Spalding Post Acute Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Griffin, Georgia.
- Location
- 415 Airport Road, Griffin, Georgia 30224
- CMS Provider Number
- 115537
- Inspections on file
- 21
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Spalding Post Acute Llc during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow infection control and hand hygiene policies for two residents. For a resident with DM2 and severe cognitive impairment, an LPN handled a metformin tablet with bare hands while placing it in a pill cutter, contrary to facility expectations that medications not be handled with bare hands. For a resident with dysphagia and a feeding tube, an LPN changed gloves during G-tube care without performing hand hygiene between glove changes, citing an empty hand sanitizer dispenser and not washing hands instead. The nurse manager and DON confirmed that facility policy requires handwashing or use of alcohol-based hand rub after glove removal and between glove changes, and that these lapses constitute infection control issues.
The facility failed to maintain an adequate Surety Bond to cover resident trust fund balances, with the bond set at $85,207.06 while monthly balances ranged from $107,015.20 to $144,539.69 over six months. The Administrator was unaware of the discrepancy, affecting 84 residents.
The facility failed to ensure that expired medications were removed from two medication storage rooms, potentially placing residents at risk. Expired containers of mineral oil lubricant laxative, iron supplement liquid, arthritis relief, and Geri Lanta were found and discarded by an LPN and an RN. The DON stated that nurses were instructed to check expiration dates when retrieving medications.
A resident with an indwelling urinary catheter had their dignity compromised when their catheter drainage bag was left uncovered and visible from the hallway, contrary to facility policy. The resident, dependent on assistance for daily activities and with a history of medical conditions, expressed concerns about privacy. Staff interviews confirmed the oversight, with the DON acknowledging the lapse in maintaining the resident's dignity.
A resident was found with unauthorized medications at their bedside without an assessment for safe self-administration. The facility's policy requires a licensed nurse and physician to determine the safety of self-administration, but no such evaluation was documented. Staff were unaware of the medications, and the DON confirmed that self-administration is not allowed without proper assessment and orders.
The facility failed to conduct required pre-employment background checks and fingerprinting for the DON and DM, as mandated by their policy on Abuse, Neglect, and Misappropriations. Despite the oversight, no concerns related to abuse or neglect were identified during the survey. The issue was attributed to a system error and the recent departure of the HR Manager.
A facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter. Despite the resident's medical history, the care plan lacked specific interventions for the catheter. The MDS Coordinator confirmed this oversight, noting it was due to the resident's initial admission for respite care.
A facility failed to ensure a resident with an indwelling urinary catheter had a qualifying medical diagnosis for its use. The resident's medical record included conditions like hemiplegia and a history of UTIs, but no genitourinary diagnoses were documented. The catheter was ordered for a history of wounds, which was not clinically qualifying. The DON confirmed the deficiency.
A facility failed to maintain a medication error rate below five percent, resulting in a 10.34 percent error rate. An LPN administered incorrect dosages and formulations to two residents, including divalproex sodium and vitamin B12, contrary to physician's orders. The DON noted the LPN was new and needed more training.
The facility failed to follow infection control policies during care for three residents. An LPN did not sanitize hands between glove changes during a blood sugar test, a Wound Care Nurse did not sanitize surfaces or use barriers during wound care, and a syringe for a resident on tube feeding was improperly stored. These actions were contrary to the facility's infection prevention policies.
The facility failed to notify the Ombudsman of the discharge of six residents, as required by their policy. There was no documentation in the residents' medical records indicating that the Ombudsman was informed. Interviews with staff revealed a lack of awareness about this requirement, leading to non-compliance with the facility's policy.
The facility failed to follow infection control procedures for glucometer use, as observed with two LPNs who did not clean the devices after use or use barriers on surfaces. The facility's policy requires glucometers to be disinfected after each use, but this was not adhered to, leading to potential cross-contamination risks.
The facility failed to provide quarterly trust fund account statements to three residents, despite having a policy requiring such distribution. Interviews revealed that the residents had not received statements, with one resident not receiving any since February. The BOM acknowledged the responsibility for managing and distributing these statements, but the process failed, potentially affecting all residents with trust fund accounts.
The facility failed to promptly file grievances for two residents who reported concerns during resident council meetings. One resident raised issues about nebulizers and medication administration, while another reported dirty washcloths, foul-smelling laundry, and a missing wallet. Despite these concerns, no grievances were documented, indicating a failure to follow the facility's grievance policy.
