Thomasville Vistas Of Journey Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Thomasville, Georgia.
- Location
- 120 Skyline Drive, Thomasville, Georgia 31757
- CMS Provider Number
- 115427
- Inspections on file
- 17
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Thomasville Vistas Of Journey Llc during CMS and state inspections, most recent first.
Two residents with documented allergies to fish and shellfish were served meals containing these allergens. One resident was given a crab cake despite a shellfish allergy, realized the error after tasting, and did not experience a reaction. Another resident with a fish allergy reported repeatedly receiving fish and returning it. Staff interviews confirmed that both dietary and nursing staff were responsible for checking meal trays for allergens, but these checks failed to prevent the errors.
Staff did not follow infection control protocols during wound and perineal care for a resident with a pressure ulcer. A CNA and an LPN both provided direct care without wearing protective gowns as required by enhanced barrier precautions, and wound care supplies were placed on an unsanitized bedside table. Staff interviews indicated gowns had not been available for a month, despite being present in the supply room.
A facility failed to obtain ordered lab tests for a resident, leading to actual harm. The resident, with multiple health conditions, had a physician order for a CBC every three months, which was not completed for March and June. In September, a critically low hemoglobin level was discovered, resulting in the resident being hospitalized for iron deficiency anemia and receiving a blood transfusion.
The facility failed to provide full RN coverage for eight hours on multiple occasions due to an automatic time clock deduction for breaks, resulting in discrepancies in the PBJ Staffing Data Report. Despite scheduling efforts, the RNs did not meet the required hours, affecting the facility's compliance with staffing regulations.
The facility failed to follow recipes for pureed carrots and chicken, affecting the nutritional value for residents on a pureed diet. Staff added water during the pureeing process, which was not in the recipe, and used an incorrect scoop size, providing less than the recommended protein portion. Interviews revealed staff were unaware of correct portion sizes and scoop measurements.
The facility failed to properly label and date food items, discard expired foods, and maintain the cleanliness of the ice machine. Observations revealed multiple unlabeled and undated food items, some past expiration, and an ice machine with chalky and black substances. Interviews confirmed lapses in adherence to policies for food handling and ice machine maintenance.
Two residents with indwelling urinary catheters were observed with uncovered catheter bags visible from their rooms, violating the facility's policy on maintaining resident dignity. Despite care plans in place, the catheter bags were not covered, which was confirmed as a dignity issue by nursing staff.
A facility failed to obtain a concurring physician's signature on a DNR order for a resident with severe cognitive impairment and no documented POA or guardian. The DNR was signed by an unauthorized person, and the resident's code status was changed to Full Code. Interviews confirmed the absence of a healthcare agent, and family members stated no legal guardianship existed.
The facility failed to provide a home-like environment, with observations of missing floor tiles, peeling paint, rust on equipment, and persistent odors in resident areas. Staff acknowledged these issues, noting offensive urine odors and rust on toilet seats and shower chairs. The Maintenance Director was unaware of needed repairs.
A facility failed to monitor a resident's dialysis access site and ensure communication with the dialysis center. The resident, with conditions like diabetes and end-stage renal disease, had no orders for site care. Staff interviews and observations confirmed lapses in documentation and communication, with missing or incomplete Dialysis Communication Sheets.
A facility failed to complete and transmit a discharge MDS assessment within 14 days for a resident who was admitted with multiple diagnoses and discharged against medical advice. Interviews revealed no discharge assessment or documentation was completed, contrary to facility policy.
A resident with end-stage renal disease did not receive proper monitoring and documentation for hemodialysis care as outlined in their care plan. The facility's records lacked consistent documentation of ongoing monitoring and communication with the dialysis center. Staff interviews confirmed missing and incomplete dialysis communication sheets, indicating a failure to adhere to the care plan.
An unsecured oxygen cylinder was found on the floor of a resident's room, posing a potential hazard. The resident, diagnosed with acute hypoxemic respiratory failure, was receiving oxygen therapy. Staff interviews revealed a lack of awareness about the danger of an unsecured cylinder, with a housekeeper, LPN, CNA, and RN failing to secure it. The LPN removed the cylinder upon discovery, and the RN expected CNAs to ensure cylinders were secured, indicating a lapse in adherence to safety protocols.
