Senior Care Center - Brunswick
Inspection history, citations, penalties and survey trends for this long-term care facility in Brunswick, Georgia.
- Location
- 2611 Wildwood Drive, Brunswick, Georgia 31520
- CMS Provider Number
- 115721
- Inspections on file
- 22
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Senior Care Center - Brunswick during CMS and state inspections, most recent first.
Surveyors found that the dumpster area was not maintained in a sanitary condition, with garbage and litter on the ground, unsecured and damaged dumpster lids, and debris including used nitrile gloves and boxes scattered around. The Dietary Kitchen Manager confirmed the unsanitary conditions and was unaware of staff responsibilities regarding dumpster maintenance.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines for care delivery.
A medication error rate of 5 percent or greater was identified, indicating that the facility did not maintain medication administration accuracy within acceptable limits as observed by surveyors.
Expired medications and biologicals were found on a medication cart and in two medication storage areas, including expired Allergy Relief, aspirin, and COVID-19 antigen rapid tests. Staff interviews revealed inconsistent checks for expired medications, with some LPNs and the central supply manager acknowledging lapses in their responsibilities. The DON and ADON confirmed that all nurses were expected to remove expired medications, but the deficiency occurred due to lack of consistent adherence to these procedures.
Two residents or their representatives did not receive timely refunds of their trust fund balances after discharge or death, as required by facility policy. Account statements and interviews confirmed that credit balances remained unpaid beyond the 30-day period, and the Administrator acknowledged the delay was due to staff not issuing refunds promptly.
A resident reported that his bed linens had not been changed for a month, which was confirmed by his tracking method and multiple observations. CNAs acknowledged that linens were not changed as often as required due to workload, and both the ADON and DON confirmed that the linens had not been changed as needed.
Four residents did not have appropriate care plan interventions developed or implemented for elopement risk, smoking, or dietary needs. Two residents with cognitive impairment and behavioral issues were not provided with timely elopement risk care plans despite documented incidents and high-risk assessments. Another resident, allowed to smoke under supervision, lacked a required smoking assessment and care plan. A resident with a mechanical soft diet order was served inappropriate food, resulting in a choking incident, despite the correct diet being documented in the care plan.
A resident with a history of coronary angioplasty and moderate cognitive impairment did not receive daily wound care as ordered by the physician. Staff changed the resident's right-hand dressing less frequently than prescribed, with one bandage remaining in place for several days. The LPN responsible was unaware of the daily order, and the Wound Care Nurse was on vacation, leading to a lapse in following the physician's instructions.
The facility did not complete required elopement and smoking risk assessments for two residents. One resident with dementia and a history of wandering was able to exit the building on multiple occasions without an elopement assessment or care plan being completed after the first incident. Another resident, identified as a smoker, did not have a smoking risk assessment or care plan in place prior to being observed smoking, despite being 'grandfathered in' for tobacco use. Staff interviews confirmed awareness of both residents' behaviors, but necessary assessments and documentation were not completed in a timely manner.
A resident with hemiplegia and dysphagia was served a hamburger patty instead of the required ground meat mechanical soft diet, leading to a choking incident. The error occurred when the resident received a meal tray intended for their roommate, and staff confirmed the meal did not meet the prescribed dietary needs.
Surveyors observed that personal care items such as bed pans, bath basins, and urinals were not bagged or labeled in several shared bathrooms, contrary to facility policy. Interviews with a CNA, ADON, and DON confirmed that these items should be cleaned, bagged, and labeled to prevent cross-contamination, but this was not consistently done.
Two shared rooms were found without privacy curtains, as required by facility policy to ensure visual privacy during care. Multiple observations confirmed the ongoing absence of curtains, and both a CNA and the DON acknowledged that all shared rooms should have privacy curtains for each bed.
A resident who was dependent on staff for mobility and required two-person assistance was being transferred from a chair to a bed using a Hoyer lift when the lift pad strap broke, causing a fall. Only one CNA was present during the transfer, and the wrong lift pad was used, resulting in the resident sustaining a skin tear and a right arm fracture.
The facility did not maintain adequate nursing staff to meet residents' needs for ADL assistance, as evidenced by multiple residents not receiving scheduled showers and staff reporting frequent short-staffing. Interviews with residents, CNAs, LPNs, and administrative staff confirmed that staffing shortages led to missed care, with some staff working alone and unable to provide required services.
Three residents with significant medical needs did not receive scheduled showers as required, with documentation and interviews confirming missed care. Staff and the DHS attributed the deficiency to ongoing CNA shortages, resulting in residents not being assisted with activities of daily living as scheduled.
