Thunderbolt Care Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Savannah, Georgia.
- Location
- 3223 Falligant Avenue, Savannah, Georgia 31404
- CMS Provider Number
- 115624
- Inspections on file
- 29
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Thunderbolt Care Center Llc during CMS and state inspections, most recent first.
Two residents experienced unwitnessed falls resulting in major injuries, but their comprehensive care plans were not updated or revised to reflect these incidents or to implement new interventions. Despite documented histories of falls and significant changes in condition, care plans remained outdated and only included general fall prevention measures. Staff interviews confirmed that care plan updates were not consistently performed after significant events, contrary to facility policy.
Two residents with cognitive impairment and high fall risk experienced repeated unwitnessed falls resulting in serious injuries, including fractures and head trauma. Despite documented histories of falls, the facility did not consistently complete post-fall or neurological assessments, update care plans, or implement recommended interventions such as increased staff monitoring. Environmental safety measures like fall mats were also lacking, and staff were sometimes unaware of injury origins.
The facility did not ensure RN coverage for at least eight consecutive hours per day on multiple occasions, with timecard reviews and staff interviews confirming insufficient RN presence and lack of direct resident care by RNs. Requested staffing documentation was not provided, and staff reported ongoing RN vacancies and inconsistent coverage, potentially affecting all residents.
Surveyors found the central supply room unlocked and open, allowing unauthorized access to various medications, including expired items. Staff interviews revealed uncertainty about procedures for securing the room and accessing keys, resulting in a lapse in compliance with medication storage policies.
The facility did not maintain daily nurse staffing data for the required 18 months. The Scheduler could not locate the records and indicated they were either in the DON's office, in storage, or discarded. The Scheduler and Regional Nurse were observed recreating the staffing information from employee punch reports. The facility census was 115.
A resident with multiple complex medical conditions experienced cardiac arrest and required CPR, but staff were unable to perform effective airway management due to missing and nonfunctional suction equipment on the crash cart. Essential supplies had not been replaced after prior use, crash cart checklists were incomplete or falsified, and staff lacked documented competency in using the suction machine, resulting in delayed emergency response and inability to clear the resident's airway.
A resident experienced a code blue event during which staff were unable to use the crash cart's suction machine due to missing supplies, resulting in an inability to clear the resident's obstructed airway. Staff had not been properly trained or assessed for competency in using the suction machine, and crash cart checklists were signed without verifying supplies. The DON and Administrator were unaware of the deficiencies until after the incident, and routine checks and documentation for emergency equipment were lacking.
A resident with moderate cognitive impairment and multiple health conditions was found to be living in a room with a persistent cockroach infestation. The resident reported the issue had been ongoing for months, and observations confirmed live and dead cockroaches in the bathroom. Facility staff, including the Maintenance Director and Administrator, were unaware of the infestation, and pest control services had not directly treated the resident's room.
A resident with severe cognitive impairment and behavioral disturbances repeatedly wandered into other residents' rooms and displayed aggressive behaviors, culminating in an incident where the resident pulled a dependent, hospice patient from her bed, causing her to fall. Staff were aware of the ongoing behaviors but did not provide adequate supervision or communicate concerns to leadership, resulting in a failure to protect residents from abuse as required by facility policy.
A resident with severely impaired cognition was involved in an incident that was only reported to the nurse on duty by CNAs, and not escalated to the DON or Administrator as required by facility policy. As a result, the mandated report of alleged physical abuse was not submitted to the appropriate authorities in a timely manner, and the Administrator, who serves as the Abuse Coordinator, was unaware of the incident.
Two residents, both with significant cognitive impairments and behavioral issues, were involved in a physical altercation where one pulled the other out of bed, causing a fall. Despite facility policy requiring thorough investigation and monitoring, staff did not complete required documentation, skin assessments, or initiate a comprehensive investigation. The DON and social worker were aware of the incident, but the Administrator was not informed, and the investigation process was not properly followed.
Two residents with severe cognitive impairment did not have required care plans addressing abuse prevention and management of abusive behaviors, despite one resident experiencing an incident involving another resident. The absence of these care plans was confirmed by the MDS Coordinator as an error, in violation of facility policy.
A resident with dementia and behavioral disturbances exhibited escalating aggression and was involved in multiple incidents, including physically harming another resident. Despite these behaviors, staff did not implement required behavioral health interventions or provide one-to-one supervision, and psychiatric services were not consulted until after a serious incident occurred. Leadership and clinical staff interviews confirmed a lack of awareness and follow-up regarding the resident's behavioral health needs.
Facility administration failed to implement its abuse prevention system, resulting in an incident where one resident physically abused another. The event was not reported to required agencies in a timely manner, and a thorough investigation was not conducted. Nursing staff notified the DON, but no skin assessments were performed, and the Administrator was unaware of the abuse allegations. Additionally, care plans for the residents involved were not created or updated following the incident.
A facility failed to implement a comprehensive care plan for a resident's nutritional intake, despite the resident being at risk for malnutrition. The care plan required monitoring and recording meal intake, but documentation was inconsistent due to computer issues in the Memory Care unit. Staff interviews revealed expectations for daily task completion, but some CNAs lacked access to personal devices for documentation, and the Administrator acknowledged ongoing computer issues.
A resident on a puree diet was given a sandwich, leading to choking and death. The facility failed to follow dietary orders, and staff were not adequately informed or trained to prevent such incidents. The resident had a history of dysphagia and dementia, and the incident was not properly investigated or documented by the facility's DON and staff.
A resident with a history of dysphagia and dementia, on a pureed diet, choked on a sandwich and died. The facility failed to follow dietary orders, and the DON did not investigate or document staff education. The Administrator was not fully informed initially, and staff education on dietary orders began after the incident.
The facility failed to ensure resident safety and proper equipment maintenance, leading to several deficiencies. A resident had unsecured oxygen cylinders, posing a fire hazard. Another resident was allowed to smoke without a proper safety assessment, contrary to facility policy. Additionally, a resident experienced a fall due to a malfunctioning mechanical lift, which was not properly reported or repaired. These incidents highlight significant lapses in safety protocols and equipment management.
