Tower Road Post Acute, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Marietta, Georgia.
- Location
- 26 Tower Rd, Marietta, Georgia 30060
- CMS Provider Number
- 115115
- Inspections on file
- 22
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Tower Road Post Acute, Llc during CMS and state inspections, most recent first.
A cognitively intact resident with depression, anxiety, and significant ADL dependence reported to an LPN that she had fallen during the night, hit her head, and that a night-shift nurse told her to get the “curse-word” up. The LPN observed redness to the resident’s eye and notified a UM, who then informed the DON. The resident and a family member later reported that a high-level staff member had cursed at the resident and her sister, and the resident identified this person as the DON. Staff, including the UM, DON, and Abuse Coordinator, acknowledged that verbal abuse is reportable and that abuse allegations must be reported to the state within two hours per facility policy. However, after the resident gave differing accounts of the incident when questioned by the DON, the DON and Abuse Coordinator decided not to report the allegation to the State Agency, resulting in a failure to report a verbal abuse allegation as required.
A resident with multiple serious diagnoses was started on IV fluids and oral antibiotics for pneumonia, but the responsible party was not notified of this change in condition as required by facility policy. Documentation did not show any notification, and staff interviews confirmed that the LPN could not recall notifying the family or responsible party. The DON acknowledged the lapse after a grievance was filed.
A resident with multiple diagnoses, including dementia, did not receive a properly documented SNF ABN regarding Medicare non-coverage. The Business Office Manager read the notice to the responsible party by phone but failed to provide or document a signed copy, and the Director of Nursing cited miscommunication about the correct process.
The facility failed to maintain a safe and homelike environment, with surveyors observing issues like peeling paint, missing vent covers, and broken fixtures across three halls. The Maintenance Director confirmed these deficiencies, noting a lack of awareness prior to the survey and indicating plans for repairs. Additional concerns included leaking toilets, slow-draining sinks, and makeshift lighting solutions, highlighting potential safety hazards.
The facility failed to maintain safe water temperatures below 120 degrees Fahrenheit in 17 out of 22 bathrooms, with temperatures ranging from 108 to 123 degrees. Residents reported the water as very hot, though no burns occurred. The Maintenance Director set the water heater at 122 degrees and did not keep a log of temperature checks, contributing to the oversight.
A resident with severe cognitive impairment was observed with an uncovered Foley catheter bag and a shirt displaying her full name in large letters, violating the facility's policies on dignity and privacy. Staff interviews confirmed the failure to adhere to established procedures for clothing labeling and catheter dignity.
A resident was found with medication at their bedside without an assessment or physician's order for self-administration, contrary to facility policy. Staff interviews confirmed that medications should not be left at the bedside unless the resident is assessed and authorized. The DON and Administrator emphasized the importance of proper assessment and adherence to protocols.
A resident with severe cognitive impairment and requiring a wheelchair was found with the call light out of reach on two occasions, despite facility policy requiring accessibility. The DON stated that staff were expected to meet residents' needs and had received training on accommodation policies.
The facility did not have an effective system for after-hours visitation, as the phone number provided for access was not answered, preventing visitors from entering. Staff interviews revealed that the phone system was supposed to transfer calls to the nurses' station, but this did not happen, potentially causing distress for visitors unable to reach their family members.
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to two residents who remained in the facility after being discharged from Medicare Part A services. Instead, only the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was given. Interviews revealed a misunderstanding of NOMNC requirements, with staff believing NOMNCs were only for residents discharged to home. The administrator expected correct notifications to prevent resident confusion.
A resident with multiple diagnoses, including dementia and Parkinson's disease, was inaccurately documented in the MDS assessment as having no dental concerns, despite being observed with missing upper teeth. A prior dental exam noted multiple missing teeth and a plan for partials. The Chief Clinical Officer confirmed the documentation error.
A facility failed to complete the PASARR Level II screening for a resident admitted with multiple diagnoses, including depression and PTSD. The facility's policy mandates a Level II screening for individuals with mental disorders or intellectual disabilities, but this was not done for the resident. The Social Services Director confirmed that Level II screenings are usually done by the hospital before admission, and acknowledged the oversight.
The facility failed to implement baseline care plans within 48 hours for several residents, as required by policy. This deficiency affected residents with various health conditions, including a resident with a urinary tract infection and another with high fall risk due to amputations. Staff interviews confirmed the oversight, and one resident experienced a fall due to delayed assistance.
