Southwell Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Adel, Georgia.
- Location
- 260 Mj Taylor Road, Adel, Georgia 31620
- CMS Provider Number
- 115655
- Inspections on file
- 18
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Southwell Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to provide a 30-day revocation period for arbitration agreements, offering only 10 days instead. Additionally, two residents were not informed about agreements signed by family members. The Admissions Director and Administrator were unaware of the requirement for a 30-day period, using a hospital-based policy instead.
The facility's arbitration agreements for three residents failed to allow for a mutually agreed upon arbitrator and venue, specifying a particular arbitrator and location in Tifton, Georgia. This non-compliance was due to the use of a hospital-based arbitration agreement, as confirmed by the Admissions Director and Administrator, who were unaware of the requirement for mutual agreement.
A facility failed to obtain or follow up on a resident's advanced directive. The resident's family member indicated they had the document but did not provide it at admission. Facility policy requires staff to encourage submission and document reminders, but no follow-up was conducted. Interviews revealed that the Social Service Coordinator and Admission Director did not pursue obtaining the directive, leaving the resident's resuscitation status unclear.
A resident with a history of stroke and severe cognitive impairment reported being physically abused by a CNA, who allegedly slapped her hand and was rough during care. The facility's investigation confirmed the abuse, resulting in the CNA's termination. The facility's abuse prevention policies were found inadequate as they did not address expectations for preventing abuse in the LTC setting.
The facility lacked comprehensive policies for preventing and investigating abuse in the LTC setting. The existing system-wide policy focused on reporting compliance concerns and did not address specific long-term care requirements, such as staff vetting or abuse recognition. Interviews with the Compliance Manager and DON confirmed the reliance on inadequate policies, highlighting a gap in addressing abuse prevention and investigation in the facility.
A resident reported being slapped by a CNA, but the facility's investigation was incomplete, lacking interviews with other residents or staff. The resident, with a history of stroke and cognitive impairment, expressed fear of further harm. The Risk Manager's investigation did not extend beyond the resident and the accused CNA, leaving potential additional abuse unexamined.
A resident diagnosed with schizoaffective disorder was not referred for a Level II PASARR as required by the facility's policy. Despite the diagnosis by a psychiatrist, the necessary referral was not made due to communication and access issues among staff. The Social Services Coordinator was unaware of the diagnosis and lacked access to request PASARR Level II, while the Compliance and Accreditation Manager confirmed the oversight.
The facility failed to implement care plans for three residents, leading to potential inadequate care. A resident with heart failure was observed without prescribed compression stockings due to laundry issues. Another resident with heart failure also lacked compression stockings despite available extras. A third resident with a urinary catheter had the catheter bag improperly placed on the floor, risking infection. Staff acknowledged these deficiencies.
A resident with an indwelling urinary catheter did not receive appropriate care to prevent UTIs. The facility lacked physician orders for catheter size and change frequency, and the catheter was observed on the floor multiple times. Staff were unsure of the catheter's rationale, and the facility had no catheter care policy. The care plan's interventions were not effectively implemented, leading to potential infection risks.
A resident with quadriplegia was found with bed rails in use without proper assessment, physician orders, or informed consent. The facility's policy requires these steps, but they were not followed, creating a potential safety risk. The resident was unable to use the bed rails due to his condition, and the Compliance Manager confirmed the oversight.
Arbitration Agreement Revocation Period Deficiency
Penalty
Summary
The facility failed to ensure that the arbitration agreements for three residents provided a 30-day period to rescind the agreement, as required. Instead, the agreements only allowed for a 10-day revocation period. This discrepancy was identified during staff and resident interviews, as well as through record reviews. The arbitration agreements were part of the facility's Conditions of Service and Consent for Treatment, which were included in the Admission Agreement. The agreements stated that any disputes related to healthcare services would be resolved through binding arbitration, and residents were waiving their right to a jury trial. However, the agreements incorrectly stated that residents had only 10 days to revoke their consent. Additionally, two residents were not informed about the arbitration agreements signed by their family members. One resident, who was cognitively intact, was unaware of the agreement but trusted their family member to sign documents on their behalf. Another resident, also cognitively intact, was not informed about the agreement, which was signed by a family member who was not the primary decision-maker according to the resident's advance directives. The Admissions Director confirmed the use of a hospital-based arbitration agreement with a 10-day revocation period, unaware of the requirement for a 30-day period. The Administrator also acknowledged the discrepancy, attributing it to the use of a hospital-based policy.