The facility failed to secure medications and maintain proper storage conditions, with unlocked medication and treatment carts observed in the East Hall and expired items found in the [NAME] Hall medication room. Staff interviews confirmed these lapses, indicating non-compliance with the facility's medication storage policy.
The facility did not record food temperatures as required by their Food Safety policy, potentially affecting all residents on an oral diet. The policy mandates that hot food and beverages be served at safe temperatures, with staff responsible for logging these temperatures at every meal. However, the logbook showed missing entries for several days in December. The Dietary Manager confirmed the importance of logging temperatures to ensure food safety and prevent residents from receiving improperly heated meals.
The facility failed to maintain an effective infection control program, with deficiencies observed in medication administration, wound care, respiratory equipment storage, and linen management. An LPN touched medication with her hand, and another did not follow Enhanced Barrier Precautions during wound care. Respiratory equipment was improperly stored, and clean and dirty linen carts were placed side by side. The facility's water management program was also found lacking.
The facility failed to properly assess and accommodate six residents for placement in the Memory Care Unit, as per their policies. Residents were placed in the unit without meeting criteria such as elopement risk or need for frequent monitoring. Observations showed that some residents, who were non-ambulatory and dependent on care, were placed in the unit due to family requests, despite not exhibiting exit-seeking behaviors. The DON acknowledged the inappropriate placements and the lack of documentation regarding family requests.
The facility failed to provide a written explanation for hospital transfers for three residents, as required by their policy. Medical records lacked documentation of notification, and staff interviews revealed a lack of awareness about the requirement. The administrator confirmed that transfer notices were not being sent with residents.
The facility failed to notify residents of the bed-hold policy before hospital transfers, affecting three residents. Despite a policy requiring written notification, staff interviews revealed confusion and lack of responsibility for issuing these notices. The Administrator confirmed that bed-hold notices were not being sent, indicating a systemic issue.
The facility failed to maintain resident dignity by referring to those needing meal assistance as 'feeders.' This was observed in the Memory Care Unit, where staff used the term in the presence of residents, and a board listing residents' names under 'feeder' was visible to visitors. A resident with dementia and other health issues was directly affected, with an LPN acknowledging the error and a lack of training on appropriate terminology.
A resident with chronic conditions and cognitive awareness was found with unauthorized medications in their room, contrary to the facility's policy. An LPN confirmed the medications were present and acknowledged the resident was taking them, but could not explain why they were not secured on the treatment cart.
The facility failed to maintain adequate lighting in a corridor with six rooms, affecting 10 residents. Three out of seven ceiling lights were not functioning, and despite the Maintenance Director's acknowledgment and intention to replace them, the lights remained unrepaired over several days. No outstanding repair orders were found in the maintenance book.
A resident experienced a fall due to a malfunctioning mechanical lift and filed a grievance, but the facility failed to follow its grievance procedures. Despite the resident's cognitive intactness and need for extensive assistance, the grievance was not addressed, and documentation was missing. Interviews with staff revealed confusion about the grievance process and a lack of follow-up.
The facility failed to provide adequate ADL care for four residents, leading to unmet needs and diminished quality of life. A resident with dementia was observed with long facial hair, indicating a lack of grooming. Another resident with severe cognitive impairment had long, dirty fingernails, despite the facility's nail care policy. A third resident was not offered showers as required, and a fourth resident with severe cognitive impairment was observed with facial hair, which staff failed to address during grooming sessions.
A resident with a urinary catheter was observed with the catheter tubing coiled and incorrectly positioned, potentially obstructing urinary flow. The catheter drainage bag was uncovered and dragging on the floor, contrary to facility policy. Staff confirmed these issues, acknowledging infection control concerns.
A resident with a diagnosis of malignant neoplasm and anemia was prescribed oxygen therapy at 4 LPM. However, observations revealed the resident was receiving oxygen at lower levels than ordered. Staff interviews confirmed the discrepancy, indicating a failure to follow physician orders.
A resident with multiple diagnoses, including dementia and schizoaffective disorder, was not seen by their primary physician within the required time frame after admission. The resident was only seen by a Nurse Practitioner initially, with the first documented visit by the primary physician occurring two months later. Interviews revealed a lack of awareness of the visitation schedule by the Medical Director and the inability of the DON to provide documentation for the required visits.
Failure to Update Care Plans After Major Injury Falls
Penalty
Summary
The facility failed to update and revise the comprehensive person-centered care plans for two residents following unwitnessed falls that resulted in major injuries. For one resident with a history of falls and multiple diagnoses including muscle weakness and lack of coordination, the most recent care plan had not been updated since several months prior to a significant fall event. This resident attempted to get out of bed unassisted, fell, and sustained multiple injuries including a head laceration, eye injury, right humerus fracture, and right femoral fracture. The care plan in place at the time only included general fall prevention interventions and did not reflect the recent incident or any new interventions tailored to the resident's changed condition. Another resident, also with a history of falls and diagnoses such as muscle weakness, lack of coordination, and dementia, experienced a severe unwitnessed fall resulting in a subdural hematoma, traumatic subarachnoid hemorrhage, hypotension, and complex lacerations to the head and face. The care plan for this resident had not been revised since several months before the incident, despite multiple prior falls being documented. The interventions listed were general in nature and did not address the specific circumstances or injuries resulting from the most recent fall. Interviews with facility staff, including MDS coordinators and social workers, revealed that while audits and cross-referencing of care plans were performed, there was a lack of timely updates to care plans following significant changes in resident condition, such as falls with major injury. Staff acknowledged that significant changes, such as fractures after a fall, should prompt reassessment and care plan revision, but this was not consistently done. The facility's own policy requires comprehensive care plans to be updated to reflect measurable objectives and interventions based on current assessments, which was not followed in these cases.