The facility failed to create comprehensive care plans for three residents, neglecting to address specific medical conditions such as UTIs, oxygen therapy, and PTSD. Despite clear expectations for baseline care plans within 48 hours of admission, these deficiencies were confirmed through staff interviews and record reviews.
A facility failed to include a resident's family in care plan meetings, contrary to its policy requiring family involvement. The resident's family was unaware of any care plan, and staff interviews revealed inconsistent communication practices. The facility's policy mandates active participation of residents and their representatives in care plan development, which was not followed, resulting in a deficiency.
A resident was discharged without proper instructions being provided to the responsible party, as required by the facility's discharge planning policy. The resident's son, who was the responsible party, was not present to receive the discharge instructions, which were reportedly discussed over the phone. The instructions lacked details on dietary/nutrition, therapy, and medications, and there was no signature from the resident or responsible party. Interviews with staff revealed that the expected discharge process was not followed.
A resident with severe cognitive impairment and dependency on staff for personal hygiene was found to have long, sharp, and dirty fingernails, indicating a failure in providing adequate fingernail care. Despite the facility's policy requiring morning ADL care, including nail care, staff interviews revealed that nail care was performed on an as-needed basis, which was insufficient for the resident's needs.
A facility failed to arrange follow-up appointments and transportation for a resident with multiple health conditions after hospital discharge. The resident required follow-up with specialists, but the facility did not document these arrangements, as confirmed by the resident's responsible party and the administrator.
A resident with a history of chest pain and heart disease was observed receiving oxygen at 1 LPM instead of the prescribed 2 LPM, as per physician orders. Despite the facility's policy requiring verification of physician orders, the discrepancy was not identified until observed by staff. The resident, who was cognitively intact, reported the incorrect oxygen level, and the LPN confirmed the error. The DON and Administrator emphasized the importance of adhering to physician orders to prevent respiratory complications.
The facility failed to discard expired medications and biologicals in two of three medication rooms, contrary to its Medication Storage policy. An observation revealed an emergency kit with expired medications, including insulin and suppositories, in a medication room refrigerator. The Unit Manager confirmed the expiration, and the DON stated that medications should not be expired.
A facility failed to ensure a resident receiving hospice care had a physician's order for hospice services. The facility's policy requires the Interdisciplinary Team to coordinate care and ensure hospice physician orders. Despite documentation in the MDS and care plan, the current physician's orders lacked hospice services. Interviews with an RN and the DON confirmed the need for a physician's order.
The facility failed to follow proper infection control practices during medication administration via a G-tube, perineal care, and tracheostomy care. An LPN did not wear a gown for a resident on Enhanced Barrier Precautions, and a CNA did not sanitize a blood pressure machine between residents. Another CNA reused a cleaning wipe during perineal care, and an LPN did not maintain sterile technique during tracheostomy care. Additionally, hand sanitizer dispensers were found empty in several areas.
The facility's call light system in the West Hall was found to be deficient, with four call lights flashing without sound, and a call device in a resident's room failing to activate the hallway light. A CNA and an RN confirmed these malfunctions during observations.
Failure to Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse to the State Agency as required by its own abuse policy and federal and state law. The facility’s policy on Abuse, Neglect and Misappropriations, revised 1/1/2025, states that all alleged violations involving abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property must be investigated and reported immediately, defined as no later than two hours after the allegation is made, to the Facility Administrator, the State Survey Agency, and other appropriate agencies. Verbal abuse is defined in the policy as the use of oral, written, or gestured language that includes any threat or frightening, disparaging, or derogatory language to residents or their families, or within their hearing distance. Staff interviews confirmed their understanding that verbal abuse allegations are reportable and must be reported within two hours. The resident involved, R11, had diagnoses including metabolic encephalopathy, depression, generalized muscle weakness, and anxiety disorder, and was care planned for fall risk and behavior related to refusing care. A recent MDS showed a BIMS score of 15, indicating she was cognitively intact, with documented depression symptoms and significant functional dependence for multiple ADLs, including toileting, bathing, and transfers. On the morning after a reported fall, an LPN documented that the resident stated she had fallen overnight, hit her side table and then the floor, and that a nurse found her on the floor and instructed her to get up. The LPN observed redness to the resident’s left eye and reported these observations to management. Subsequent progress notes documented that the DON and Unit Manager spoke with the resident and her sister about the incident, and that the resident gave differing accounts of what happened and refused further evaluation and interventions. Interviews and documentation showed that R11 alleged that a night-shift nurse cursed at her in connection with the fall. LPN GG reported that during shift change rounds, the resident stated she