Southland Healthcare And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dublin, Georgia.
- Location
- 606 Simmons St, Dublin, Georgia 31040
- CMS Provider Number
- 115376
- Inspections on file
- 27
- Latest survey
- March 15, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Southland Healthcare And Rehab Center during CMS and state inspections, most recent first.
The facility conducted blood glucose and urinalysis testing for multiple residents without a current CMS CLIA Certificate of Waiver, as the certificate had expired and was not renewed during a company transition. Staff confirmed the lapse, and the deficiency was identified through interviews and record review.
The facility did not employ a qualified RD for approximately two months, with staff and leadership unaware of the vacancy and unable to provide documentation or confirm interim coverage. This left 56 residents at risk of unmet nutritional needs due to the absence of required oversight in the food and nutrition service.
A facility licensed for 126 beds did not have a qualified Social Service Worker employed full-time to provide necessary services. Personnel files and staff interviews confirmed that the position had been vacant since the previous Social Services Director left, with no one providing consultation or oversight for residents during this period.
The facility did not provide or document the required in-service training for its CNAs, as mandated by its own policy. The DON was responsible for providing education, and the HRD for submitting in-service hours to the State Agency, but the 2024 records were missing and had not been submitted, potentially affecting 56 residents.
Staff did not ensure that a resident's oxygen concentrator was kept clean and that respiratory masks, including nebulizer and CPAP masks, were stored in protective bags when not in use. The resident, who was dependent on staff for mobility and respiratory care, had her equipment left uncovered and exposed to the environment, and staff interviews confirmed lapses in proper cleaning and storage procedures.
A resident with multiple respiratory conditions was observed receiving oxygen at a higher flow rate than ordered by the physician. Despite facility policy requiring staff to set the oxygen flow meter according to the physician's order, staff provided oxygen at 4 LPM instead of the ordered 3 LPM. Staff interviews confirmed the discrepancy, and the unit manager acknowledged the expectation to follow physician orders.
A resident experienced respiratory distress with symptoms like shortness of breath and low oxygen saturation, but the facility failed to notify the physician or Administrator of the condition or the resident's subsequent death. Staff interviews revealed a lack of communication and documentation, leading to an Immediate Jeopardy situation due to the potential for serious harm.
A resident in a LTC facility experienced respiratory distress and was neglected by staff, leading to his death. Despite showing signs of distress, such as sweating and holding his chest, the staff did not notify a physician or send him to the hospital. The RN Supervisor and LPN CC assessed the resident but focused on administrative tasks, dismissing the severity of the situation due to the resident's DNR status. Vital signs and assessments were not documented, and the facility's staff failed to follow the policy on abuse, neglect, and exploitation prevention.
A resident in respiratory distress was neglected by facility staff, resulting in their death. Despite the resident's ability to communicate their needs, the staff failed to notify the physician of the resident's significant change in condition, including shortness of breath and low oxygen saturation. The DON and Administrator were unaware of the circumstances until after the incident, and the physician stated the resident should have been sent to the ER immediately.
A facility failed to manage a resident's burial account funds properly, using them to pay care costs without authorization. The Business Office Manager transferred funds from the trust account to the burial account, unaware that burial funds were restricted to burial expenses. Checks from the burial account were issued, including one payable to the facility, indicating misuse of funds.
The facility failed to document vital signs as ordered for two residents, potentially affecting their health. One resident with hypertension and diabetes had no vital signs recorded in May and incomplete records in June. Another resident with hypertension and depression also lacked vital sign documentation in May. The DON stated that staff should document vital signs during the shift and enter any missing documentation within 24 hours.
A facility failed to maintain complete and accurate clinical documentation for a resident, resulting in a deficiency. The resident exhibited symptoms such as sweating, shaking, and chest pain, and was assessed by two nurses. However, there was no documentation of these observations or vital signs in the resident's medical records, contrary to the facility's policy. The Director of Nursing confirmed that documentation should be completed within 24 hours, which was not done.
Expired CLIA Certificate of Waiver for Laboratory Testing
Penalty
Summary
The facility failed to maintain a current Centers for Medicare & Medicaid Services (CMS) CLIA Certificate of Waiver, as required by the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Review of facility records showed that the CLIA waiver had expired, and the facility continued to conduct blood glucose checks for 15 residents daily and urinalysis testing as ordered by physicians. Staff interviews confirmed that the certificate had expired and was not renewed due to a transition between companies, and a renewal request had been denied. The deficiency was identified through staff interviews, record review, and verification against CDC and CLIA regulations.