Failure to Provide Adequate Supervision and Fall Risk Reassessment Resulting in Harm
Penalty
Summary
The facility failed to ensure adequate supervision and timely reassessment of fall risk for two residents with a history of repeated falls, resulting in significant injuries. For one resident with moderate cognitive impairment and a high fall risk score, there were four unwitnessed falls over five months, culminating in a fall that caused a head laceration, closed traumatic eye injury, right humerus fracture, and right femoral fracture. Despite an interdisciplinary team (IDT) discussion recommending increased staff monitoring, there was no documentation that this intervention was implemented. Additionally, post-fall assessments and neurological checks were either incomplete or missing, and care plans were not updated to reflect the resident's ongoing fall risk or new interventions after each incident. Another resident with severe cognitive impairment and a high fall risk score experienced multiple falls with injuries, including a recent incident resulting in a subdural hematoma, traumatic subarachnoid hemorrhage, hypotension, and complex facial lacerations. The facility did not conduct updated fall risk assessments after the initial assessment, and post-fall and neurological assessments were inconsistently completed. There was no evidence that the IDT met or revised the care plan in response to the resident's increased fall frequency or injuries. Observations revealed that environmental safety measures, such as fall mats, were not present, and staff were unaware of the origins of some injuries. Interviews with facility staff, including the DON and Medical Director, confirmed that falls and injuries occurred and that standard protocols for assessment and intervention were not consistently followed. The facility's policy required evaluation, implementation, and monitoring of interventions to prevent accidents, but documentation and practice did not align with these requirements. The lack of reassessment, incomplete documentation, and failure to update care plans contributed to the residents' repeated falls and resulting harm.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. During a 30-day review period, there were five days when no RN was on duty for the minimum required hours. Review of timecard punches and staffing grids confirmed that on these dates, RN coverage was insufficient, with some days showing only partial RN presence and others lacking any RN time punches. The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Infection Preventionist (IP), all of whom are RNs, did not consistently have time punches or provide direct resident care during these periods. The facility was unable to provide requested documentation, including the facility assessment, staffing policy, and daily staffing posts for the previous 30 days. Interviews with staff revealed that RN coverage was often provided by the DON and ADON, but the exact amount of time and consistency of this coverage was unclear. Staff also indicated that RN coverage was sometimes lacking on weekends. The IP and ADON confirmed they did not provide direct resident care, and the DON stated that there were multiple RN vacancies and that agency RNs were used to attempt to fill shifts. The Regional Nurse's hours could not be verified, and the Administrator was unavailable for interview. The facility census at the time was 115 residents, all of whom had the potential to be affected by the lack of required RN coverage.
Failure to Secure Central Supply Room Containing Medications
Penalty
Summary
The facility failed to ensure that the central supply closet containing over-the-counter medications was closed and locked, as required by facility policy and professional standards. During an observation at 11:15 pm, the central supply room was found unlocked and open, providing access to various medications and supplies, including expired items such as six bottles of Zinc 50 mg and one package of AZO urinary pain relief. The facility's policy mandates that all drugs and biologicals be stored in locked compartments under proper conditions, but this was not followed in this instance. Interviews with staff revealed confusion and lack of clear direction regarding access and security of the central supply room. An LPN reported being unable to reach the ADON or RDO for guidance and expressed concern about locking the door without having a key for future access. Another staff member indicated that the key to the central supply room is typically left at the front desk for staff use, and that she checks daily to ensure the door is locked. Despite these procedures, the room was found open and accessible during the survey, in violation of facility policy.
Failure to Maintain Required Nurse Staffing Records
Penalty
Summary
The facility failed to maintain daily nurse staffing data for at least 18 months as required. During an interview, the Scheduler was unable to locate the daily nurse staffing information and stated that it was usually kept in the DON's office, in storage, or discarded. An observation confirmed that the Scheduler and the Regional Nurse were attempting to recreate the daily nurse staffing information using employees' punch reports. The facility census at the time was 115.
Failure to Maintain Crash Cart Supplies and Staff Competency During CPR Event
Penalty
Summary
The facility failed to ensure that emergency equipment on the crash cart was maintained and operational, resulting in staff being unable to perform adequate respirations during CPR for a resident who experienced cardiac arrest and had emesis obstructing the airway. The crash cart on the affected wing was missing multiple essential emergency supplies, including a Yankauer suction catheter, suction tubing, suction canister, electric cord, CPR board, and tongue depressors. Staff interviews and observations confirmed that these items had been used during a previous code event and were not replaced, and the crash cart checklist was either missing or not properly completed, with staff signing off without verifying the actual contents. The resident involved had a complex medical history, including Guillain-Barre Syndrome, dysphagia following cerebrovascular disease, gastrostomy status, dementia, pulmonary embolism, and GERD. The resident was dependent on enteral feeding and at risk for aspiration, with care plan interventions to mitigate this risk. On the day of the incident, the resident was found unresponsive, and a code blue was initiated. During the resuscitation attempt, staff discovered that the necessary suction equipment was not available or functional, which delayed their ability to clear the resident's airway of vomit and perform effective ventilation. Staff had to retrieve missing supplies from another unit, further delaying emergency response efforts. Interviews with nursing staff and the DON revealed that agency nurses had not been formally trained on the use of the suction machine, and there was no documentation of such training. The DON was unsure if the orientation checklist included suction equipment, and it was confirmed that the crash cart was only restocked after the survey team arrived. The responsibility for stocking the crash cart was unclear, with central supply, the ADON, and the UM all mentioned as points of contact for equipment concerns. The memory care unit's crash cart was described as outdated and not actively used, and the process for routine checks and restocking was not followed, contributing to the deficiency.