had fallen off the bed, hit her head, and that the night nurse told her to get the “curse-word” up. UM FF confirmed that she was notified by LPN GG that the resident reported being cursed at by the night nurse and that she then notified the DON. UM FF defined verbal abuse as being spoken to harshly and acknowledged knowing that abuse allegations must be reported to the state within two hours. The DON stated that when he spoke with the resident, she initially said the staff told her to get the “curse word” off the floor, then changed her account to say the staff only told her to get out of bed after he informed her he would have to report the incident, and then returned to her original statement. The DON and the Abuse Coordinator/AIT both confirmed that the allegation was not reported to the State Agency because the resident changed her story, despite the facility policy requiring immediate reporting of all abuse allegations and staff acknowledging that verbal abuse is reportable. Further interviews with the resident and her family corroborated that the resident reported being cursed at by staff. The resident described the alleged perpetrator as a tall, slender Black man in a high position at the facility and identified him as the DON, and she told the surveyor that this person had cursed her and her sister because he wanted her to leave. A family member stated that the resident told her she had fallen and that the nurse had cursed at her. The Abuse Coordinator confirmed that the administrator was aware of the incident and that, although he was the abuse coordinator, the administrator determined what would be reported to the state. Despite multiple staff being aware of the allegation of verbal abuse and the facility’s written requirement to immediately report all such allegations to the State Survey Agency, the facility did not report this allegation, resulting in the cited deficiency.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in condition involving the initiation of intravenous fluids and antibiotics. According to the facility's policy, the interdisciplinary team is required to communicate with residents and/or families or responsible parties when there is a change in clinical condition, including changes in medication. For one resident with diagnoses including acute respiratory failure with hypoxia, pneumonitis due to inhalation, and dementia, physician orders were initiated for IV sodium chloride and oral levofloxacin for pneumonia. Documentation in the electronic medical record confirmed the administration of these treatments, but there was no evidence that the responsible party was notified of these changes. Staff interviews revealed that the LPN responsible for the resident's care could not recall if the family or responsible party had been notified and did not believe any such notification was documented. The unit manager confirmed that changes in medication or clinical condition should prompt family notification. The Director of Nursing acknowledged that the responsible party had not been notified and that a grievance had been filed by the family. The lack of notification was not in accordance with facility policy and resulted in the responsible party not being informed of the resident's change in condition.
Failure to Provide Proper SNF ABN and Documentation to Resident's Responsible Party
Penalty
Summary
The facility failed to provide an accurate and properly documented Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for one resident who was reviewed for beneficiary notices. The resident, who had diagnoses including hypertension, dementia, and hyperlipidemia, was admitted to the facility and had a responsible party (RP) managing their affairs due to cognitive deficits. The facility's records showed that the Notice of Medicare Non-Coverage (NOMNC) and SNF ABN were not properly signed or dated, and there was no evidence that the required notice was physically provided to the RP. Instead, the Business Office Manager (BOM) stated that the information was read to the RP over the phone, but there was no documentation to confirm this communication or to indicate that the RP was informed of the resident's financial responsibility for continued services. Interviews with the BOM confirmed the lack of documentation and the absence of a signed SNF ABN form. The BOM acknowledged that the notice was not provided in accordance with requirements and that the resident remained in the facility after the notice was given. The Director of Nursing (DON) indicated there was a miscommunication regarding the proper use of the SNF ABN form and expected the BOM to follow the correct procedure.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents across three halls, as observed by surveyors. Specific deficiencies included peeling paint, missing air vent covers, holes in walls, bent or broken blinds, a broken light fixture pull cord, a loose electrical wall socket, and cracked floors. These issues were identified in multiple rooms, affecting a sample size of 59 residents. The Maintenance Director confirmed these observations during an interview, acknowledging the need for repairs but indicating a lack of awareness of the specific concerns prior to the survey. The Maintenance Director also mentioned that maintenance concerns are reported directly to him or entered into a logbook at each nurse's station, which he checks regularly. Additional observations revealed further deficiencies, such as a leaking toilet, slow-draining sink, and a water temperature of 125 degrees Fahrenheit in one room, which could pose safety risks. Makeshift solutions, like using grocery bags to extend a broken string light, were noted, indicating inadequate lighting solutions. Structural issues, such as uneven and raised bathroom floors, exposed wiring from a wall socket, and gaps between the floor and baseboard, were also observed, highlighting potential safety hazards. The Maintenance Director stated that repairs were planned, starting with painting resident rooms and bathrooms, but he was operating as a one-man team and would request assistance for more extensive repairs.