A resident with a history of urinary tract infections and sepsis had an indwelling catheter without a physician's order. The catheter tubing was frequently observed in improper positions, such as coiled, touching the floor, or obstructed by the chair's armrest, potentially impeding urine flow. Staff confirmed the absence of an active order and improper tubing positioning, despite being informed about correct procedures.
A resident receiving oxygen therapy was administered oxygen at a rate below the physician's order, and the facility failed to place required oxygen warning signage on the resident's door. The LPN and RN were unaware of these deficiencies until informed by the surveyor.
A resident with multiple diagnoses, including mood disorder and anxiety, was administered Haloperidol for agitation without prior alternative interventions. Staff interviews revealed the resident was restrained during medication administration, despite not acting out. A recommendation for Ativan as an alternative was not followed, contributing to the deficiency.
A facility failed to report an incident where a resident was allegedly restrained by the DON and LPNs during medication administration, despite the resident not acting out. The resident, with multiple health conditions, was calm and wanted to discuss the confiscation of his vape pen. The incident was not reported to the State Agency due to unfamiliarity with the process, and the Administrator was initially unaware of the situation.
A facility failed to comply with regulations for PRN antipsychotic medications. A resident returned from the ER with a PRN Haldol order, which was extended without a required physician re-evaluation. The resident received Haldol beyond the 14-day limit without proper documentation. A behavioral consultant recommended Ativan and Haldol, but there was no physician documentation for continued PRN use.
A resident with multiple health conditions was not provided with recommended restorative services after being discharged from skilled physical therapy. Communication breakdowns between the Physical Therapy Assistant, LPN, and DON led to a delay in implementing the restorative program, which included ambulation, range of motion, and transfer activities.
Residents Served Meals Containing Documented Allergens
Penalty
Summary
Two residents with documented allergies to fish and shellfish were served meals containing these allergens. One resident, with a history of gastro-esophageal reflux disease and vitamin deficiency, had shellfish listed as an allergy in both the admission record and active orders. Despite this, the resident was served a crab cake, took a bite, and then realized it contained shellfish, prompting her to spit it out and rinse her mouth. The incident was reported by a CNA, and it was confirmed by the Certified Dietary Manager that the resident had received the wrong tray. The resident did not experience an allergic reaction, but the event was documented in the facility's incident report. Another resident, diagnosed with adult failure to thrive and with a documented fish allergy, reported receiving fish every time it was on the menu and consistently sent it back. A CNA confirmed that the resident had been served a meal with fish and that she returned the tray to dietary for a replacement. Staff interviews revealed that both dietary and nursing staff were responsible for checking meal trays for allergens, but these checks failed to prevent the residents from being served foods to which they were allergic.
Failure to Follow Enhanced Barrier Precautions During Wound and Perineal Care
Penalty
Summary
Staff failed to follow infection control protocols during wound care and perineal care for a resident with an unstageable pressure ulcer. Specifically, a Certified Nursing Aide (CNA) provided perineal care and removed a soiled brief without wearing a protective barrier gown, and a Licensed Practical Nurse (LPN) performed wound care on the resident's right heel without donning a gown. Additionally, the LPN placed wound care supplies directly on a bedside table without sanitizing the surface or using a barrier, contrary to facility policy. Interviews revealed that gowns had not been available to staff for the past month, and staff were aware that gowns should be worn during high-contact care activities, especially for residents on enhanced barrier precautions. The Infection Preventionist confirmed that gowns should be used in these situations but was unsure why staff were not wearing them. An observation later confirmed that gowns were present in the supply room, indicating a breakdown in the process of making gowns available to staff at the point of care.