Failure to Maintain and Monitor Emergency Crash Cart Supplies and Staff Competency
Penalty
Summary
The facility failed to provide adequate oversight and management of emergency crash carts, resulting in missing and nonfunctional emergency equipment during a code blue event involving a resident. Staff interviews and record reviews revealed that when the resident was found unresponsive, staff attempted to use the crash cart's suction machine but discovered that essential supplies, including suction tubing, a Yankauer, and a canister, were missing. As a result, the suction machine could not be operated, and staff were unable to clear the resident's airway, which was obstructed by vomit and food particles. Attempts to ventilate the resident with an Ambu bag were also unsuccessful due to the airway obstruction. Further investigation showed that the crash cart checklists for March and April had not been properly maintained, with staff signing off on checks without verifying the presence of necessary supplies. The Director of Nursing (DON) was unaware of the crash cart deficiencies during the incident and only learned of the missing supplies after the event. Additionally, it was confirmed that staff, including agency nurses, had not been appropriately trained or assessed for competency in using the suction machine, and there was a lack of routine checks and documentation for emergency cart supplies. The Administrator was not informed of the missing equipment or the incident until several days after it occurred, and did not receive a completed incident report in a timely manner. The Administrator acknowledged that facility policies were not followed, and that the crash cart checklist had been incorrectly signed. The lack of oversight, failure to ensure staff competency, and absence of routine equipment checks contributed to the facility's noncompliance, which was determined to have caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
Failure to Provide Pest-Free Environment for Resident
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment and multiple medical diagnoses, including dementia and hemiplegia, was found to be living in a room infested with cockroaches. The resident reported that his bathroom had been infested for several months and that, to his knowledge, no treatment had been applied to his room. During an observation, three live cockroaches were seen in the resident's bathroom, and photographic evidence was obtained. Additionally, an outside physician's office reported that, during a recent visit, more than one cockroach fell off the resident, and staff were observed stomping on the bugs to kill them. The Maintenance Director confirmed the presence of live cockroaches in the resident's bathroom and stated he was unaware of the infestation. He also revealed that while the facility has a pest control contract with monthly service, he was unsure if the resident's room had been treated. The Administrator later confirmed that pest control services focus on the perimeter and exterior of the building, and that residents' rooms are not directly treated. The Administrator was previously unaware of the infestation in the resident's bathroom.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident, resulting in an Immediate Jeopardy situation. The incident involved a resident with severe cognitive impairment and behavioral disturbances who repeatedly wandered into other residents' rooms, displayed aggressive and inappropriate behaviors, and was not adequately supervised. Despite documented patterns of wandering, aggression, and inability to be redirected, the facility did not implement sufficient oversight or interventions to prevent resident-to-resident abuse, as required by its own policies. On the night of the incident, the resident with behavioral disturbances entered the room of another resident who was dependent for all activities of daily living, minimally responsive, and receiving hospice care. The aggressive resident, who was undressed at the time, pulled the dependent resident out of bed, causing her to fall to the floor. Staff interviews and progress notes revealed that the aggressive resident had a history of similar behaviors, including entering other residents' rooms, verbal aggression, and physical altercations. Staff were aware of these behaviors but failed to maintain adequate supervision or implement effective interventions to prevent further incidents. Documentation and interviews indicated that staff did not consistently communicate or escalate concerns about the aggressive resident's behaviors to facility leadership. The Director of Nursing and Administrator were not made aware of the full extent of the resident's wandering and aggressive behaviors prior to the incident. The facility's policies required ongoing oversight and supervision to protect residents from abuse, but these measures were not effectively implemented, resulting in a failure to safeguard vulnerable residents from harm.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident with severely impaired cognition. According to the facility's policy, all alleged violations of abuse, neglect, or exploitation must be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes. However, after an incident involving two residents, Certified Nursing Assistants (CNAs) only reported the event to the nurse on duty and did not escalate it further. The Director of Nursing (DON) and the Administrator, who also serves as the Abuse Coordinator, were not made aware of the incident in a timely manner, resulting in the required report not being submitted as mandated by policy. Interviews confirmed that both CNAs involved in the incident only informed the nurse, and neither the DON nor the Administrator was notified until later. The Administrator acknowledged that she was unaware of the abuse allegation and confirmed that, had she known, she would have reported it immediately. A review of facility-reported incidents showed no evidence that the allegation of physical abuse was reported as required. The Immediate Jeopardy related to this noncompliance was determined to have existed for a period of time and was ongoing at the time of the survey exit.
Failure to Investigate and Protect After Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation and implement timely protective measures following an allegation of resident-to-resident physical abuse involving two residents. According to the facility's Abuse Prevention Policy & Procedure, all incidents are to be documented in the resident's medical record with intense monitoring for at least 72 hours. However, after an incident where one resident with dementia and behavioral disturbances pulled another resident with severe cognitive impairment out of bed, resulting in a fall, the facility did not perform required skin assessments or initiate a comprehensive investigation. The incident was reported to the DON, physician, and family, but the Administrator was not informed, and the investigation process was not properly initiated. Interviews revealed that staff, including the DON and social worker, were aware of the incident and communicated with the involved parties, but failed to follow the facility's policy for abuse investigation and documentation. The DON acknowledged that negative behaviors should have been documented and that no skin assessments were completed after the incident. The Administrator confirmed that a thorough investigation was not conducted and indicated that changes would be made to the investigation process. The Immediate Jeopardy was identified as ongoing at the time of survey exit.
Failure to Develop and Implement Abuse-Related Care Plans for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with severe cognitive impairment. One resident, diagnosed with dementia and muscle weakness, experienced an incident where another resident entered her room, pulled her out of bed, and disrobed her. Despite this event, there was no care plan implemented to address abuse prevention or ensure her safety from future occurrences. Review of her records confirmed the absence of an abuse care plan. Another resident, also with dementia and behavioral disturbances, did not have a care plan in place to address his abusive behaviors or interventions to monitor and ensure the safety of other residents. Both omissions were confirmed by the MDS Coordinator, who acknowledged that the lack of care plans was an error by the MDS staff. The facility's policy requires the development and implementation of comprehensive care plans for each resident, but this was not followed for these two individuals.