The facility failed to protect residents from abuse, resulting in incidents of sexual and physical abuse. A resident was sexually abused by another resident with a history of inappropriate behavior, and a CNA physically and verbally abused another resident. The facility's abuse prevention and reporting protocols were not effectively implemented, leading to an Immediate Jeopardy situation.
The facility failed to thoroughly investigate allegations of potential sexual abuse between two residents, lacking interviews with the victim, staff, or other residents. Documentation was insufficient, with only two sheets of paper, and no evidence of assessments, notifications, or psychiatric evaluations. Staff interviews revealed a lack of awareness and documentation, leading to an Immediate Jeopardy situation.
The facility failed to create care plans for three residents, leading to deficiencies in addressing abuse and elopement. A resident with severe cognitive impairment was sexually abused without a care plan in place. Another resident experienced verbal and physical abuse from a CNA, yet no care plan was developed. Additionally, a resident at moderate risk for elopement was found outside the facility without a care plan addressing safety precautions. The Administrator was unaware of these omissions, highlighting a lack of communication and oversight.
The facility administration failed to oversee an abuse prevention program, leading to a resident being sexually abused by another resident with a known history of aggressive behavior. The administration did not investigate or prevent further abuse, and care plans for affected residents were not developed. Staff interviews revealed a lack of awareness and communication regarding these issues.
An LPN administered her personal melatonin to two residents without a physician's order, resulting in lethargy. The facility's policies on medication administration and abuse prohibition were not followed, as the LPN did not verify the correct medication or have a physician's order. Staff observed the LPN with melatonin on the medication cart and witnessed her administering it to residents, despite the lack of documentation in the residents' eMAR.
The facility failed to prevent cross-contamination of linens and resident equipment, with clean and dirty linen carts placed side by side and a standup lift used without cleaning. Staff were unaware of proper infection control practices despite recent training, and no related policy was provided during the survey.
A resident in the Memory Care Unit was found with unauthorized medication in their room, which belonged to another resident. The facility's policy requires that no residents in this unit self-administer medications, and staff confirmed that no such assessments had been made. The medication was discovered during an observation, and both the LPN and Administrator acknowledged the oversight, emphasizing the need for regular monitoring of residents' rooms for medications.
A facility failed to report an abuse incident involving a CNA and a resident to the State Agency within the required timeframe. The incident, which included physical and verbal abuse, was observed by two CNA students. Although the former DON stated the incident was reported to local law enforcement and the SA the day after it occurred, there is no evidence of notification to the SA until several days later, violating the facility's policy.
The facility failed to develop discharge plans for several residents, despite their participation in discharge planning. Residents with conditions such as cerebral palsy, dementia, and respiratory failure had no documented discharge care plans in their EMRs. Staff interviews revealed confusion about responsibility for completing these plans, with the administrator stating that nursing staff or a social worker should handle them.
A facility failed to provide a complete discharge summary for a resident discharged with a hip fracture and Stage 2 Pressure Ulcer. The discharge summary lacked a medication list and a post-discharge plan of care. Interviews with staff revealed that the RN Supervisor was unaware of the requirements for medication reconciliation and discharge summary completion. The MDS Coordinator confirmed the form was available in the EMR but not completed, and the Administrator stated that the nursing staff or social worker should have completed these tasks.
A resident with cerebral palsy and functional quadriplegia did not receive necessary passive range of motion (PROM) treatment for stiffness in the right hand, despite being referred to occupational therapy. The facility lacked a structured restorative program, and communication failures among staff led to the resident's decline not being addressed in meetings, resulting in a deficiency.
The facility failed to properly store respiratory equipment for two residents, leading to potential risks of respiratory complications. An AutoPap mask and a container of distilled water were not stored or labeled correctly, and nebulizer and Trilogy masks were left on a bedside dresser. Staff interviews revealed a lack of clarity and compliance with storage policies.
A resident was administered PRN Ativan beyond the 14-day limit without a stop date or documented rationale. Facility staff, including the DON and RN Supervisor, were unaware of the regulatory requirements for PRN psychotropic medications. Despite pharmacy recommendations, the necessary documentation and orders were not updated, leading to non-compliance with facility policy and regulations.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
Surveyors observed that the facility failed to maintain the dumpster area in a sanitary condition. During an initial tour, garbage and litter were found on the ground around the dumpsters, and three out of four dumpster lids were not secured and remained open. One dumpster lid was damaged, preventing it from closing properly and allowing trash to be exposed. Additional debris, including used nitrile exam gloves, boxes, and other litter, was found both around and behind the dumpsters. Interviews with the Dietary Kitchen Manager (DKM) confirmed the unsanitary conditions, including the unsecured lids and the presence of debris and litter. The DKM acknowledged that the lids should always be closed and that trash should not be left on the ground or behind the dumpsters. The DKM also stated he was unaware that maintaining the dumpster area was the kitchen staff's responsibility and was not previously aware of the condition of the dumpsters. Subsequent observation revealed no improvement in the dumpster area's condition.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices.