Unsafe Water Temperatures in Facility Bathrooms
Penalty
Summary
The facility failed to maintain safe water temperatures below 120 degrees Fahrenheit in 17 out of 22 bathrooms sampled across three halls. This deficiency was identified during an initial observation on 9/16/2024, where the water from bathroom sinks was found to be too hot to touch. Specific temperature readings ranged from 108 to 123 degrees Fahrenheit, with several rooms recording temperatures at or above the 120-degree threshold. Interviews with residents revealed that they perceived the water as very hot, although no burns were reported. The Maintenance Director (MD) acknowledged setting the water heater at 122 degrees Fahrenheit to supply hot water to various facility areas, including the kitchen and laundry, and admitted to not maintaining a log of water temperature checks. The MD stated that he conducted random weekly checks of water temperatures but had not received any complaints or reports of burns. Despite this, the lack of a formal policy on water temperatures and the absence of a documented monitoring process contributed to the oversight. The review of facility records, including the Grievance Log, Resident Council Minutes, and Incident Reports, showed no prior concerns related to hot water. This oversight had the potential to cause serious injury to residents due to the excessively high water temperatures in the bathrooms.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident with a Foley catheter. The resident was observed sitting in the hallway in a wheelchair with a urinary catheter bag left uncovered and visible, which is against the facility's policy that requires the use of a dignity bag or leg bag for Foley catheters, especially when the resident is out of their room. Additionally, the resident was wearing a shirt with her full name written in large black marker across the front, which is contrary to the facility's clothing labeling policy that requires labeling to be done inside the clothing near the label to maintain privacy. The resident involved had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 00, and required partial/moderate assistance for activities of daily living. The resident's care plan included interventions to encourage social interaction and participation in activities. Interviews with staff, including the Unit Manager LPNs and the Director of Nursing, confirmed the facility's policies on clothing labeling and catheter dignity, and acknowledged the failure to adhere to these policies in this instance.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medication before leaving medications at the bedside. The facility's policy requires that residents who wish to self-administer medications must be assessed by a Licensed Nurse and have a physician's order confirming the safety of this practice. However, in the case of the resident in question, there was no assessment or physician's order found in the electronic health record to authorize self-administration of medication. During an observation, a tube of diclofenac sodium topical gel was found on the resident's bedside table. The resident's electronic health record did not contain any documentation of an assessment or physician's order for self-administration of medication. Interviews with staff, including a CNA and an LPN, confirmed that medications should not be left at the bedside unless the resident has been assessed and deemed capable of self-administration. The staff also confirmed that they had received in-service training regarding the protocol for medications at the bedside. The Director of Nursing and the Administrator both emphasized that medications should not be stored at the bedside unless the resident has been properly assessed and authorized to self-administer. The DON highlighted the importance of assessing residents' ability to self-administer medications and noted the potential negative outcomes if residents take medications outside the prescribed times. The Administrator reiterated the expectation that residents should not have any medications by their bedside table.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as R112, by not ensuring that the call light was within reach, which is a requirement under the facility's policy titled 'Residents Rights Accommodation of Needs and Preference and Homelike Environment.' The policy, effective from February 1, 2024, mandates that call lights should be accessible to residents both in their rooms and bathrooms. R112, who has a severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of five, requires a manual wheelchair and two-person assistance. On September 16, 2024, at 12:00 pm, R112 was observed sitting in her wheelchair, screaming for help with the door closed, and her call light device was found wrapped around her bed rail, out of reach. A subsequent observation on September 18, 2024, at 3:00 pm, revealed R112 sitting in her wheelchair watching television, again with the call light device out of reach. During an interview on September 19, 2024, the Director of Nursing (DON) stated that her expectation was for staff to ensure residents' needs and preferences are met and to provide a homelike environment, noting that in-service education on resident accommodation and policy had been provided to the nursing staff.