Failure to Provide Behavioral Health Services and Supervision
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of adjustment disorder, unspecified dementia with behavioral disturbances, and depression. The resident exhibited significant worsening behaviors, including increased agitation, wandering into other residents' rooms, use of profanity, and physical aggression. Documentation showed that the resident was involved in multiple incidents, such as pulling another resident out of bed, disrobing, and threatening or aggressive behavior toward both staff and other residents. Despite these escalating behaviors, there were no documented interventions or referrals to psychiatric services prior to a serious incident of physical abuse. Observations revealed that the resident was frequently unsupervised and not within the line of sight of staff, even after incidents of aggression. Nursing staff were observed performing other duties away from the resident, and there was no evidence of one-to-one supervision or close monitoring, as would be expected for a resident with such behaviors. The facility's policy required monitoring and support for behavioral health needs, but these measures were not implemented for the resident in question. Interviews with facility leadership and clinical staff confirmed a lack of awareness and follow-up regarding the resident's behavioral health needs and required supervision. The Director of Nursing was aware of the incident but did not ensure appropriate psychiatric follow-up or increased supervision. The Physician Assistant was unaware of the resident's aggressive behaviors and stated that psychiatric services and closer monitoring should have been provided. The failure to implement necessary behavioral health interventions and supervision led to an incident where another resident was harmed.
Failure to Implement Abuse Prevention and Timely Reporting
Penalty
Summary
Facility administration failed to implement all components of its abuse prevention system in a thorough and timely manner, resulting in noncompliance with regulatory requirements. Specifically, the administration did not ensure that incidents of physical abuse involving two residents were properly addressed. The incident involved one resident pulling another resident out of bed, causing a fall, and occurred in the early morning hours. Documentation shows that the resident who initiated the incident was found unclothed and aggressive, while the other resident was found on the floor. Despite these events, the administration did not maintain an environment free from abuse, as required by their job descriptions and facility policy. The incident was not reported to the appropriate agencies in a timely manner, and a thorough investigation was not conducted. Interviews with nursing staff revealed that the Director of Nursing (DON) was notified of the incident, but no skin assessments were performed on the residents involved, and the DON did not report the incident. The Administrator, who also serves as the Abuse Coordinator, was unaware of the abuse allegations and confirmed that the report was not submitted on time. The lack of timely reporting and investigation contributed to the facility's failure to protect residents from abuse. Additionally, the facility did not create or update care plans for the residents involved in the abuse incident. The absence of care planning for both the resident who was abused and the resident who perpetrated the abuse further demonstrates the administration's failure to address the situation adequately. These deficiencies were identified during a survey, and the situation was determined to be an Immediate Jeopardy to resident health and safety.
Failure to Implement Comprehensive Care Plan for Nutritional Intake
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident, specifically regarding nutritional intake. The resident, who was admitted with diagnoses including dementia, adult failure to thrive, and type two diabetes mellitus, was identified as being at risk for malnutrition due to sepsis. Despite having a care plan in place that required monitoring and recording of meal intake, the facility did not consistently document the percentage of meals consumed by the resident. Over a 30-day period, meal intake was only recorded on a few specific dates, indicating a lack of adherence to the care plan. Interviews with facility staff revealed that the Director of Nursing expected all tasks to be completed daily, but computer issues in the Memory Care unit hindered documentation. Some CNAs had to use personal devices to complete their tasks, but not all had access to such devices. The facility's Administrator confirmed ongoing issues with desktop computers and stated that meal intake could be documented on paper forms, suggesting a lack of consistent and reliable documentation methods for monitoring the resident's nutritional intake.
Failure to Follow Dietary Orders Leads to Resident's Death
Penalty
Summary
The facility failed to adhere to dietary orders for a resident, identified as R572, who was on a puree diet. On the day of the incident, R572 was provided with a sandwich, which was not in accordance with her prescribed diet. This led to the resident choking, resulting in cardiac arrest and subsequent death. The incident was observed by a CNA who attempted to perform the Heimlich maneuver, but it was unsuccessful. The resident was pronounced dead at the facility, and the cause of death was listed as cardiopulmonary arrest. R572 had a medical history that included a cerebrovascular accident (CVA), dysphagia, cognitive communication deficit, and unspecified dementia. Her diet order specified a regular diet with pureed texture and thin consistency. Despite this, on the morning of the incident, a sandwich was found in front of her, and evidence suggested she had consumed part of it. Interviews with staff revealed that the night shift CNAs had provided snacks, including sandwiches, to residents, and there was confusion about whether R572 had taken the sandwich from another resident or if it was given to her. The facility's Director of Nursing (DON) and other staff members were not fully informed or did not follow up adequately on the incident. There was a lack of documentation and investigation into the circumstances surrounding R572's death. Interviews with various staff members indicated that there was no prior education or in-service training related to following dietary orders or monitoring residents for behaviors that could lead to choking. The facility's failure to ensure that dietary orders were followed and to provide adequate supervision and education contributed to the tragic outcome.
Removal Plan
- The policy on Therapeutic Diet Orders and Provision of Quality Care was reviewed by the Administrator, Medical Director and Nurse Consultant with no revisions made.
- The Dietary Manager started to audit all resident's diet orders on PCC and reconciled with software to ensure accuracy of what's ordered by MD and what's on the meal ticket. 11 residents were on large portions, and this is now reflected in PCC. Staff interviews were conducted by the nurse managers to identify any other residents who tend to retrieve food from other areas, and no other resident was identified to have this behavior.
- The Regional Nurse educated the Nurse Managers and dietary manager regarding the importance of ensuring that residents are served the appropriate diet, as prescribed by MD to prevent any adverse effects. Facility wide education for monitoring any resident for choking was completed by the nurse consultant. Staff were educated using the [NAME] if you see something say something. Education included that any resident noted to have any behavior which poses self-risk, such as taking/grabbing/retrieving food or drinks not meant for them should immediately be reported to the nurse/nurse manager/DON. Residents on a mechanically-altered diet who manifest this type of behavior should sit with peers with similar diet to prevent risk of choking. Staff were also educated to provide direct supervision to residents with that known behavior when food is served. Admin 1 out of 1 100 (percent) %, DON 1 out of 1, Nurse manager 2 out of 2 100%, social worker 2 out of 2 100%, maintenance 2 out of 2 100%, housekeeping/laundry manger 1 out of 1 100%, rehab manager 1 out of 1 100%, activities 1 out of 2 100% (second is on vacation and will not return to work until next week), business development specialist 1 out of 1 100%, Business office/human resources 2 out of 2 100%, dietary 12 out of 14 85%, medical records
- The remaining nursing staff and dietary staff will be in-serviced on the next scheduled workday prior to beginning their shift by the nurse manager/food service director
- The Regional Nurse implemented a monitoring tool called Diet Audit Tool to note consistency of food/snacks served to residents and to determine resident's tolerance to the food/snacks provided.