Expired Medications Found in Multiple Storage Areas
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were discarded prior to their expiration dates, as required by both professional standards and the facility's own policy. During observations, expired medications were found on one of nine medication carts (Harbor Side) and in two of six medication storage areas (Central Supply and Ocean Breeze). Specifically, a bottle of Allergy Relief with an expiration date of January 2025 was found on a medication cart, two bottles of aspirin with a June 2025 expiration date were found in central supply, and two boxes of COVID-19 antigen rapid tests with a use-by date of April 2025 were found in a medication room. Staff interviews revealed that nurses and aides did not consistently check for expired medications, especially when working outside their usual assignments or after returning from days off. Some staff acknowledged that checking for expired medications was their responsibility but admitted to oversights. Further interviews indicated that the central supply manager was responsible for auditing and rotating stock in the supply closet, but was unsure if expired items were returned to her area by nursing staff. The Director of Nursing and Assistant Director of Nursing confirmed that all nurses were expected to dispose of expired medications immediately and that the pharmacy conducted monthly checks. However, the presence of expired medications in multiple locations demonstrated that these procedures were not consistently followed, leading to the deficiency.
Failure to Timely Refund Resident Trust Fund Balances After Discharge or Death
Penalty
Summary
The facility failed to ensure that residents or their representatives received a final refund of trust fund balances within 30 days of discharge or expiration, as required by facility policy. Specifically, two out of three resident accounts reviewed showed that the refunds were not issued in a timely manner. One resident, who had expired, had a credit balance of $25.01 that was not refunded to the representative within the required timeframe. Another resident, who was discharged, had a credit balance of $57.66 that was also not refunded promptly. Interviews with the residents' representatives confirmed that they had not received the funds and had experienced delays and difficulties in obtaining the refunds. The deficiency was further substantiated by interviews with the facility Administrator, who acknowledged that the financial services staff responsible for issuing refunds had been terminated due to failure to return funds to residents or their representatives in a timely manner. The Administrator confirmed the outstanding balances owed to both residents' representatives and indicated that the issue was known to facility leadership. The review of facility policy and resident account statements supported the finding that the required refunds were not processed within the specified 30-day period.
Failure to Provide Clean Bed Linens for Resident
Penalty
Summary
A deficiency was identified in one resident room on the 200 hall where clean bed linens were not provided for an extended period. The resident in the affected room reported that his sheets had not been changed in a month and demonstrated to the surveyor that he had placed his initials on the underside of the sheet to track changes. Observations over three consecutive days confirmed the presence of the resident's initials, indicating the sheets had not been changed during that time. Certified Nurse Assistants (CNAs) working on the 200 hall confirmed that bed linens were not being changed as often as required, stating that linens should be changed on bath days or as needed, but that workload prevented them from completing this task. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that CNAs were responsible for changing linens and agreed that the resident's sheets had not been changed as required, with the DON stating that the situation was unacceptable.
Failure to Develop and Implement Comprehensive Care Plans for Elopement, Smoking, and Diet Orders
Penalty
Summary
The facility failed to develop and implement appropriate care plan interventions for four residents, resulting in deficiencies related to elopement risk, smoking, and dietary orders. For one resident with dementia and a history of behavioral disturbances, there were multiple documented incidents of attempted elopement, including leaving the facility grounds and packing belongings to go home. Despite these behaviors and a high-risk elopement assessment, an elopement risk care plan was not developed until after a significant incident occurred. Another resident with severe cognitive impairment was identified as high risk for elopement through an assessment, but no corresponding care plan was created to address this risk. A third resident, who was cognitively intact and identified as a tobacco user, was allowed to participate in supervised smoking breaks without a completed "Smoking Observation Form" or a care plan related to smoking. The required assessment and care plan were only completed after the deficiency was identified. Staff interviews confirmed that the resident was "grandfathered in" for smoking privileges, but the necessary documentation and planning were not in place prior to the surveyor's review. For a fourth resident with hemiplegia, dysphagia, and a physician-ordered mechanical soft diet, the care plan specified the correct diet, but staff failed to follow it, resulting in the resident being served a hamburger, which is not considered mechanical soft. This led to a choking incident. Staff interviews confirmed that the resident's dietary needs were documented in multiple locations, including the care plan, but the prescribed diet was not adhered to during meal service.