Failure to Follow Hand Hygiene and Medication Handling Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its infection prevention and control program and hand hygiene policies. The facility’s Handwashing/Hand Hygiene policy states that all personnel must follow hand hygiene procedures to prevent the spread of infections, including using alcohol-based hand rub or soap and water before and after direct resident contact and after removing gloves, and clarifies that glove use does not replace hand hygiene. The Infection Prevention and Control Program policy states the facility maintains a program to prevent the development and transmission of communicable diseases and infections according to accepted standards. For one resident with diabetes mellitus type 2, admitted with diagnoses including diabetes and assessed as having severe cognitive impairment, the physician’s orders directed administration of metformin 500 mg tablets, two tablets by mouth twice daily. During a medication pass, an LPN used her bare hands to place a metformin tablet into a pill cutter to split a 1000 mg tablet into two halves for administration, rather than using gloves or another barrier. The LPN later confirmed she had handled the tablet with bare hands and acknowledged that this could cause cross contamination. The DON stated her expectation that nurses do not handle medications with bare hands because bare hands could contaminate pills and residents could receive whatever contamination was on the pills, possibly infection. For another resident admitted with diagnoses including dysphagia, rarely or never understood, and receiving nutrition via a feeding tube, the care plan documented the need for bolus PEG tube feeding and monitoring for signs and symptoms of aspiration and infection at the tube site. Physician’s orders directed cleansing of the G-tube site with sterile saline, drying, applying skin protectant, and covering with split gauze secured with tape. During G-tube care, an LPN changed gloves but did not sanitize or wash her hands between glove changes. The LPN confirmed she did not perform hand hygiene between glove changes, explaining that the hand sanitizer station in the room was empty and acknowledging she should have washed her hands. The nurse manager and DON both confirmed that facility expectations are that staff wash or sanitize hands any time gloves are removed and between glove changes, and that failure to do so is an infection control issue that could lead to healthcare-associated infections.
Inadequate Surety Bond Coverage for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a Surety Bond in an adequate amount to cover the resident trust fund account balance for six consecutive months. The Surety Bond was set at $85,207.06, while the resident trust fund account balances exceeded this amount each month from August 2024 to January 2025, with balances ranging from $107,015.20 to $144,539.69. This discrepancy was identified through staff interviews, record reviews, and a review of the facility's policy on Patient/Resident Trust Funds. The Administrator confirmed that the Surety Bond amount was insufficient compared to the resident trust fund balances and acknowledged being unaware of this issue. The facility's policy required all resident trust fund money, except for petty cash, to be maintained in an interest-bearing checking account. The deficiency had the potential to adversely affect the finances of 84 residents with trust fund accounts managed by the facility.
Expired Medications Found in Storage Rooms
Penalty
Summary
The facility failed to ensure that there were no expired medications in two of its medication storage rooms, which could potentially place residents at risk of receiving expired medications. During an observation of the Gardenia Hall medication storage room, it was found that there were three containers of mineral oil lubricant laxative, three containers of iron supplement liquid, and two containers of arthritis relief, all of which were expired. The Licensed Practical Nurse (LPN) present confirmed the expiration and discarded the expired drugs. In a separate observation of the Sunnyville Hall medication storage room, three containers of Geri Lanta were found to be expired. The Registered Nurse (RN) confirmed the expired medication and discarded it. The RN expressed uncertainty about why the expired medication was present in the storage room and mentioned that nurses randomly checked medication expiration dates. The Director of Nursing (DON) stated that nurses were instructed to check expiration dates when retrieving medications from storage rooms.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain and protect the dignity of a resident with an indwelling urinary catheter. The facility's policy on catheter care mandates that catheter drainage bags be covered at all times to ensure privacy and dignity. However, observations revealed that the resident's catheter drainage bag was not in a privacy bag and was visible from the hallway, compromising the resident's privacy. The resident expressed concerns about the lack of privacy, and a Licensed Practical Nurse acknowledged that the catheter should have been covered. The resident, who had recently transferred from a personal care home, had a medical history including hemiplegia, hemiparesis, major depressive disorder, generalized anxiety disorder, and a history of urinary tract infections. The resident was dependent on assistance for activities of daily living. A Certified Nursing Assistant confirmed that the catheter drainage bag had been uncovered before she replaced it. The Director of Nursing admitted that the staff had forgotten to cover the catheter bag after the resident's return to the facility.