- The Administrator reviewed the results of the audit.
- The Quality Assurance Performance Improvement (QAPI) team comprised of the administrator, nurse managers, MDS nurse, Wound care nurse, SW, rehab director, dietary manager, activities director, business office manager, HR, medical records, business development marketer, nurse consultant and regional director of operations. The medical director attended the meeting via the phone.
Failure to Follow Dietary Orders Leads to Resident's Death
Penalty
Summary
The facility administration failed to ensure dietary orders were followed, resulting in a resident's death due to choking. The resident, who had a medical history including cerebrovascular accident (CVA), dysphagia, and dementia, was on a prescribed pureed diet with thin consistency. However, the resident was found with a deli sandwich, which was not in accordance with her dietary orders, leading to her choking and subsequent death despite attempts to perform the Heimlich maneuver. The Director of Nursing (DON) was aware of the incident but did not follow up with an investigation or speak with the night CNAs involved. The DON reported that she left messages for the CNAs, who were as-needed employees, but did not receive a response. Additionally, there was no documentation to verify that staff education regarding dietary orders had been provided, and the DON acknowledged the lack of investigative information related to the resident's death. The Administrator was not fully informed of the situation at the time of the incident and only learned about the circumstances later. The Administrator acknowledged that there should have been in-servicing of the staff and that the DON should have communicated the details of the incident to him. The CNAs involved claimed that the resident took the sandwich from another resident, and the Administrator reported that education for staff on following dietary orders had since started.
Removal Plan
- The Administration failed to effectively and efficiently oversee the wound care program. The Administration also failed to provide oversight to ensure dietary orders were being followed.
- The Administrator was re-educated and the DON will be re-educated by the Regional Nurse on Wound Treatment Management Policy, Skin Assessment Policy, Pressure Injury Prevention Policy, Notification of Change of Condition Policy, and Comprehensive Care Plan Policy. They were also educated on the Therapeutic Diet Orders Policy.
- The Administrator was re-educated on his job description by the Regional Director of operations and the DON will be re-educated on her job description by the Regional Nurse Consultant.
- The administrator and DON will report with each other to get updates regarding the process of the plan, identified concerns and non-compliance regarding choking incidents, and initiate the process to begin further investigation of the event. No such event has been noted at this time.
- Nurse implemented immediate notification form regarding sentinel events which has been placed on green paper and posted at each nurse's station, the time clock and given to each department.
- The Regional Nurse Consultant and/or Regional Director of Operations will visit the assessment daily to ensure compliance and identify any areas of concern with not accurately performing and documenting skin assessment, not providing care to prevent pressure ulcer, not following the care plan related to completing skin assessment and providing treatment, as ordered, and not ensuring the diet order for a resident on pureed diet. No concerns noted at this time.
- The DON will receive a 1:1 counseling from the Nurse regarding communicating with the administrator unexpected deaths, to notify the administrator immediately so an investigation can be initiated.
Deficiencies in Resident Safety and Equipment Maintenance
Penalty
Summary
The facility failed to ensure a safe environment for residents, staff, and visitors, as evidenced by several deficiencies observed during the survey. One resident, identified as R9, had unsecured oxygen cylinders in their room, which posed a potential fire hazard. The facility's policy on oxygen safety requires that cylinders be properly chained or supported to prevent them from falling. However, during an observation, two small oxygen cylinders were found lying on the floor next to an oxygen holder containing six cylinders. The staff, including the Administrator and a Registered Nurse, confirmed the risk and acknowledged that the oxygen storage was not in compliance with the facility's policy. Another deficiency involved a resident, R96, who was not properly assessed for safe smoking. Despite being observed smoking on the Memory Care Unit patio, the resident's admission records indicated that they were not a smoker. The facility's policy requires that all residents wishing to smoke be assessed for their ability to do so safely, and this assessment was not conducted for R96. The Director of Nursing and Activity Director confirmed that the resident was permitted to smoke without the necessary evaluation and care planning, which is a violation of the facility's smoking policy. Additionally, the facility failed to provide adequate supervision and equipment maintenance for a resident, R73, who required assistance with transfers. The resident reported an incident where a mechanical lift malfunctioned, causing them to fall and sustain injuries. The lift was reportedly faulty, and the staff did not mark it as inoperable or report it for repair. Interviews with staff revealed a lack of proper procedures for handling malfunctioning equipment, and the Administrator later confirmed that the lift was not in proper working order. This failure to maintain equipment and ensure resident safety during transfers is a significant deficiency in the facility's care practices.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to secure medications and maintain proper storage conditions, as observed during a survey. Medication and treatment carts were found unlocked multiple times in the East Hall, and the medication storage room on the [NAME] Hall contained expired items, including hydrocortisone, tuberculin syringes, and injection needles. These observations indicate a lack of adherence to the facility's policy on medication storage, which requires all drugs and biologicals to be stored in locked compartments under proper temperature controls. Interviews with staff, including LPNs and the Unit Manager, confirmed the presence of expired items and the failure to lock medication carts. The Director of Nursing acknowledged that periodic checks are conducted for expired items and temperature maintenance, but the survey findings suggest lapses in these practices. The facility's policy mandates that medications must be under direct observation or locked when not in use, a requirement that was not consistently met, leading to the potential for unsafe medication administration.