Failure to Follow Physician's Order for Daily Wound Care
Penalty
Summary
A deficiency was identified when staff failed to follow a physician's order for wound care treatment for one resident with a history of coronary angioplasty and moderate cognitive impairment. The physician's order specified that the resident's right-hand skin tear should be cleaned with wound cleaner, patted dry, and covered with calcium alginate and a dry dressing once daily. However, observations over several days revealed that the resident's bandage had not been changed daily as ordered, with one bandage remaining in place for multiple days. The resident reported that their dressing was changed every six days, and staff interviews confirmed that the dressing change schedule did not align with the physician's daily order. Further investigation revealed that the LPN responsible for the dressing change was unaware of the specific daily order and believed the dressing should be changed on Mondays, Wednesdays, and Fridays or as needed. The Wound Care Nurse, who typically managed these treatments, was on vacation, and the responsibility had shifted to unit nurses. The Direct Health Service confirmed that nurses are expected to follow physician orders for treatments in the absence of the Wound Care Nurse. The failure to administer wound care as prescribed resulted in noncompliance with the facility's medication administration policy and the physician's written orders.
Failure to Complete Elopement and Smoking Risk Assessments
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, specifically in the areas of elopement and smoking risk assessment. One resident with diagnoses including dementia, diabetes, and major depressive disorder exhibited repeated wandering and exit-seeking behaviors, including packing belongings and attempting to leave the facility. On two separate occasions, the resident was able to exit or attempt to exit the building, once following EMS out the front doors and another time through a propped-open smoking door. Despite these incidents and the resident's history of wandering, an elopement risk assessment was not completed after the first occurrence, and interventions were not implemented until after the second incident. Staff interviews confirmed that the resident regularly attempted to leave the building and that staff were aware of her behaviors. The LPN and housekeeper both described the resident's repeated efforts to exit, with the housekeeper discovering the resident outside the facility property during one incident. The administrator acknowledged that an elopement assessment and care plan should have been completed after the initial event but were not, and the nurse consultant confirmed that assessments should occur after such attempts or significant changes. In a separate case, another resident with a history of tobacco use and multiple medical conditions, including nicotine dependence, was identified as a smoker. However, the required smoking risk assessment and care plan were not completed until after the resident was observed smoking in the designated area. Staff interviews revealed that the resident was 'grandfathered in' to smoke at the facility, but the necessary documentation and assessment were missing from the electronic health record until after the deficiency was identified. The MDS coordinator confirmed that the assessment and care plan should have been in place but were not completed until after the oversight was discovered.
Failure to Provide Properly Prepared Mechanical Soft Diet Results in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, and dysphagia following a cerebral infarction was not provided with food prepared in accordance with their prescribed mechanical soft diet. The resident's medical records, care plan, and physician orders all indicated the need for a mechanically altered, therapeutic diet, specifically requiring ground meats. Despite these documented requirements, the resident was mistakenly served a hamburger patty, which does not meet the criteria for a mechanical soft diet, resulting in a choking incident. Staff interviews confirmed that the error occurred when the resident received their roommate's meal tray, which did not match the resident's dietary needs. The Registered Dietician clarified that mechanical soft meats are considered ground meats and that a hamburger patty is not appropriate for this diet. The Dietary Manager also confirmed the dietary error and observed the incorrect tray delivery. The incident highlights a failure in ensuring that food provided matched the resident's individualized dietary requirements as documented in their care plan and physician orders.
Improper Storage of Personal Care Items in Shared Bathrooms
Penalty
Summary
Staff failed to properly store resident personal care items in three of twelve shared bathrooms on the 200 Hall, as observed during multiple surveyor visits. Specifically, bed pans, bath basins, and urinals were found not bagged or labeled in bathrooms shared between rooms 216 and 218, 215 and 217, and 205 and 207. These observations were made on several occasions, indicating a pattern of non-compliance with the facility's policy on standard precautions, which requires that such items be handled in a manner that prevents contamination and cross-contamination. Interviews with a CNA, the ADON, and the DON confirmed that the expectation is for all urinals and bath basins to be cleaned, bagged, and labeled with the resident's name and room number. The DON acknowledged the presence of unbagged and unlabeled items in the shared bathrooms, confirming the failure to follow established infection prevention and control procedures as outlined in the facility's policy.