Failure to Employ a Qualified Registered Dietitian
Penalty
Summary
The facility failed to employ a qualified Registered Dietitian (RD) to oversee the food and nutrition service, as required. During the survey, staff interviews and document reviews revealed that the facility had been without an RD for approximately two months. The Dietary Manager confirmed the absence of an RD and stated that she communicated with the MDS nurse regarding residents' diets. However, the MDS Coordinator reported that she did not communicate with the Dietary Manager about residents' diets. The facility was unable to provide a job description for the RD position, and the only documentation available described the Dietary Manager's role as assisting the Dietitian. Further interviews indicated confusion among facility leadership regarding the RD's status. The Administrator initially believed the former RD was still offering support until a replacement was hired, but the former RD clarified that her last day was over two months prior and she was no longer affiliated with the facility. The Administrator was unaware that there was no RD currently serving the facility and could not confirm any interim coverage. The Building Manager, involved in a change of company ownership, was also unaware that the RD's contract had ended. This lack of a qualified RD had the potential to affect the nutritional needs and quality of life for the 56 residents in the facility.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility, licensed for 126 beds, failed to employ a qualified Social Service Worker on a full-time basis to provide services to its residents. Review of personnel files confirmed that there was no Social Services Worker employed at the time of the survey, and no evidence of consultation or oversight for the resident population was found. Staff interviews revealed that the previous Social Services Director's last day was February 28, 2025, and since then, no one had filled the role. The Human Resources Director and Administrator both acknowledged the absence of a qualified Social Service Worker, while the Building Manager was unaware of the vacancy.
Failure to Provide Required CNA In-Service Training and Documentation
Penalty
Summary
The facility failed to provide the required in-service training for its Certified Nursing Assistants (CNAs), as evidenced by the absence of documentation for the mandated continuing education programs. The facility's own policy required CNAs to attend a minimum of 12 continuing education programs to maintain certification. Interviews with the Human Resource Director (HRD) and Administrator revealed that the Director of Nursing (DON) was responsible for providing the education, while the HRD was responsible for submitting in-service hours to the State Agency. However, the DON had not submitted the 2024 in-service hours, and the HRD confirmed that the State Agency had not received them. Additionally, the Administrator was unable to provide evidence of the required in-service training for the CNAs for 2024, and the education records could not be found. This deficiency had the potential to adversely affect the 56 residents residing in the facility.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
Staff failed to maintain respiratory equipment in a sanitary manner for a resident with multiple respiratory diagnoses, including respiratory failure, COPD, emphysema, and heart failure. The resident was dependent on staff for mobility and unable to reposition herself or reach her nightstand. Observations revealed that the oxygen concentrator used by the resident was covered with debris on multiple occasions. Additionally, the nebulizer and CPAP masks were found lying uncovered and exposed to the environment on the resident's nightstand, rather than being stored in protective bags as required. Interviews with the resident and staff confirmed that the resident could not independently manage her respiratory equipment and that nurses were responsible for placing and removing the masks. Staff acknowledged that the masks had been left uncovered and that there was confusion regarding responsibility for cleaning the oxygen concentrator and bagging the masks. The unit manager confirmed the findings after reviewing photographic evidence and stated that staff were expected to keep the equipment clean and properly stored. The facility was unable to provide a policy related to oxygen equipment maintenance and storage when requested.
Failure to Follow Physician Order for Oxygen Therapy
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for oxygen therapy for a resident with multiple respiratory diagnoses, including acute and chronic respiratory failure, asthma, COPD, and pneumonia. The facility's policy required staff to check the clinical record for the physician's order and set the oxygen flow meter to the ordered rate. However, observations on multiple occasions showed that the resident was receiving oxygen at 4 liters per minute (LPM) via nasal cannula, while the physician's order specified 3 LPM as needed. Interviews with staff confirmed that the oxygen was set higher than ordered, and the unit manager stated that staff are expected to follow physician orders and ensure the correct oxygen flow rate. The resident was cognitively intact, as indicated by a BIMS score of 15, and was documented as receiving oxygen therapy in the medical record. The failure to adhere to the ordered oxygen flow rate constituted a deviation from both physician orders and facility policy.
Failure to Notify Physician of Resident's Respiratory Distress and Death
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident experiencing respiratory distress, which included symptoms such as shortness of breath, tripoding, and a decreased oxygen saturation of 83 percent. Despite these symptoms, there was no evidence in the Electronic Medical Record (EMR) that the physician or the Administrator was informed of the resident's condition or subsequent death. Interviews with staff revealed that the Licensed Practical Nurse (LPN) documented a call to the Director of Nursing (DON) and the Administrator, but there was no evidence of notification to the Administrator. The Registered Nurse (RN) Supervisor and LPN involved did not contact the physician, believing the resident was stable, and the physician was unaware of the resident's death until informed by the surveyor. The deficiency was identified as an Immediate Jeopardy situation, indicating the facility's noncompliance had the potential to cause serious harm or death. The facility's Administrator, DON, and Corporate President of Compliance and Regulatory Services were informed of the Immediate Jeopardy, but an acceptable Immediate Jeopardy Removal Plan had not been received by the time of the survey exit. Interviews with the DON and Administrator revealed a lack of awareness regarding the resident's death circumstances, and the Administrator only became aware after the surveyor's interviews, prompting an Ad Hoc meeting to address notification and documentation procedures.