Failure to Assess Resident for Safe Medication Self-Administration
Penalty
Summary
The facility failed to ensure that a resident, identified as R55, was assessed for safe medication self-administration before allowing medications to be stored at the bedside. The facility's policy requires that a licensed nurse and physician determine the safety of self-administration for each resident. However, R55's electronic medical record showed no documentation of an evaluation for self-administration of medications, and there were no physician orders or care plan interventions for medication self-administration. Despite this, observations revealed that R55 had a container of diclofenac sodium cream and sore throat spray at the bedside, which were not authorized for bedside storage. Interviews with facility staff, including a CNA and the Unit Manager, revealed that they were unaware of the medications in R55's room. The Director of Nursing confirmed that the facility does not allow self-administration of medications without a physician's order and assessment by the interdisciplinary team. The DON acknowledged that unauthorized medications should be removed and that education should be provided to the resident and family. This oversight in monitoring and assessing the resident's ability to self-administer medications led to the deficiency.
Failure to Conduct Pre-Employment Background Checks
Penalty
Summary
The facility failed to conduct pre-employment screenings, specifically background checks and fingerprinting, for two employees, the Director of Nursing (DON) and the Dietary Manager (DM). The facility's policy on Abuse, Neglect, and Misappropriations, effective February 1, 2024, mandates that criminal background checks be conducted prior to permanent employment. However, upon review, it was found that the DON, hired on February 22, 2023, and the DM, hired on February 7, 2023, did not have the required background checks and fingerprints completed. This oversight was confirmed by the facility's Employee Roster Georgia Criminal History Check System (GCHEXS) report, which did not list the DON or DM. Interviews with the Human Resources/Payroll Manager and the Administrator revealed that the corporate office was aware of the missing background checks and fingerprints. The Administrator acknowledged an issue with the system in retrieving these checks and confirmed the absence of the required documentation. Despite the lack of background checks, there were no concerns identified related to abuse or neglect within the facility during the survey. The Administrator also noted that the facility's HR Manager had recently left employment, which contributed to the inability to locate the necessary reports.
Lack of Comprehensive Care Plan for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter had a person-centered comprehensive care plan for its use. The facility's policy requires a comprehensive care plan to be developed after the completion of the resident assessment (MDS). However, a review of the resident's care plan revealed no care area or interventions for the indwelling urinary catheter. The resident's medical record included diagnoses such as hemiplegia, hemiparesis, major depressive disorder, generalized anxiety disorder, and a history of urinary tract infections. Despite these conditions, the care plan dated 2/14/2025 did not address the catheter. During an interview, the MDS Coordinator confirmed the absence of care areas or interventions for the catheter, attributing the oversight to the resident's initial admission for respite care, where the catheter was not prioritized.
Lack of Qualifying Diagnosis for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter had a qualifying medical diagnosis for its use. The resident, identified as R475, had an electronic medical record with diagnoses including hemiplegia, hemiparesis, major depressive disorder, generalized anxiety disorder, and a personal history of urinary tract infections. However, the Admission Minimum Data Set did not include any genitourinary diagnoses, and the Physician's Orders indicated the catheter was for a diagnosis/history of wounds, which was not clinically qualifying. The Director of Nursing confirmed the lack of a qualifying diagnosis for the catheter use, acknowledging the deficiency.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 10.34 percent during the observation of medication administration for two residents. The errors involved incorrect dosages and formulations of medications administered by an LPN. Specifically, one resident was prescribed divalproex sodium oral capsule delayed release sprinkle 125 mg, four capsules by mouth once daily, but was only given one capsule. Another resident was prescribed vitamin B12 oral tablet extended release 1000 mcg and calcium carbonate 600 mg oral tablet, but received vitamin B12 regular release and calcium carbonate 500 mg instead. The LPN involved confirmed the discrepancies between the administered medications and the physician's orders. The Director of Nursing acknowledged that the LPN was new and required additional training. The facility's policy on medication administration emphasizes the importance of following physician's orders and accepted standards of practice to ensure a safe and effective medication administration process. These errors had the potential to place the residents at risk of medical complications and decreased therapeutic effects of their medications.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during the care of three residents, leading to potential exposure to infections. In the case of a resident requiring fingerstick blood sugar (FSBS) tests, an LPN did not sanitize her hands between glove changes while performing the procedure. This was contrary to the facility's hand hygiene policy, which mandates handwashing between resident contact and after glove removal. The Infection Control Nurse and the Director of Nurses both confirmed that the expected procedure was not followed. Another deficiency was observed during wound care for a resident, where the Wound Care Nurse placed a tray of supplies on the resident's bedside table without sanitizing the surface or using a barrier. After completing the wound care, the tray was placed on the treatment cart without cleaning or using a barrier. Additionally, a resident receiving tube feeding had an unbagged and unlabeled catheter tip syringe on the bedside table, which was not stored or disposed of properly. The DON confirmed that enteral feeding syringes should be labeled, bagged, and properly stored or discarded after use.