Failure to Provide Privacy Curtains in Shared Resident Rooms
Penalty
Summary
The facility failed to provide adequate visual privacy for residents in two shared rooms, specifically rooms 217 A and 218 B, as privacy curtains were missing in both locations. This deficiency was identified through multiple observations over several days, during which surveyors noted the continued absence of privacy curtains. Review of the facility's policy confirmed that full visual privacy during routine care and treatments is required by means of privacy curtains and closed doors. Interviews with a CNA and the DON confirmed that all shared rooms should have privacy curtains for each bed, and both acknowledged the lack of curtains in the identified rooms.
Resident Fall Due to Improper Hoyer Lift Transfer and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with diagnoses including unspecified dementia, muscle weakness, and Alzheimer's disease, who was dependent on staff for all self-care and mobility and required two-person assistance for activities of daily living, was being transferred from a chair to a bed using a Hoyer lift. During the transfer, the lift pad strap broke, causing the resident to fall. The resident sustained a skin tear to the left lower arm and was subsequently found to have a nondisplaced transverse fracture of the mid-shaft of the right ulna after evaluation at the emergency department. Record review and staff interviews revealed that the transfer was not performed according to the resident's care requirements. The resident required two-person assistance, but at the time of the incident, only one CNA was present in the room during the transfer. The other CNA had left the room after helping attach the lift pad to the Hoyer lift, leaving the first CNA to complete the transfer alone. Additionally, the administrator confirmed that the wrong lift pad was used, and the seams of the pad broke during the transfer, directly leading to the resident's fall. Documentation from staff statements and the facility's investigation confirmed that the improper use of equipment and lack of adequate staff supervision during the transfer resulted in the accident. The incident was reported by multiple staff members, and the sequence of events was corroborated by written and verbal statements, as well as the facility's internal investigation records.
Insufficient Staffing Resulting in Missed ADL Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, specifically in assisting with activities of daily living (ADLs) such as scheduled showers. Multiple residents with intact cognition reported not receiving showers as scheduled, with some only receiving a few showers over several weeks due to lack of staff. Staff interviews confirmed that the facility was frequently short-staffed, with CNAs sometimes working alone and unable to provide showers or get residents up for therapy as required. The facility assessment indicated a required minimum of 3.48 hours per resident day (HPRD) of total nurse staffing, including specific requirements for RN and CNA hours, but these standards were not consistently met. Further interviews with nursing and administrative staff corroborated the ongoing staffing shortages, with reports of residents missing scheduled showers and therapy sessions due to insufficient staff coverage. The Director of Health Services and other staff acknowledged complaints from residents and families regarding missed showers and confirmed that staffing levels were inadequate. The facility had to close a wing due to lack of staff, and staff members, including the DHS, were required to perform direct care duties to compensate for shortages. These findings demonstrate a pattern of insufficient staffing that affected the delivery of essential care services to all residents.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide scheduled showers to three residents who required assistance with activities of daily living. One resident, admitted with multiple diagnoses including paroxysmal atrial fibrillation, COPD, Parkinsonism, and muscle weakness, reported receiving only three showers during a 20-day stay, while records showed four showers in that period. Another resident with a history of cerebral infarction, hemiplegia, and osteoarthritis stated that he last received a shower five days prior to the interview, despite being scheduled for showers three times a week. A third resident, with chronic respiratory failure, COPD, and a traumatic amputation, also reported not receiving scheduled showers, attributing the missed care to staff shortages. Staff interviews confirmed that the facility was consistently short-staffed, making it difficult to provide showers as scheduled. Certified Nursing Assistants reported being unable to give showers when they were the only CNA on the floor or when there were not enough staff members. The Director of Health Services acknowledged the staffing issues and confirmed that residents were not receiving showers as scheduled, and that complaints had been received from both residents and families regarding this deficiency.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents of sexual and physical abuse. One resident, identified as R84, was sexually abused by another resident, R41, who had a history of inappropriate sexual behavior. Despite this history, R41 was not adequately monitored or managed, leading to an incident where R41 was found rubbing R84's genitals, legs, and feet. The staff intervened and moved R84 to another room, but the incident was not properly documented or reported to the necessary authorities, including psychiatric services, for further evaluation and intervention. Another incident involved a Certified Nursing Assistant (CNA) identified as AA, who physically and verbally abused a resident, R14. The CNA was witnessed hitting R14 on the arm and using inappropriate language to get the resident out of bed. Despite being witnessed by other staff members, the incident was not immediately reported to the Director of Nursing or law enforcement, and the CNA received only a written reprimand. This lack of immediate and appropriate response highlights a failure in the facility's abuse prevention and reporting protocols. The facility's policy on abuse prohibition was not effectively implemented, as evidenced by the delayed response to these incidents and the lack of proper documentation and follow-up. Interviews with staff revealed a lack of awareness and training on monitoring and reporting abuse, contributing to the ongoing risk to residents. The facility's failure to address these deficiencies promptly resulted in an Immediate Jeopardy situation, indicating a serious threat to resident safety.