Failure to Facilitate After-Hours Visitation
Penalty
Summary
The facility failed to have a system in place that allows visitors to enter after hours, which is a violation of the residents' rights to receive visitors of their choosing at any time. Observations revealed that the entrance to the facility was very dark, with only security lights on, and a small sign instructed visitors to call a number for after-hours access. However, when the number was called multiple times, the phone rang continuously without being answered or redirected to voicemail. Surveyors had to walk around to a side entrance to gain access to the building. Interviews with staff, including LPNs and the Director of Nursing (DON), indicated that the phone system was supposed to transfer calls to the nurses' station after hours, but this did not occur. The DON and the Administrator both stated that while visiting hours were from 8:00 am to 8:00 pm, visitors were not stopped from coming after hours if they called ahead. However, the phone system's failure to transfer calls as expected could lead to visitors being unable to contact their family members, potentially causing upset or worry.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to two residents who remained in the facility after being discharged from Medicare Part A services. The facility's policy requires that if a resident is unable to sign, the NOMNC can be issued by telephone, with written confirmation sent the same day. However, for both residents, only the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was provided, indicating their discharge from Medicare Part A services. The records for one resident showed a Medicare stay from July 19, 2024, to August 30, 2024, while the other resident's stay was from June 25, 2024, to August 7, 2024. Interviews with the Business Office Manager and therapy staff revealed a misunderstanding of the NOMNC requirements. The Business Office Manager believed NOMNCs were only for residents discharged to home, while SNF ABNs were for those remaining in the facility. Therapy staff confirmed the discharge of the residents from therapy services, noting they had met their maximal potential. The facility administrator expected staff to provide the correct notification at the time of discharge from Medicare Part A, acknowledging that failure to do so could lead to resident confusion or incorrect information.
Inaccurate Dental Status Documentation in MDS Assessment
Penalty
Summary
The facility failed to accurately document the dental status of a resident in the annual Minimal Data Set (MDS) assessment. The resident, who was admitted with diagnoses including cognitive communication deficit, unspecified dementia, unspecified neurocognitive disorder with Lewy bodies, depression, and Parkinson's disease, was observed to be missing all but one of her upper teeth. However, the MDS assessment inaccurately recorded that there were no dental concerns. A dental exam conducted earlier documented multiple missing teeth and a plan for upper and lower partials. The Chief Clinical Officer confirmed the inaccuracy in the MDS assessment and acknowledged the expectation for the MDS Coordinator to perform accurate assessments.
Failure to Complete PASARR Level II Screening for Resident
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) Level II was completed for one of the residents, identified as R92. The facility's policy requires that all potential admissions undergo a PASARR Level I screening to determine if a Level II screening is necessary for individuals with mental disorders or intellectual disabilities. However, for R92, who was admitted with diagnoses including encephalopathy, depression, altered mental status, cognitive communication deficit, alcohol dependence, cannabis abuse, and PTSD, the Level II screening was not completed. This oversight was identified during a review of the facility's records and staff interviews. The electronic medical record for R92 showed a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness, yet the care plan highlighted dependencies on staff for emotional, intellectual, physical, and social needs. Despite being seen by psychiatric services for depression, there was no documentation of a PTSD diagnosis in the psychiatric progress notes. An interview with the Social Services Director revealed that Level II screenings are typically completed by the hospital prior to admission, and she acknowledged the absence of a Level II screening for R92, indicating a lapse in the facility's adherence to its own policy.
Failure to Implement Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for five residents, which is a requirement according to their policy. The policy mandates that an individualized interdisciplinary plan of care be in place within 48 hours of admission, but this was not completed for the residents in question. Interviews with staff, including the MDS Coordinator and the Director of Nursing, confirmed that the baseline care plans were not completed as expected, which could potentially affect the level of care and services provided to these residents. For instance, one resident was admitted with a urinary tract infection and other health issues but did not have a baseline care plan in place. The resident and their family expressed concerns about the resident's slow healing process. Another resident, who had been at the facility for six weeks, also did not have a baseline care plan, and the family was unaware of any care plan being in place. The MDS Coordinator acknowledged the oversight and stated that the comprehensive assessment should be completed by day 14, but the baseline care plan was expected within 48 hours. Additionally, a resident with a high risk for falls due to bilateral below-the-knee amputations and other health conditions did not have a baseline care plan completed within the required timeframe. This resident experienced a fall after using the call light without receiving timely assistance. The fall assessment was only completed after the incident, highlighting the lack of a proactive care plan to address the resident's needs and risks. Interviews with nursing staff and the DON revealed that the expected procedures for fall risk assessment and care planning were not followed, contributing to the deficiency.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which included measurable objectives and timeframes to meet their medical, nursing, mental, and psychosocial needs. For one resident, identified as R49, the facility did not create a baseline care plan or address the resident's urinary tract infection (UTI) in the care plan. Despite the resident being alert and oriented, the absence of a care plan for the UTI was confirmed by both the Registered Nurse and the MDS Coordinator. The Director of Nursing acknowledged that baseline care plans should be completed within 48 hours of admission. Another resident, R111, was receiving oxygen therapy for hypoxia, with specific physician orders to maintain oxygen saturation levels. However, the care plan lacked specific interventions for the oxygen therapy. Interviews with the Director of Nursing and the Administrator confirmed that residents on oxygen therapy should have corresponding care plans, and it was expected that baseline care plans be completed within 48 hours of admission. For resident R92, who had diagnoses including depression and PTSD, the care plan did not address PTSD, despite the resident being seen by psychiatric services for depression. The care plan noted the resident's dependence on staff for emotional and social needs but failed to include interventions for PTSD. Progress notes from psychiatric services did not mention PTSD, indicating a gap in addressing this aspect of the resident's care needs.