Arbitration Agreement Lacks Mutual Agreement on Arbitrator and Venue
Penalty
Summary
The facility failed to ensure that arbitration agreements for three residents allowed for a mutually agreed upon arbitrator and venue. The arbitration agreements specified a particular arbitrator and location in Tifton, Georgia, which did not comply with the requirement for both parties to agree on the arbitrator and venue. This issue was identified during a review of the facility's Conditions of Service and Consent for Treatment, which included the arbitration agreement as part of the Admission Agreement. Interviews with the Admissions Director and the Administrator revealed a lack of awareness regarding the requirement for mutual agreement on the arbitrator and venue. The Admissions Director admitted to implementing the hospital's arbitration agreement, which is part of the same organization, without knowledge of the specific requirements. The Administrator also acknowledged the discrepancy, stating that the arbitration agreement was hospital-based, which led to the specification of the arbitrator and venue in the agreement.
Failure to Obtain and Follow Up on Resident's Advanced Directive
Penalty
Summary
The facility failed to ensure they had a copy or had followed up to obtain the Advanced Directive for one resident, identified as R80. At the time of admission, R80's family member, F80, indicated that they had the advanced directive documentation but did not bring it to the facility. The facility's policy requires personnel to encourage the patient or representative to provide a copy as soon as possible and to include a reminder in the patient's medical record. However, there was no documentation in R80's electronic medical record indicating that the advanced directive was provided or that follow-up was conducted to obtain it. Interviews with facility staff revealed a lack of follow-up regarding the advanced directive. The Social Service Coordinator (SSC) stated that she typically followed up if advanced directives were not provided, but in this case, she did not follow up with F80. The Admission Director confirmed that while she asked for the advanced directive at admission, she did not follow up afterward, leaving the responsibility to the SSC. R80, who was cognitively intact, deferred decisions regarding resuscitation to F80, indicating uncertainty about the advanced directive in place. The facility's administrator verified that staff should have followed up to obtain the advanced directive copies.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, specifically a Certified Nurse Assistant (CNA). The incident involved a resident who alleged that she was slapped hard on the hand by CNA 1. The resident, who had a history of stroke and was severely cognitively impaired at the time of the incident, reported that the CNA was rough during care, loud, and did not stop when the resident yelled for help. The resident expressed fear of the CNA, stating she was afraid the CNA might smother her with a pillow. The facility's investigation confirmed the resident's allegations, leading to the suspension and subsequent termination of CNA 1. The facility's policies on abuse prevention were found lacking, as the provided policy did not address expectations related to the prevention of abuse in the long-term care setting. Interviews with the resident, the Director of Nursing, and the health care system's Risk Manager corroborated the incident and the actions taken against CNA 1.
Inadequate Abuse Prevention Policies in LTC Facility
Penalty
Summary
The facility failed to ensure that comprehensive policies and procedures were in place to prevent and investigate abuse in the long-term care setting. The existing policy, titled Compliance Investigations, dated 1/1/2020, was system-wide and primarily focused on reporting potential compliance concerns. It did not address specific expectations related to the prevention of abuse and neglect, such as mandatory staff vetting prior to hire or staff recognition of abuse. Additionally, it lacked the necessary elements for investigating allegations of potential abuse in the long-term care environment. Interviews with the Health System's Compliance and Accreditation Manager and the Director of Nursing (DON) revealed that the facility relied solely on the healthcare system's Compliance Investigations Policy, which did not meet the specific requirements for long-term care. The Compliance and Accreditation Manager confirmed that the policy only covered reporting timeframes and did not include procedures for abuse prevention or investigation. The DON acknowledged the absence of specific long-term care policies and indicated that there had been an attempt to merge the facility's policies with the healthcare system's hospital policies, which were more focused on risk management rather than the specific needs of long-term care.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported being slapped on the hand by a CNA. The investigation was limited to interviews with the resident and the accused CNA, without extending to other residents or staff who might have witnessed or experienced similar incidents. The facility's abuse prevention policies did not specifically address the expectations for investigating potential abuse allegations, which contributed to the incomplete investigation. The resident involved had a history of stroke and was initially cognitively intact, but later assessments indicated severe cognitive impairment. Despite the resident's report of rough treatment and fear of further harm, the investigation did not include interviews with other residents or staff to determine if there were additional instances of abuse by the CNA. The facility's Risk Manager conducted the investigation but did not gather statements from other potential witnesses or victims, leaving the investigation incomplete.