Failure to Record Food Temperatures
Penalty
Summary
The facility failed to record food temperatures, which could potentially affect all residents receiving an oral diet. The facility's policy, dated April 2024 and titled Food Safety, requires that hot food items and beverages be served at safe and palatable temperatures, with nutrition staff responsible for monitoring and recording these temperatures at every meal. However, a review of the food temperature logbook revealed that temperatures were not logged for several days in December 2024, including multiple instances for breakfast, lunch, and dinner. During an interview, the Dietary Manager confirmed that temperatures should be logged at all meals and acknowledged that failing to do so could result in residents receiving food that is either too cold or too hot, potentially making some residents sick.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure an effective infection control program, as evidenced by several deficiencies observed during the survey. One incident involved a Licensed Practical Nurse (LPN) who touched a resident's medication with her hand during administration, which is against infection control standards. The LPN acknowledged the mistake and mentioned she would use a different technique in the future. Another deficiency was observed during wound care for a resident with a pressure ulcer. The LPN performing the wound care did not wear a gown, which is required under Enhanced Barrier Precautions (EBP) for residents with certain conditions. The LPN also inadvertently brought tape used on the resident back to the treatment cart, which could lead to contamination. The Director of Nursing (DON), who was temporarily filling the role of Infection Control Preventionist, confirmed that the resident should have been on EBP and that items should not be taken out of treatment areas. Additional issues were noted with the storage and management of respiratory equipment for two residents. Oxygen and nebulizer tubing were found uncovered on the floor, and the equipment was not properly managed or stored in plastic bags as required. Furthermore, the facility's water management program was found lacking, as the Maintenance Director was unaware of the plan, and only water temperatures were being checked weekly. The facility also had issues with the placement of clean and dirty linen carts, which were found side by side, and personal items were improperly stored in clean linen carts, posing a risk of contamination.
Inappropriate Placement in Memory Care Unit
Penalty
Summary
The facility failed to adequately assess and accommodate the needs of six residents for placement in the Memory Care Unit, as per their policies. The facility's policy requires an Interdisciplinary Team (IDT) to evaluate residents for eligibility to be transferred to Memory Care, particularly those who exhibit elopement risk or require more frequent monitoring. However, the report indicates that several residents were placed in the Memory Care Unit without meeting these criteria, potentially preventing them from receiving care that accommodates their individual needs. One resident, identified as R36, was moved to the Memory Care Unit due to high fall risk and dementia, despite not exhibiting exit-seeking behaviors. Observations revealed that this resident was approached by wandering residents, which could pose a risk to their safety. Similarly, another resident, R37, was placed in the Memory Care Unit despite being non-ambulatory and having no exit-seeking behaviors. The report highlights that these residents were dependent on care and did not require the secure environment that the Memory Care Unit is designed to provide. The Director of Nursing (DON) acknowledged that the Memory Care Unit was being used to house residents who did not meet the criteria for placement, often due to family requests. This included residents with feeding tubes, catheters, and those requiring total care, which could lead to safety concerns due to the behaviors of wandering residents. The DON admitted that the facility should have addressed these issues with the families and confirmed the lack of documentation regarding family requests for residents to remain in the Memory Care Unit.
Failure to Provide Transfer Notification to Residents
Penalty
Summary
The facility failed to provide a written explanation of the reason for transfer to an acute care hospital for three residents. The facility's policy on Transfer and Discharge requires that a transfer/discharge notice be provided to the resident and their representative in a language and manner they can understand, including the specific reason for transfer, the effective date, and the specific location to which the resident is being transferred. However, the medical records for three residents did not indicate that such notifications were provided prior to their transfers to the hospital. Interviews with facility staff revealed a lack of awareness and adherence to the policy. An LPN reported sending a face sheet and orders with residents when they are transferred to the hospital but was not aware of other required notices. The facility administrator confirmed that while documents are sent to the hospital with residents, transfer notices are not being sent with them upon transfer. This indicates a systemic issue in the facility's process for handling transfers and discharges, leading to non-compliance with regulatory requirements.
Failure to Notify Residents of Bed-Hold Policy Before Hospital Transfer
Penalty
Summary
The facility failed to ensure that residents were informed of the bed-hold and reserve bed payment policy before and upon transfer to a hospital. This deficiency was identified for three residents who were transferred to the hospital without receiving the required notification. The facility's policy, titled 'Bed Hold Prior to Transfer,' mandates that written information regarding bed-hold policies be provided to residents or their representatives prior to any hospital transfer or therapeutic leave. However, a review of the medical records for these residents revealed no evidence of such notifications being provided. Interviews with facility staff, including a Unit Manager LPN, an Agency LPN, the HR/Business Office Manager, and the Administrator, highlighted a lack of clarity and responsibility regarding the issuance of bed-hold notices. The Unit Manager LPN and Agency LPN were unaware of the bed-hold notices, while the HR/Business Office Manager mentioned a form that should be sent but was unsure who was responsible for sending it. The Administrator confirmed that bed-hold notices were not being sent with residents upon transfer to the hospital, indicating a systemic issue in the facility's process for handling these notifications.
Inappropriate Terminology Used for Residents Requiring Meal Assistance
Penalty
Summary
The facility failed to maintain the dignity and respect of residents by referring to those who required assistance with meals as 'feeders.' This was observed multiple times in the Memory Care Unit, where staff, including CNAs and an LPN, used the term 'feeder' in the presence of residents. Additionally, a white dry erase board visible to visitors and residents listed the names of residents needing meal assistance under the heading 'feeder.' One resident, identified as R58, who had diagnoses including dementia, acute respiratory failure, type 2 diabetes, and Adult Failure to Thrive, was directly affected by this practice. R58's care plan noted a self-care deficit and dysphagia, requiring assistance with meals. During an observation, an LPN referred to R58 as a 'feeder' while assisting with a meal, acknowledging the error and indicating a lack of in-service training on appropriate terminology.