Failure to Include Family in Care Plan Meetings
Penalty
Summary
The facility failed to include a resident, their family, or family representative in baseline care plan meetings and care plan meetings, as required by their policy. The policy mandates that the Interdisciplinary Team (IDT) develop the care plan in conjunction with the Resident Assessment Instrument (RAI) and conduct a Comprehensive Care Plan meeting by Day 21 post-admission. However, a review of the electronic medical record for the resident revealed no documentation of who attended the care plan meeting. Interviews with staff, including the MDS RN and Social Services Director, indicated that typically only the resident attends these meetings, and there was a lack of consistent communication with families regarding care plan meetings. The resident's family was unaware of any care plan, highlighting a communication breakdown. The Director of Medical Records and the Director of Nursing provided insights into the processes for scheduling and documenting care plans, but there was no clear timeframe for when care plans should be uploaded into the system. The facility's policy states that residents and their representatives should play an active role in care plan development, but this was not adhered to in this case, leading to the deficiency.
Failure to Provide Adequate Discharge Instructions
Penalty
Summary
The facility failed to provide adequate discharge instructions to the responsible party of a resident, identified as R366, upon discharge. The facility's policy on discharge planning, revised on 7/19/2024, mandates that discharge plans include the location of discharge, anticipated referrals, and durable medical equipment, and that a copy of the discharge plan be given to the resident or their representative. However, the responsible party, R366's son, reported that he was not provided with necessary information regarding medications and therapy needs for his mother, who was discharged with diagnoses including cerebral infarction, atrial fibrillation, cognitive communication deficit, type 2 diabetes, and hypertension. The son was informed of the discharge after receiving the Notice of Medicare Non-Coverage and was not present at the facility to receive discharge instructions, which were reportedly discussed over the phone. The discharge instructions lacked dietary/nutrition and therapy special instructions, and the medications the resident was to receive at home were not listed. Additionally, there was no signature from the resident or the responsible party on the discharge summary. Interviews with facility staff, including an LPN and the Director of Nurses, revealed that the discharge process involves obtaining a discharge order from the physician, notifying the family, and ensuring the resident is clean and stable for transport. The Director of Nurses expected that discharge instructions would be reviewed with the resident and/or family, and documented to ensure understanding, but this was not adequately done in this case.
Failure to Provide Adequate Fingernail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate fingernail care for a dependent resident, identified as R80, who was unable to perform activities of daily living independently. R80 was admitted with diagnoses including type 2 diabetes and cerebral infarction, and had a severely impaired cognition with a BIMS score of 2. The resident's care plan indicated a need for full staff assistance with self-care ADLs. Despite this, observations on multiple occasions revealed that R80 had long, sharp, and dirty fingernails, which were not being properly maintained as per the facility's policy titled AM Care. Interviews with facility staff, including a CNA and the Unit Manager, indicated that nail care was provided on an as-needed basis, which was not sufficient for R80's needs. The CNA confirmed that R80's nails were too long, and the DON expressed an expectation for all residents' nails to be clean and groomed. However, the observations and interviews demonstrated a failure to adhere to these expectations, resulting in the deficiency noted in the report.