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of potential sexual abuse involving two residents, R84 and R41. The investigation lacked interviews with the victim, other staff, or residents who might have witnessed or been affected by the incident. The facility's policy on abuse prohibition mandates immediate reporting and investigation of such allegations, but there was no evidence of compliance with these procedures. The incident involved R41, who had a history of inappropriate sexual behavior, being observed in a compromising situation with R84, who had severe cognitive impairment. The documentation related to the incident was insufficient, consisting of only two sheets of paper, one of which was an undated, unsigned handwritten statement. There was no documented assessment of the residents involved at the time of the incident, nor were the physician or local police notified. Additionally, there was no evidence of psychiatric evaluations or written statements from witnesses. The facility's failure to follow its own procedures for investigating abuse allegations was evident in the lack of comprehensive documentation and follow-up actions. Interviews with facility staff, including the Administrator and Director of Nursing, revealed a lack of awareness and documentation regarding the incident. The new Administrator, who had only been in the position for two weeks, was unable to locate any additional documents related to the incident. The Licensed Practical Nurse on duty at the time of the incident could not recall specific details or whether a statement was made. The Social Services worker was not informed to monitor the residents for any negative effects from the incident. This lack of thorough investigation and documentation highlights the facility's noncompliance with regulatory requirements, resulting in an Immediate Jeopardy situation.
Failure to Develop Care Plans for Abuse and Elopement
Penalty
Summary
The facility failed to develop and implement care plans for three residents, leading to a deficiency in meeting the residents' needs. Resident R84, who had severe cognitive impairment and a history of unspecified dementia and psychosis, was sexually abused by another resident, R41. Despite the incident being documented, no care plan or interventions were put in place to address the abuse. The Social Services staff reported not being informed to develop a care plan for abuse or to monitor the resident for any negative effects from the incident. Resident R14, who had diagnoses including dementia and kidney failure, experienced verbal and physical abuse from a Certified Nursing Assistant. The abuse involved the CNA using profanity and hitting the resident. However, no care plan was created to address the abuse, and the Social Services staff indicated that the resident was not considered a target for abuse, which contributed to the lack of a care plan. Resident R115, with severe dementia and anxiety disorder, was assessed for moderate risk of wandering and elopement. Despite being placed in a secure unit, the resident eloped from the facility. The facility's records showed no care plan addressing elopement and safety precautions. The RN Supervisor found the resident outside the facility, and the Administrator was unaware of the missing care plans for both abuse and elopement, indicating a lack of communication and oversight in care planning.
Failure to Oversee Abuse Prevention Program
Penalty
Summary
The facility administration failed to effectively oversee an abuse prevention program, resulting in a situation where residents were not adequately protected from abuse. Specifically, the administration did not monitor, supervise, or address the sexually aggressive behavior of a resident with a known history of such behavior, leading to the sexual abuse of another resident. This incident caused psychosocial trauma to the victim. Additionally, the facility did not protect another resident from verbal abuse by staff. The administration also failed to investigate, correct, and prevent allegations of abuse between residents. A thorough investigation was not completed for a reportable incident involving sexual abuse, and there was no evidence that the previous administrator took necessary actions such as contacting medical professionals or updating care plans. This lack of action left the facility unable to address and mitigate the risks associated with resident-to-resident abuse. Furthermore, the facility did not develop and implement person-centered comprehensive care plans related to abuse for the affected residents. One resident did not have a care plan addressing the abuse they suffered, and another resident's care plan did not address identified elopement risks. Interviews with staff revealed a lack of awareness and communication regarding the need for these care plans, indicating a breakdown in the facility's processes for ensuring resident safety and care.
Unauthorized Administration of Melatonin to Residents
Penalty
Summary
The facility failed to ensure that two residents, R136 and R302, were given medication only with a physician's order. This deficiency was identified when an LPN administered her personal melatonin to these residents, resulting in them becoming lethargic. The facility's policies on medication administration and abuse prohibition were not adhered to, as the LPN did not verify the correct medication or have a physician's order before administering the melatonin. Resident R136, who had severe cognitive impairment and a history of dementia, major depressive disorder, and other conditions, did not have a physician's order for melatonin in their January 2024 records. Similarly, Resident R302, with moderate cognitive impairment and a history of dementia and other conditions, also lacked a physician's order for melatonin. Despite this, the LPN was witnessed administering melatonin to these residents, which was not documented in their electronic Medication Administration Records (eMAR). The incident was reported by staff who observed the LPN with melatonin on the medication cart and witnessed her administering it to residents. The LPN admitted to having melatonin on her cart, claiming it was for personal use, but denied using it on residents. However, staff interviews and video surveillance provided evidence that the LPN was administering melatonin without orders, leading to the residents' lethargy.