Unauthorized Medications Found in Resident's Room
Penalty
Summary
The facility failed to ensure that unauthorized medications were not stored at the bedside for one resident. The facility's policy on Resident Self-Administration of Medication requires that a resident may only self-administer medications after the interdisciplinary team has determined it is safe. However, a review of the resident's medical record showed that the resident was not authorized to self-administer medications. Despite this, an observation revealed that a bottle of zinc oxide hydro nystatin and a bottle of normal saline were found on the resident's dresser in open view, indicating a breach of the facility's policy. The resident involved had diagnoses including Adult Failure to Thrive, chronic kidney disease, and atrial fibrillation, with a cognitive assessment indicating little to no cognitive impairment. During an interview, an LPN confirmed the presence of unauthorized medications in the resident's room and acknowledged that the resident had been taking these medications. The LPN could not explain why the medications were left in the room and stated that they should have been on the treatment cart, highlighting a lapse in following the facility's medication management procedures.
Inadequate Lighting in Resident Corridor
Penalty
Summary
The facility failed to maintain adequate and comfortable lighting levels in one corridor with six rooms in the [NAME] Wing, affecting the environment for 10 residents. On multiple observations, three out of seven ceiling lights in the corridor were not functioning. The Maintenance Director (MD) acknowledged the issue and mentioned that repair requests are typically recorded in a maintenance book at each nursing station, but no outstanding orders for the ceiling lights were found in the book for the [NAME] Wing. Despite the MD's statement that he would replace the lights, subsequent observations revealed that the lights remained unrepaired.
Failure to Follow Grievance Procedures for Resident's Fall Incident
Penalty
Summary
The facility failed to adhere to its grievance procedures for a resident who experienced a fall due to a malfunctioning mechanical lift. The resident, who was cognitively intact and required extensive assistance for activities of daily living, reported that the lift's wheels locked up, causing it to flip over and result in a fall. This incident led to the resident being admitted to the emergency department for three days. Despite filing a grievance about the incident, the resident did not receive a response, indicating a lapse in the facility's grievance handling process. Interviews with facility staff, including the Social Services Director, Certified Nursing Assistant, Registered Nurse, and Director of Nursing, revealed a lack of clarity and communication regarding the grievance process. The Social Services Director acknowledged conducting an investigation but could not locate the documentation. Additionally, the Registered Nurse was unaware of who the grievance official was, and the Administrator confirmed the absence of investigation records. This lack of documentation and follow-up highlights the facility's failure to ensure grievances are properly managed and resolved.
Deficiencies in ADL Care and Grooming in LTC Facility
Penalty
Summary
The facility failed to provide adequate care for activities of daily living (ADLs) for four residents, leading to unmet needs and diminished quality of life. Resident 69, diagnosed with unspecified dementia and schizoaffective disorder, was observed with long facial hair on multiple occasions, indicating a lack of personal grooming. The facility's policy on ADLs, which includes grooming, was not followed, as the resident's care plan required assistance with ADLs. Resident 100, with severe cognitive impairment, was found with long, dirty fingernails despite the facility's policy requiring regular nail care. Observations and interviews revealed that the resident's nails were not trimmed or cleaned, and staff acknowledged the oversight. The facility's policy on nail care, which mandates routine cleaning and inspection during ADL care, was not adhered to, resulting in the resident's unkempt appearance. Resident 113, who required assistance with showering and bathing, was not offered showers as per the facility's policy. Despite requesting a shower, the resident was not attended to promptly, and documentation showed infrequent shower offerings. Interviews with staff confirmed that showers should be offered three times a week and upon request, but this was not consistently practiced. Additionally, Resident 101, with severe cognitive impairment, was observed with facial hair, which staff failed to address during grooming sessions, contrary to the facility's grooming policy.
Improper Catheter Care and Infection Control Issues
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, identified as R36, who had an indwelling urinary catheter. Observations revealed that the catheter tubing was coiled and incorrectly positioned, which could obstruct urinary flow. Additionally, the catheter drainage bag was uncovered and dragging on the floor underneath the resident's wheelchair. These issues were confirmed by a Licensed Practical Nurse (LPN) during an observation, who acknowledged that the tubing and drainage bag touching the floor were infection control issues. The resident, R36, had a medical history that included dementia and obstructive and reflux uropathy. The facility's policy required catheter drainage bags to be covered with dignity bags and positioned below the bladder level. However, during the observation, the catheter drainage bag was not covered, and the tubing was coiled around the resident's foot, potentially obstructing urine flow. Interviews with staff, including the Director of Nursing (DON), confirmed that staff were trained to ensure catheter tubing was positioned correctly and not touching the floor, but these practices were not followed in this instance.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders regarding oxygen administration for a resident, identified as R42, who was receiving oxygen therapy. The resident's medical records indicated a diagnosis of malignant neoplasm of an unspecified part of the bronchus or lung, anemia in other chronic diseases, and was receiving palliative care. The physician's order specified that the resident should receive oxygen at 4 liters per minute (LPM) via nasal cannula continuously for shortness of breath. However, observations on multiple occasions revealed that the resident was receiving oxygen at lower levels than prescribed, specifically at 2.5 LPM and 3.5 LPM. Interviews with facility staff, including a Registered Nurse and the Unit Manager, confirmed that the oxygen levels were not set according to the physician's orders. The Registered Nurse acknowledged that the oxygen should have been set at 4 LPM, and the Unit Manager confirmed the discrepancy during a separate interview. The Unit Manager also stated that the expectation was for the oxygen to be set according to the orders, indicating a lapse in following the prescribed care plan for the resident.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that residents were seen by a physician in the facility at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Specifically, one resident, identified as R69, was not seen in a timely manner by their primary physician. R69 was admitted with multiple diagnoses, including dementia, chronic pulmonary embolism, hypertension, dysphagia, hyperlipidemia, schizoaffective disorder, and bipolar type. The resident's medical records indicated that they were only seen by a Nurse Practitioner following admission and during a follow-up visit, with the first documented visit by the primary physician, who is also the facility's Medical Director, occurring two months after admission. Interviews with the Medical Director and the Director of Nursing revealed a lack of awareness and adherence to the required visitation schedule. The Medical Director was unaware of the time frame for visiting residents, and the Director of Nursing confirmed that residents should be seen by their primary physician within the first 30 days. Despite efforts to locate medical records of physician visits, the Director of Nursing was unable to provide documentation for R69, confirming the deficiency in ensuring timely physician visits for newly admitted residents.
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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