Failure to Arrange Follow-Up Appointments and Transportation
Penalty
Summary
The facility failed to arrange follow-up appointments and transportation for a resident after discharge from the hospital, which was a deficiency identified by surveyors. The resident, who was admitted with conditions including cerebral infarction, atrial fibrillation, cognitive communication deficit, type 2 diabetes, and hypertension, had a BIMS score indicating moderate cognitive impairment and was dependent on staff for ADLs. Hospital discharge instructions required follow-up with a hematologist, neurologist, and cardiologist. However, the facility did not provide documentation of appointments or transportation for these follow-ups, as confirmed by the resident's responsible party and the facility administrator.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to physician orders for oxygen therapy for a resident, identified as R111, who was on oxygen therapy. The facility's policy on oxygen administration required verification of a physician's order and adjustment of the oxygen delivery device to ensure the proper flow of oxygen. However, observations and interviews revealed that R111's oxygen was set at 1 liter per minute (LPM) instead of the prescribed 2 LPM. This discrepancy was noted during an observation on September 16, 2024, and confirmed again on September 18, 2024, despite the resident's electronic health record indicating a physician's order for 2 LPM to manage hypoxia and maintain oxygen saturation at 90% or above. The resident, R111, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported that her oxygen level was supposed to be at 2 LPM. Licensed Practical Nurse (LPN) CC confirmed the physician's order for 2 LPM but was unaware that the oxygen level was set below the prescribed amount. The Director of Nursing (DON) and the Administrator both expressed expectations that nursing staff adhere strictly to physician orders for oxygen therapy, acknowledging that failure to do so could lead to respiratory complications for the resident.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure that medications and biologicals were discarded on or after their expiration date in two of three medication rooms, as observed during a survey. The facility's policy on Medication Storage mandates that outdated, contaminated, discontinued, or deteriorated medications be immediately removed from stock and disposed of according to procedures. However, an observation revealed an emergency kit in one medication room refrigerator containing expired medications, including insulin vials, insulin pens, Tylenol suppositories, aspirin suppositories, Phenergan, and lorazepam. The Unit Manager confirmed the expiration date during the observation. An interview with the Director of Nursing indicated that her expectations were that medications should not be expired.
Lack of Physician's Order for Hospice Services
Penalty
Summary
The facility failed to ensure that a resident receiving hospice care had a physician's order for hospice services. The facility's policy, last reviewed on 9/15/2023, requires that the Interdisciplinary Team (IDT) coordinate care and ensure hospice physician and applicable attending physician orders for residents. A review of the clinical record for a resident with diagnoses including peripheral vascular disease and Alzheimer's disease indicated that hospice care was documented in the Quarterly Minimum Data Set (MDS) and the care plan. However, the current physician's orders did not include orders for hospice services, despite the facility having a hospice contract with the agency providing services to the resident. Interviews with a Registered Nurse and the Director of Nursing confirmed that the resident should have had a physician's order for hospice.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices during several procedures, including medication administration via a gastrostomy tube (G-tube), perineal care, and tracheostomy care. For one resident with a G-tube, a Licensed Practical Nurse (LPN) did not wear a gown during medication administration, despite the resident being on Enhanced Barrier Precautions (EBP). The LPN admitted to not receiving education on the necessity of wearing a gown for this procedure. Additionally, a Certified Nursing Assistant (CNA) was observed using an electronic blood pressure machine on multiple residents without cleaning or sanitizing it between uses, which she acknowledged should have been done. Another deficiency was noted during perineal care for a resident with an indwelling catheter, where a CNA reused a cleaning wipe instead of using a clean one for each swipe. This was confirmed by both the CNA and an LPN. Furthermore, during tracheostomy care for a resident, an LPN failed to maintain sterile technique by contaminating the sterile field and not wearing sterile gloves properly. The facility also had empty hand sanitizer dispensers in several locations, which were confirmed by a floor technician responsible for refilling them, and a CNA who attempted to use an empty dispenser.
Deficient Call Light System in West Hall
Penalty
Summary
The facility failed to maintain a working resident call light system in one of its hallways, specifically the West Hall. During an observation, it was noted that four call lights on the nursing unit call light board were flashing without any accompanying sound, which is necessary for alerting staff to resident needs. A Certified Nursing Assistant (CNA) confirmed the malfunction, stating that the call lights should both light up and make a sound when activated, and that a flashing light indicates a high alert. Additionally, in a separate incident, the call device in a specific resident's room failed to activate the hallway light when used by the resident. This was verified by a Registered Nurse (RN) during an observation and interview.
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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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