Failure to Obtain Ordered Labs Results in Harm
Penalty
Summary
The facility failed to ensure laboratory orders were obtained as ordered by the physician for a resident, resulting in actual harm. The resident, identified as R21, was admitted to the facility with multiple diagnoses, including idiopathic gout, cerebral infarction, aphasia, hemiplegia, diabetes mellitus, chronic systolic congestive heart failure, hypertensive heart disease, hypercholesterolemia, angina pectoris, major depressive disorder, and epilepsy. A physician order dated March 7, 2023, required the collection of a complete blood count (CBC) with differential every three months in March, June, September, and December. However, the facility did not obtain the ordered labs for March 2023 and June 2023. On September 19, 2023, the facility received lab results indicating that R21 had a critically low hemoglobin level of 5.9 g/dl, significantly below the normal range of 13.5 - 17.5 g/dl. This critical lab result prompted the facility to contact the medical director, who decided to send the resident to the emergency room. The resident was subsequently admitted to the hospital, diagnosed with iron deficiency anemia, and received two units of blood. An interview with the unit manager revealed that the CBC results for March and June 2023 were not completed and could not be located in the electronic laboratory system or the resident's medical record.
Failure to Provide Full RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for a full eight hours within a 24-hour period on multiple dates during the first quarter of 2024. The Payroll-Based Journal (PBJ) Staffing Data Report indicated that there were no RN hours recorded for specific dates, despite the facility's attempts to schedule RN coverage. The Business Office Manager confirmed that the time clock system automatically deducted 30 minutes for lunch, which resulted in the RN not being recorded as working a full eight hours. This issue was acknowledged by the Administrator, who was aware that the discrepancy could trigger a report. The Licensed Practical Nurse (LPN) Unit Manager, responsible for staffing RN coverage, reported that the new time clock system automatically clocks out staff for breaks, regardless of whether they were taken. This led to the RNs not meeting the required eight hours of coverage. The facility's census at the time was 40 residents, and the failure to provide adequate RN coverage was a recurring issue on several dates, as confirmed by the PBJ report and staff interviews.
Failure to Follow Puree Diet Recipes and Portion Sizes
Penalty
Summary
The facility failed to ensure that the recipe for pureed carrots and chicken was followed, which compromised the nutritional value of the food provided to residents on a pureed diet. During an observation, it was noted that a staff member added tap water to the carrots and chicken during the pureeing process to achieve the desired consistency, which was not indicated in the recipe. The facility also did not ensure that residents on a pureed diet received the recommended three ounces of protein during meal service. The scoop used to measure the pureed foods was a number 16 scoop, which only provided 2 3/4 ounces, falling short of the required three ounces. Interviews with staff revealed a lack of knowledge regarding the correct portion sizes and the appropriate scoop to use for measuring food. A staff member was unable to verbalize the amount of protein needed for residents on a pureed diet and was unaware of the measurement of the scoop used. The Dietary Manager confirmed that the incorrect scoop was used and acknowledged that the guide indicating the scoop sizes by color was no longer posted in the kitchen. The Dietary Manager also mentioned that staff sometimes add water or milk during the pureeing process to achieve the right consistency, which was not part of the recipe instructions.
Deficiencies in Food Labeling and Ice Machine Maintenance
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and dating of food items, as well as the timely disposal of expired foods. Observations revealed multiple instances of unlabeled and undated food items in the kitchen's reach-in coolers and on a steel table. These included a pan of tuna salad, a bag of cooked macaroni noodles, bottles of Zesty Italian dressing and strawberry syrup, a bag of brown sugar, and various salads and cheese products. Additionally, some items were found to be past their expiration dates, such as a bag of fried onions and a pan of macaroni salad. These deficiencies were confirmed by the Dietary Manager, who acknowledged the expectation that all foods should be labeled and dated, and leftovers discarded after three days. The facility also failed to maintain the cleanliness of the ice machine located in the staff break area. Observations noted white chalky streaks and a thick layer of chalky substance on the machine's exterior, as well as a thin layer of black substance on the inside panel. Interviews with the Administrator and Maintenance Director revealed that the ice machine should be cleaned daily by dietary staff and quarterly by maintenance, but the last quarterly cleaning was missed. The Dietary Manager, who was on vacation, confirmed that the machine was not cleaned as expected, and the Maintenance Director admitted that the last cleaning was incomplete.