Infection Control Deficiencies in Linen and Equipment Handling
Penalty
Summary
The facility failed to adhere to infection control standard practices, leading to potential cross-contamination of linens and resident equipment. Observations on Hall OB revealed that a dirty linen cart and a clean linen cart were positioned side by side, and a CNA was seen transferring items between the two carts. Similar issues were noted on Turtle Dove Hall, where a clean linen cart was placed between trash barrels containing dirty items, and a bath shower bed was positioned next to a dirty linen barrel. Staff members, including a CNA and a housekeeping tech, were unaware of the need to separate clean and dirty items, despite having received training on infection control. Additionally, a standup lift on Turtle Cove Hall was observed with a buildup of a dark greyish substance, and it was used to transfer a resident without being cleaned. The Director of Nursing confirmed the issues with the lift and the positioning of the linen carts and trash barrels, acknowledging the risk of cross-contamination. The facility's Administrator also expressed concern over these findings, noting that infection control training had been provided to staff shortly before the surveyor's observations. However, no policy related to these concerns was provided during the survey.
Unauthorized Medication Found in Resident's Room
Penalty
Summary
The facility failed to ensure that a resident in the Memory Care Unit did not have unsecured unauthorized medications stored at the bedside. This deficiency was identified during an observation where a prescription bottle of Nyamyc, an antifungal powder, was found on the sink counter in the bathroom of a resident's room. The medication was labeled for another resident, indicating a lapse in medication management and security. The resident in question had a diagnosis of dementia with moderate cognitive impairment and was assessed for wandering behaviors, which further underscores the importance of secure medication storage. Licensed Practical Nurse (LPN) LLL confirmed that no residents in the Memory Care Unit had been assessed to self-administer medications, and acknowledged that the medication should not have been in the resident's room. The Director of Nursing (DON) and the facility Administrator both confirmed that nurses are expected to conduct rounds to monitor for medications in residents' rooms. The presence of the medication in the resident's room was unexplained, and it was acknowledged that the medication should not have been left out, highlighting a failure in the facility's medication management procedures.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency (SA) in a timely manner, as required by their policy. The policy mandates that the Abuse Coordinator or designee must notify the State Survey Agency immediately, but not longer than two hours after an allegation is made if it involves abuse or results in serious bodily injury. In this case, the incident involved a Certified Nursing Assistant (CNA) who was physically and verbally abusive to a resident. The incident was observed by two CNA students and involved the CNA hitting the resident on the arm and using profanity. The incident occurred on June 7, 2023, but was not reported to the SA until June 13, 2023, which is beyond the required reporting timeframe. The former Director of Nursing (DON) confirmed that the incident was reported to local law enforcement and the SA on June 8, 2023, but there is no evidence to support that the SA was notified before June 13, 2023. The Administrator also confirmed the late reporting of the incident. This delay in reporting is a violation of the facility's policy and the regulatory requirement to report such incidents promptly to the appropriate authorities.
Failure to Develop Discharge Plans for Residents
Penalty
Summary
The facility failed to develop a discharge plan of care for seven residents, as identified through record reviews, staff interviews, and facility policies. The facility's Discharge Planning Policy and Nursing Care Planning policy were not adhered to, resulting in the absence of documented discharge plans for residents R78, R81, R84, R98, R115, R104, and R454. These residents had participated in discharge planning and were expected to remain in the facility, yet no formal discharge care plans were documented in their Electronic Medical Records (EMR). The residents involved had various medical conditions, including cerebral palsy, dementia, respiratory failure, and hypertension, among others. Despite their participation in discharge planning, the facility did not document any discharge plans or care plans for these residents. For instance, R78, who has cerebral palsy and functional quadriplegia, was expected to remain in the facility, but no discharge plan was documented. Similarly, R454 was expected to discharge to a community facility, but the discharge care plan and summary were not completed. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of discharge care plans. Social Services staff acknowledged the omission of discharge care plans for the residents and expressed uncertainty about who was responsible for completing the discharge summary. The facility administrator indicated that the discharge summary and care plan should be completed by nursing staff or a social worker, but this was not done for the residents in question.