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman regarding the discharge of six residents, as required by their policy. The policy mandates that the Ombudsman be informed of resident discharges, including emergency transfers, either immediately or in a monthly list. However, the facility did not adhere to this requirement for any of the six residents reviewed, resulting in a deficiency. For each of the six residents, there was no documentation in their electronic medical records indicating that the Ombudsman was notified of their discharge. These residents were either transferred to a hospital and did not return or were discharged to other care settings, such as hospice. The facility's policy on transfer and discharge, which includes notifying the Ombudsman, was not followed, as evidenced by the lack of documentation and the Social Service Director's admission of being unaware of the requirement. Interviews with facility staff revealed a lack of awareness regarding the necessity of notifying the Ombudsman about resident discharges. The Social Service Director stated she was unaware of this requirement, and the Administrator confirmed that the Ombudsman had not been notified of discharges. This oversight led to the facility's failure to comply with its own policy and regulatory requirements, resulting in the identified deficiency.
Infection Control Deficiency in Glucometer Use
Penalty
Summary
The facility failed to adhere to its infection control process, specifically in the disinfection of glucometers used for blood glucose testing. Observations revealed that two out of three nurses did not follow the established protocol for cleaning and disinfecting glucometers after each use. The facility's policy, dated November 2017, clearly states that glucometers should be cleaned and disinfected after each use according to the manufacturer's instructions, regardless of whether they are intended for single or multiple resident use. However, during observations, it was noted that the nurses placed the glucometers on surfaces without using a barrier and did not clean the devices with a sanitizing wipe before storing them back in the medication cart. The first incident involved an LPN who placed the glucometer on the medication cart and the resident's overbed table without a barrier and failed to clean it after use. Similarly, the second LPN placed the glucometer and supplies on the medication cart and overbed table without a barrier and did not sanitize the surfaces. Both nurses acknowledged the need for a barrier and cleaning, but did not follow through with the required procedures. The Director of Nursing confirmed that the glucometers should be cleaned with a germicidal disposable wipe after each use and that a barrier must be used when placing the glucometer and supplies on any surface.
Failure to Provide Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements for resident trust fund accounts to three residents, R4, R6, and R9, out of 100 residents with such accounts managed by the facility. The facility's policy, dated February 1, 2024, requires that residents receive quarterly statements at the end of each calendar quarter. However, interviews with the residents revealed that they had not received these statements. R6 reported not receiving a statement since February 2024, and R9 stated he did not know the balance of his account due to not receiving statements. R4 also confirmed not receiving a quarterly statement and relied on the front office for balance inquiries. The Business Office Manager (BOM) acknowledged managing the residents' trust fund accounts and stated that the statements were prepared and given to the Receptionist and Activities Director for distribution. However, the BOM admitted it was ultimately her office's responsibility to ensure the residents received their statements. Despite the procedure in place, the residents did not receive their quarterly statements, indicating a lapse in the distribution process. This deficiency had the potential to affect all residents with trust fund accounts managed by the facility.
Failure to File Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly file grievances for two residents who verbally reported their concerns, as required by their grievance policy. One resident, who was cognitively intact, expressed concerns during a resident council meeting about the lack of nebulizers and the failure to receive medications at night. However, there was no documented grievance filed for this resident in the grievance log for the month. Another resident, also cognitively intact, reported issues with dirty washcloths, foul-smelling laundry, and a missing wallet during a resident council meeting. Despite these concerns, no grievance was documented for this resident either. Interviews with staff revealed that the Social Service Director (SSD) was responsible for tracking grievances, and grievances could be verbal or written. The SSD stated that grievances should be resolved within three days. The Activities Director mentioned that concerns raised during resident council meetings should be addressed immediately by the relevant department head or documented if the department head was unavailable. However, the SSD confirmed that no grievances were filed for the two residents in question, indicating a failure to adhere to the facility's grievance policy.
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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