cover was located on top of the ice machine. The 4th floor Unit Manager stated that kitchen staff cleaned the scoops once a week and acknowledged that the scoop should be clean. On the 3rd floor, observation of the ice chest/cooler used to serve residents revealed the ice scoop submerged in ice and water. The 3rd floor Unit Manager later confirmed that the ice scoop was not supposed to be left in the cooler. The Maintenance Director reported that maintenance staff were responsible for cleaning the ice machines, which were checked weekly and monthly, while nursing staff were responsible for cleaning the ice scoops and covers. The Staff Development Coordinator/Infection Control staff stated that all staff had been trained in infection control procedures, including hand hygiene and handling of the ice scoop and holder, and that staff had been educated that the ice scoop should be placed in the scoop holder after use and never left in the ice. Documentation in the maintenance logbook showed monthly checks and cleaning of all four ice machines, and the ice machine cleaning log showed that the ice machines on the 2nd, 3rd, and 4th floors and in the kitchen had been cleaned on specific dates. Staff training records indicated that an in-service on handwashing and ice scoop protocol had been provided for all staff.
Neglect Related to Inadequate Supervision and Unsafe Side Rail Use Leading to Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to inadequate supervision and oversight of side rail use, resulting in entrapment. Facility policies on Abuse, Neglect and Exploitation required protections to prevent neglect, defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy on Proper Use of Bed Rails required a person-centered approach, attempts at alternatives before bed rail use, and ensuring correct installation, use, and maintenance of bed rails, including attention to entrapment risk. For this resident, the Medicare 5-day MDS indicated moderate cognitive impairment (BIMS score of 8), total dependence on staff for all ADLs, and documented that bed rails were not used, while an admission assessment documented side rails were placed to assist with movement in bed. Facility records showed no evidence that safe rail spacing and regular inspection of side rails and beds had been completed. The resident had multiple serious medical diagnoses, including acute and subacute infective endocarditis, end stage renal disease, hemiplegia and hemiparesis following cerebral infarction, bacteremia, and cervical disc degeneration, and was dependent on staff for all ADLs. Nursing staff last observed the resident at 12:46 am when a sponge bath was provided; there was no documented monitoring or ADL assistance between 12:46 am and 4:30 am. The assigned CNA reported coming on duty at 11:00 pm, seeing the resident up with the bed in a low position, placing the call light in the resident’s hands, and not seeing or checking the resident again until approximately 4:30–5:00 am, stating that the resident did not press the call light during that time. Around 5:00 am, the CNA requested help from the RN, reporting that the resident needed assistance. The RN found the resident with the lower part of his body hanging off the bed and the upper body still on the bed, with his elbow wedged into the half side rail, requiring three staff to reposition him back into bed. The RN stated the resident, who was quadriplegic, was no longer as alert as when put to bed, did not respond to sternal rubs, had open but unfocused eyes, and was not verbally interactive. The CNA described finding the resident on his knees, all the way out of bed, with one hand tangled in the side rail, and noted that he was moaning but not talking after being returned to bed. Progress notes documented that EMS was called for evaluation and treatment due to the resident’s condition, and hospital ER records indicated he arrived with altered mental status and respiratory failure, agonal respirations, and a GCS of 3. The facility’s Maintenance Director stated bedrails had been checked the prior year but could not provide proof, and requested documentation of safe rail spacing and regular inspection was not provided.
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