Failure to Maintain Resident Dignity with Uncovered Catheter Bags
Penalty
Summary
The facility failed to uphold the dignity of two residents with indwelling urinary catheters, as observed by surveyors. Resident R11, who has a history of cerebral infarction, hemiplegia, hemiparesis, urinary retention, and is at risk for pressure ulcers, was found with an uncovered urinary catheter bag visible from the door on multiple occasions. Despite having a care plan in place to manage the urinary catheter and prevent infections, the catheter bag was not covered, which was confirmed as a dignity issue by a registered nurse. Similarly, Resident R20, diagnosed with chronic kidney disease and diabetes, was observed with an uncovered urinary catheter bag visible from the door. The resident's care plan included catheter care, yet the catheter bag remained uncovered during several observations. A registered nurse confirmed the lack of a dignity bag as a dignity issue. Both residents' catheter bags were not covered, contrary to the facility's policy on promoting and maintaining resident dignity.
Failure to Obtain Concurring Physician Signature on DNR Order
Penalty
Summary
The facility failed to obtain a concurring physician's signature on a Do Not Resuscitate (DNR) order for a resident, identified as R29, who was reviewed for DNR status. R29's medical record indicated diagnoses including Alzheimer's Disease, paranoid schizophrenia, and hyperlipidemia. The resident was originally admitted to the facility on May 4, 2022, and re-admitted on November 22, 2023. The medical record showed no Power of Attorney (POA) or Legal Guardian listed for R29. The Quarterly Minimum Data Set (MDS) assessments revealed severe cognitive impairment with Brief Interview Mental Status Scores (BIMS) of four and two, respectively. The DNR order for R29 was signed by an Authorized Person, purportedly a guardian, on May 4, 2022, and by one physician on May 7, 2022. However, there was no documentation confirming the existence of a guardian, POA, or healthcare agent for R29. An interview with a family member confirmed that no family member had legal guardianship or had been appointed as POA, although R29's preference was to remain a DNR. Interviews with the Unit Manager RN and LPN confirmed the absence of a healthcare agent and that R29's code status was changed to Full Code. The surveyor was unable to contact another family member to verify POA or guardianship status.
Facility Fails to Maintain Home-like Environment
Penalty
Summary
The facility failed to maintain a consistent home-like environment, as evidenced by several deficiencies observed in the living conditions of residents. Observations revealed missing floor tiles, peeling paint on walls, rust on resident equipment such as raised toilet seats, and persistent odors in resident areas. Specifically, rooms on the 300 hall were noted to have various issues, including dark brown substances on the frames of raised toilet seats, missing shower fixtures, stained tiles, and strong urine odors that permeated the resident rooms. Additionally, peeling paint and dark substances were observed on walls and ceilings in certain rooms. During an environmental tour, staff, including the RN Supervisor, Maintenance Director, and Housekeeper Supervisor, acknowledged the presence of these issues. The RN Supervisor noted that the urine odor was offensive to both residents and visitors, and the Maintenance Supervisor confirmed that the odor was embedded in the bathroom tiles, which required replacement. The Maintenance Director was unaware of the needed repairs and stated that maintenance repair forms were available at nurse stations. The staff also confirmed the presence of rust on the raised toilet seat frames and shower chairs, with the Maintenance Director indicating an attempt would be made to remove the rust.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide ongoing monitoring and care for a dialysis access site and did not ensure communication and collaboration with the dialysis center for a resident receiving dialysis services. The facility's policy on hemodialysis care, dated February 12, 2022, outlined the need for ongoing assessment and communication with the dialysis center, but these were not adhered to. The resident, who had diagnoses including type two diabetes mellitus with kidney complications, end-stage renal disease, and anemia in chronic kidney disease, had no physician orders for monitoring and care of the dialysis access site. The resident's medical records from September 5, 2023, to August 9, 2024, lacked consistent documentation of monitoring the dialysis access site and communication with the dialysis center. Interviews with nursing staff revealed that there were no specific orders for monitoring the dialysis access site, and it was the nurses' responsibility to ensure the site remained dry and intact. Observations confirmed the presence of a dialysis port with a dry dressing, but no written orders for its care. Additionally, the Dialysis Communication Sheets, which were supposed to be completed and exchanged between the facility and the dialysis center, were often missing or incomplete. Staff acknowledged the importance of these communication sheets but admitted to lapses in their completion and documentation, leading to a lack of proper communication and collaboration with the dialysis center.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment within 14 days of discharge for a resident identified as R37. According to the facility's policy on Assessment Frequency/Timelines, an OBRA discharge assessment should be completed within 14 days of discharge. However, interviews with the Unit Manager and the MDS Coordinator revealed that no discharge assessment was completed for R37, and there was no documentation of the resident's stay in the facility's medical record system. R37 was admitted to the facility with diagnoses including lipoprotein deficiency, essential hypertension, low back pain, dementia, major depressive disorder, and altered mental status. The resident was admitted in February 2024 and discharged in March 2024 after being taken out of the facility against medical advice by the family. Despite the facility's policy requiring timely documentation of discharge needs and plans, there was no record of a discharge assessment or any documentation related to R37 in the facility's system.