Failure to Refer Resident for PASARR Level II After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure that a resident diagnosed with schizoaffective disorder was referred for a Level II Pre-Admission Screening and Resident Review (PASARR) as required. The facility's policy mandates that when a mental disorder diagnosis is identified, appropriate services and treatment should be provided, including a PASARR Level II referral. However, despite the resident's new diagnosis of schizoaffective disorder by a psychiatrist, the facility did not initiate the necessary referral process. Interviews with facility staff revealed gaps in communication and access to PASARR processes. The Social Services Coordinator (SSC) indicated that she was unaware of the resident's new diagnosis and lacked electronic access to request PASARR Level II. The Compliance and Accreditation Manager confirmed that the resident had not been referred for the necessary PASARR Level II evaluation. The facility's Administrator acknowledged that the referral should have been made following the diagnosis, highlighting a breakdown in the facility's adherence to its own policies and procedures.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement the comprehensive care plan for three residents, leading to potential inadequate care. Resident 35, who was admitted with combined systolic and diastolic heart failure and vascular dementia, was observed multiple times without the prescribed compression stockings, which were intended to manage fluid volume excess and prevent edema. Interviews with nursing staff revealed that the stockings were not available due to laundry issues, and there was only one pair available for the resident. Similarly, Resident 71, with chronic systolic congestive heart failure, was also observed without the required compression stockings, despite physician orders and care plan interventions specifying their use during the daytime. The Director of Nursing confirmed that extra stockings were available, yet they were not utilized. Additionally, Resident 25, who had an indwelling urinary catheter, was found with the catheter bag lying directly on the floor, posing a risk of infection. The care plan required catheter care every 12 hours, but there were no specific physician orders for changing the catheter, and staff acknowledged the improper placement of the catheter bag.
Inadequate Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who was moderately impaired in cognition, had a catheter without documented physician orders specifying the size or frequency of changes. The medical director and attending physician were unsure of the rationale for the catheter, and the resident herself was unaware of the reason for its use. The catheter was initially inserted in the hospital due to urinary retention and obstruction, but this information was not adequately documented or communicated within the facility. During the survey, the resident's catheter and tubing were observed resting on the floor on multiple occasions, which was confirmed by staff interviews. The catheter bag was not properly secured, and staff acknowledged that it should not be on the floor due to the risk of infection and potential for dislodgement. The facility lacked a policy and procedure for catheter care, and there were no physician's orders detailing when the catheter should be changed or the size of the catheter. The facility's care plan for the resident included goals for optimal bladder function and interventions to evaluate for symptoms of UTI, promote hydration, and ensure proper catheter care. However, these interventions were not effectively implemented, as evidenced by the catheter's improper placement and lack of specific physician orders. The Director of Nursing confirmed that the catheter bag should be hung and not placed on the floor, and there should be clear orders for catheter management.
Failure to Assess and Document Bed Rail Use for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R27, was properly assessed and documented for the use of bed/side rails. Despite the facility's policy requiring an evaluation for bed rail use, a physician's order, a care plan update, and informed consent, these steps were not followed for R27. The resident, who was admitted with a diagnosis of quadriplegia, was observed with bilateral 1/3 bed/side rails in the raised position on multiple occasions. However, the resident's records, including the Admission Record, Annual Minimum Data Set (MDS), and Physician's Orders, did not reflect the use of bed/side rails, nor was there any documentation of informed consent or a recent bed rail assessment. Interviews with the resident and the Compliance and Accreditation Manager confirmed the oversight. R27, who was cognitively intact but completely dependent on staff for mobility due to quadriplegia and contractures, stated he was unable to use the bed/side rails. The Compliance and Accreditation Manager acknowledged the absence of necessary documentation and confirmed that R27 should not have had bed/side rails, as he was unable to use them. This lack of compliance with the facility's policy created a potential risk for the resident's safety.
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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