Incomplete Discharge Summary and Medication Reconciliation
Penalty
Summary
The facility failed to provide a completed discharge summary with a recapitulation of the resident's stay for a discharged resident, identified as R454. The resident was admitted with a hip fracture and a Stage 2 Pressure Ulcer and was discharged on 10/13/2023. The discharge summary indicated that the resident was to be discharged home with medications, home health services, and follow-up appointments with healthcare providers. However, there was no evidence that a medication list was provided to the resident at discharge, nor was there a post-discharge plan of care developed. Interviews with facility staff, including the Financial Counselor, RN Supervisor, and MDS Coordinator, confirmed the omission of a complete discharge summary in the resident's records. The RN Supervisor, who discharged the resident, was unaware of the requirement to reconcile medications with the resident or family and did not complete the necessary discharge summary. The MDS Coordinator noted that the discharge form was accessible in the EMR system but was not completed. The facility Administrator confirmed that the nursing staff or social worker should have completed the discharge summary and post-discharge plan of care, with all medications signed off by the discharge nurse with the family.
Failure to Provide PROM Treatment for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate passive range of motion (PROM) treatment for a resident with limited range of motion in the right upper extremity, specifically the right hand. The resident, who was admitted with diagnoses including cerebral palsy and functional quadriplegia, was referred to skilled occupational therapy due to increased stiffness in the right hand. An occupational therapist evaluated the resident and recommended a wrist hand splint and PROM/AAROM exercises to address the stiffness. However, the facility did not ensure that these therapeutic interventions were consistently implemented, as the resident did not receive the necessary PROM treatment. Interviews with facility staff revealed a lack of a structured restorative program and inadequate communication regarding the resident's therapy needs. A CNA assigned to restorative services reported that her duties were primarily focused on ambulation and weighing residents, with limited involvement in providing range of motion exercises. The Director of Nursing expected that range of motion exercises would be performed during resident baths and positioning, but this was not consistently done. The OT Director was unaware of the closure of the restorative program and confirmed that therapeutic interventions could have prevented further contractures. The resident's decline in hand function was not addressed in the facility's morning meetings, indicating a breakdown in communication and follow-up care.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for two residents receiving respiratory treatment. For one resident, the AutoPap mask was observed lying on the bedside dresser without being stored in a plastic bag as required by the facility's policy. Additionally, a container of distilled water used with the AutoPap machine was not labeled with an open date. Interviews with staff revealed a lack of clarity regarding responsibility for maintaining respiratory supplies, with a CNA indicating that nurses were responsible for the equipment. Another resident's nebulizer and Trilogy masks were also found not properly stored while not in use. The resident had a history of chronic respiratory failure and was non-compliant with using the Trilogy machine. Observations confirmed that the masks were left on the bedside dresser without being placed in a plastic bag. Interviews with staff, including a CNA and an LPN, revealed that the staff were aware of the storage requirements but failed to ensure compliance. The LPN admitted to not noticing the improper storage and acknowledged the potential risk of microbial contamination. The Director of Nursing confirmed that the expectation was for supplies to be properly stored and labeled, and that all nurses were responsible for ensuring compliance with these regulations. The failure to adhere to the facility's policies on storing respiratory equipment had the potential to increase the risk of respiratory complications for the residents involved.
Failure to Comply with PRN Psychotropic Medication Regulations
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of PRN psychotropic medications, specifically Ativan, for a resident identified as R111. The resident, who was admitted with diagnoses including dementia with behavioral disturbances and a psychotic disorder, was readmitted to the facility from the hospital with a PRN order for Ativan. The order did not include a stop date, and the medication was administered multiple times beyond the 14-day limit without documented rationale or reassessment by a provider. Interviews with facility staff, including the LPN, DON, ADON, and RN Supervisor, revealed a lack of awareness and understanding of the regulations requiring PRN psychotropic medications to have a stop date and be reassessed for continued use. The DON and ADON admitted they were unaware of the need for a stop date or reassessment, and the RN Supervisor, who was new to the facility, was uncertain about the requirements. The pharmacy consultant had provided recommendations to address the PRN Ativan usage, but these were not acted upon, and the necessary documentation and orders were not updated in the resident's medical record. The deficiency was further compounded by communication lapses within the facility. The RN Supervisor received a signed recommendation from the physician to continue the PRN Ativan for 180 days but failed to document this in the progress notes or update the order with a stop date. The recommendation was placed on a clipboard in the DON's office and was not followed up due to the RN Supervisor's schedule and responsibilities. This oversight resulted in the continued administration of Ativan without proper documentation or justification, violating the facility's policy and regulatory requirements.
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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