Failure to Follow Hemodialysis Care Plan
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R31, who required hemodialysis due to end-stage renal disease. The care plan, dated June 12, 2024, specified interventions such as assessing the arteriovenous (AV) shunt for bruit and thrill every shift, maintaining communication with the dialysis center, and monitoring for signs of infection or renal insufficiency. However, a review of the administration record from August 1 to August 31, 2024, revealed no orders or documentation for ongoing monitoring and treatment of R31's dialysis access site. Additionally, progress notes from September 5, 2023, to August 9, 2024, lacked consistent documentation and proof of ongoing monitoring and communication with the dialysis center. Interviews with facility staff, including an LPN responsible for developing care plans and an RN who reviewed dialysis communication sheets, confirmed the absence of complete documentation and monitoring for R31's dialysis needs. The RN noted missing and incomplete dialysis communication sheets from September 11, 2023, to August 2, 2024. The LPN Unit Manager expressed that her expectation was for nurses to follow the care plans for residents, indicating a lapse in adherence to established protocols for R31's hemodialysis care.
Unsecured Oxygen Cylinder Poses Hazard
Penalty
Summary
The facility failed to ensure a safe environment by not securing an oxygen cylinder in a holder for a resident receiving oxygen therapy. During an observation, an unsecured oxygen cylinder was found on the floor of a resident's room, posing a potential accident hazard. The resident, who was diagnosed with acute hypoxemic respiratory failure, was receiving oxygen via a nasal cannula at the time. The facility's policy requires oxygen to be stored according to safety guidelines, which was not adhered to in this instance. Interviews with staff revealed a lack of awareness regarding the potential danger of an unsecured oxygen cylinder. A housekeeper, LPN, CNA, and RN all interacted with the resident's room but did not ensure the cylinder was secured. The LPN acknowledged the hazard and removed the cylinder upon discovery. The RN stated that her expectation was for CNAs to remove any unused oxygen cylinders from resident rooms and to ensure those in use were placed in holders, indicating a lapse in following these expectations.
Failure to Maintain Proper Catheter Care and Physician Orders
Penalty
Summary
The facility failed to have a physician's order for a resident with an indwelling catheter, identified as R20, who was one of eight residents with such catheters. R20 had a history of urinary tract infections and sepsis, and the medical record did not show an active order for the catheter. The catheter order was mistakenly discontinued shortly after being put in place. Observations revealed that R20's catheter tubing was improperly positioned, often coiled, touching the floor, or obstructed by being placed on the armrest of a chair, which could impede urinary flow. Multiple staff members, including registered nurses and licensed practical nurses, confirmed the absence of an active catheter order and acknowledged the improper positioning of the catheter tubing. Despite being informed and in-serviced about the correct positioning of catheter tubing, a certified nursing assistant was unaware that hanging the tubing on the armrest could obstruct urine flow. The facility staff, including the MDS Coordinator and unit manager, were observed repositioning the catheter tubing multiple times, indicating a repeated failure to maintain proper catheter care for R20.