Neglect Leads to Resident's Death Due to Inadequate Response to Respiratory Distress
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in a significant change in the resident's condition and eventual death. The resident, identified as R1, experienced respiratory distress and required further medical treatment. Despite showing signs of distress, such as sweating, shaking, and holding his chest, the staff did not adequately respond to his needs. The resident was placed back in bed by staff without proper medical intervention, and he expired less than four hours later. Interviews with staff revealed that there was a lack of communication and documentation regarding R1's condition. Certified Nursing Aides (CNAs) reported that R1 was asking for help and was in distress, but the assigned nurse was unavailable. The RN Supervisor and LPN CC assessed R1 but did not take appropriate action, such as notifying a physician or sending the resident to the hospital. Instead, they focused on administrative tasks and dismissed the severity of the situation due to R1's Do Not Resuscitate (DNR) status. Further investigation showed that vital signs and assessments were not documented in the Electronic Medical Record (EMR), and the facility's staff failed to follow the policy on abuse, neglect, and exploitation prevention. The physician and Director of Nursing (DON) were not informed of the resident's critical condition, and the facility's Administrator was unaware of the circumstances until the surveyor's investigation. This lack of communication and failure to provide necessary care contributed to the resident's death.
Neglect of Resident in Respiratory Distress
Penalty
Summary
The facility administration failed to ensure that a resident, identified as R1, was free from neglect while experiencing respiratory distress. Despite R1's cognitive ability to verbalize his needs, he was left unattended and in need of further medical treatment, ultimately resulting in his death. The staff did not notify the physician of R1's significant change in condition, which included shortness of breath, tripoding, and a decreased oxygen saturation level of 83 percent. This lack of action and oversight by the facility's administration, including the Administrator and Director of Nursing (DON), contributed to the neglect of R1. Interviews with the facility's staff revealed a lack of awareness and communication regarding R1's condition and subsequent death. The DON was unaware of the circumstances surrounding R1's death and was misinformed that R1 had passed in his sleep. The Administrator also did not know about the situation until the surveyor began interviewing the staff. The physician, identified as Physician QQ, stated that R1 should have been sent to the emergency room immediately and expressed that there was no excuse for the lack of care provided, emphasizing that a Do Not Resuscitate (DNR) status does not mean withholding necessary medical care.
Improper Use of Resident Burial Account Funds
Penalty
Summary
The facility failed to properly manage a resident's burial account funds, which were inappropriately used to pay for care costs. The Resident Fund Management Service document indicated that the resident's trust fund account was meant for care cost payments with a monthly allowance, while the burial account was designated solely for burial expenses. However, a significant amount of money was transferred from the trust fund to the burial account, and subsequently, funds from the burial account were used to settle an outstanding care cost balance without proper authorization from the responsible party. The Business Office Manager admitted to transferring funds from the trust account to the burial account but was unaware that burial funds could not be used for care costs. The review of financial documents showed that checks were issued from the burial account, one of which was made payable to the facility, indicating the use of burial funds for care costs. The resident in question had passed away, and there was no evidence of authorization for the transfer of funds from the burial account to cover care costs, highlighting a deficiency in the facility's management of resident funds.
Failure to Document Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that vital signs were obtained as ordered for two residents, R1 and R3, which had the potential to negatively affect their physical health and well-being. R1 was admitted with diagnoses including hypertension and type 2 diabetes mellitus. An order was placed for R1 to have vital signs taken every Monday during the day shift starting from May 8, 2024. However, no vital signs were documented in May 2024, and only two entries were recorded in June 2024, with missing documentation for June 10 and June 17, 2024. Similarly, R3, who was admitted with diagnoses including hypertension and major depressive disorder, had an order for vital signs to be taken every Monday during the day shift starting from January 15, 2024. The records showed no evidence of vital signs being obtained in May 2024. The Director of Nursing confirmed that staff should document vital signs during the shift and that any missing documentation should be entered within 24 hours.
Incomplete Clinical Documentation for Resident
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for a resident, identified as R1, which is a violation of their policy titled Clinical Documentation. The policy mandates that nursing staff document the provision of care according to nursing standards and regulatory requirements, ensuring that all interdisciplinary team members have access to appropriate information regarding treatment interventions and responses. However, a review of R1's medical records revealed a lack of documentation of vital signs and events leading up to R1's death, with the last recorded vital signs dated several days prior to the incident. Interviews with staff members highlighted further discrepancies in documentation. A Certified Nursing Assistant (CNA) reported that on the evening of the incident, R1 exhibited symptoms such as sweating, shaking, and chest pain, and was assessed by two nurses who checked his pulse, oxygenation, and vital signs, and administered oxygen. Despite these critical observations, there was no corresponding documentation in R1's medical records. The Director of Nursing confirmed that staff are expected to document during their shift and complete any missing documentation within 24 hours, which was not adhered to in this case.
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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