Oxygen Therapy Administration and Signage Deficiency
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with the physician's order for a resident, identified as R20, who was receiving oxygen therapy. The physician's order specified that oxygen should be administered via nasal cannula or simple mask at a rate of 2-4 liters per minute as needed for oxygen saturation below 90% or shortness of breath. However, observations revealed that R20 was receiving oxygen at a rate of 1.5 liters per minute, which was below the prescribed rate. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) who was unaware of the correct oxygen setting until it was pointed out by the surveyor. Additionally, the facility did not place oxygen warning signage on the resident's door, as required by the facility's policy. This was observed on multiple occasions, and the absence of signage was confirmed by a Registered Nurse (RN) who was also unaware of this oversight until informed by the surveyor. The lack of signage posed a potential risk, as it is intended to prevent visitors from smoking in the room while oxygen is in use.
Failure to Use Alternative Interventions Before Administering Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of Haloperidol without attempting other interventions to manage the resident's behaviors. The resident, who had multiple diagnoses including mood disorder and anxiety disorder, was administered Haloperidol on several occasions for agitation and combative behavior. However, there was no documentation of alternative interventions being attempted prior to the administration of the medication. On one occasion, the resident was agitated and threw objects, leading to the administration of Haloperidol without any prior intervention attempts. Interviews with staff revealed that the resident was held down by staff members during the administration of Haloperidol, despite not acting out at the time. The resident expressed feeling overmedicated and reported being restrained by staff. Additionally, a Nurse Practitioner recommended an alternative medication, Ativan, for agitation, but there was no evidence that this recommendation was followed or that the order was initiated. The lack of documented interventions and the use of physical restraint during medication administration contributed to the deficiency identified in the report.
Failure to Report Alleged Restraint of Resident
Penalty
Summary
The facility failed to ensure that staff reported an allegation of restraining a resident during the administration of medication. The incident involved a resident with multiple diagnoses, including chronic obstructive pulmonary disease, hypertension, and anxiety disorder, who was reportedly agitated and received Haldol. According to a Certified Nurse Aide, the Director of Nursing (DON) and two Licensed Practical Nurses (LPNs) were involved in holding the resident down while the medication was administered, despite the resident not acting out at the time. This incident was not reported immediately to the Administrator or designee as required by the facility's policy. Further interviews revealed that another LPN observed the DON restraining the resident during a separate incident, where the resident was calm and wanted to discuss the confiscation of his vape pen. The LPN did not report the incident to the State Agency due to unfamiliarity with the reporting process. The Administrator was not initially aware of the restraint incident and later received a denial from the DON regarding the use of restraint. The failure to report these incidents promptly and appropriately constitutes a deficiency in the facility's adherence to its abuse and neglect policy.
Non-compliance with PRN Antipsychotic Medication Regulations
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of PRN antipsychotic medications, specifically Haldol, for a resident. The resident was sent to the emergency room and returned with a PRN order for Haldol, which was entered into the electronic medical record as indefinite. This order was supposed to have an end date of 14 days later, but a new order was entered by an LPN extending the PRN Haldol without a face-to-face re-evaluation by a physician, as required. The resident received a dose of PRN Haldol beyond the 14-day period without the necessary physician evaluation and documentation. Additionally, a behavioral consultant recommended Ativan and Haldol for the resident's agitation, and while the physician and family were informed, there was no documentation from the physician indicating a continued need for the PRN medication. An interview with the physician confirmed that no progress note was made for the renewal of the PRN Haldol, highlighting a lapse in the documentation and evaluation process required for the continuation of PRN antipsychotic medications.
Failure to Provide Restorative Services
Penalty
Summary
The facility failed to provide restorative services for a resident who was discharged from skilled physical therapy with a recommendation for a Restorative Program. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus, was recommended to receive restorative services for ambulation, range of motion, transfer to a wheelchair, and bed mobility. However, there was no evidence in the medical records that these restorative recommendations were implemented prior to a specified date. Interviews with staff revealed communication breakdowns that contributed to the deficiency. The Physical Therapy Assistant (PTA) indicated that the resident was discharged from skilled therapy about two weeks prior, but the necessary form for restorative services was not provided. The Licensed Practical Nurse (LPN) stated that she did not receive communication from the therapy department regarding the resident's need for restorative services until a later date. The Director of Nursing (DON) acknowledged a lack of communication from the therapy department to the restorative nurse, which resulted in the resident not receiving the recommended services.
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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