Westbury Center Of Conyers For Nursing And Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Conyers, Georgia.
- Location
- 1420 Milstead Road, Conyers, Georgia 30012
- CMS Provider Number
- 115469
- Inspections on file
- 23
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Westbury Center Of Conyers For Nursing And Healing during CMS and state inspections, most recent first.
A resident with bowel and bladder incontinence, UTI, muscle weakness, and moderately impaired cognition required staff assistance for toileting hygiene and perineal care. During observed incontinence care, a CNA changed gloves without performing required hand hygiene between glove removal and donning new gloves, contrary to the facility’s infection prevention and control and hand hygiene policies. In interviews, the CNA, SDC, and DON all confirmed that hand washing or sanitizing is expected between glove changes and that not doing so can lead to spread of germs, cross-contamination, or infection.
A resident with upper extremity impairment and total dependence for care was not provided with a call device she could use, despite staff awareness of her inability to activate the standard call light. The care plan did not address her needs, and no appropriate assessment or device was provided, leaving her unable to independently request assistance.
A resident who was not cognitively intact was transferred to a hospital on two occasions without being provided a written bed hold notice or reason for transfer, as required by facility policy. The resident's representative confirmed not receiving the notice, and staff interviews revealed confusion over who was responsible for providing and documenting the bed hold information. No documentation was found in the resident's record to show that the required notice was given.
The facility's medication error rate exceeded 5% due to two incidents: an LPN crushed and administered atorvastatin calcium tablets to a resident with kidney and neurological conditions, despite this being contraindicated, and another LPN gave two scoops of polyethylene glycol to a resident with neurological deficits instead of the prescribed one scoop, based on the resident's request and without provider approval.
A resident with a history of medical conditions was in visible distress and pain, yet the facility staff failed to provide adequate pain management. Despite having an order for a stronger medication, only Tylenol and Zofran were administered, which were ineffective. The resident's condition worsened throughout the day, and she was eventually sent to the hospital with a diagnosis of colitis. Interviews revealed a lack of urgency in addressing the resident's needs, leading to actual harm.
The facility inaccurately reported staffing data to CMS for Q1 2024, resulting in a One-Star Staffing Rating. The PBJ report showed issues such as missed deadlines, insufficient RN staffing hours, and audit failures. The facility's assessment recommended four RNs for its 173-bed capacity and 145 average daily census. The DON and Administrator acknowledged the rating, citing high turnover and agency reliance.
A medication error rate of 11.11% was identified when an LPN administered medications to a resident with hypertension and cerebral infarction too early, outside the facility's policy of a 60-minute window around the scheduled time. The LPN adjusted the timing for residents in the skilled hall, and the ADON confirmed the error, noting that exceptions require physician approval.
A facility failed to ensure consistent documentation of a resident's code status, with discrepancies between the EMR, physician orders, and POLST. Staff interviews revealed confusion, as the EMR and orders indicated a DNR status, while the POLST showed a Full Code. The DON confirmed the expectation for consistent documentation, which was not met.
A resident with contracted hands did not receive adequate ADL care, resulting in poor nail care and hand hygiene. Despite being cognitively intact and dependent on staff for ADL care, the resident expressed dissatisfaction with the care provided. Observations showed dirty and untrimmed nails, and staff interviews confirmed that the facility's ADL protocols were not followed, leading to unmet care needs.
A resident with a urostomy was sent to an outside appointment without a urostomy bag, as the facility ran out of supplies. The resident's stoma was covered with an adult brief and a disposable bed pad. The incident was reported by the resident's caseworker, and the facility staff explained that the resident had removed the appliance before leaving. The Administrator noted that the supplies were special-order items not available through usual resources.
The facility failed to follow infection control practices by not bagging a resident's C-PAP mask when not in use and an LPN handling medications with bare hands. The C-PAP mask was found unbagged on a resident's bed, contrary to policy, and the LPN admitted to touching medications with bare hands, which is against infection control protocols.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinence Care
Penalty
Summary
The deficiency involves failure to follow the facility’s infection prevention and control and hand hygiene policies during incontinence care for one resident. The facility’s Infection Prevention and Control Program Description policy requires implementation of control measures and precautions, including hand hygiene, and the Hand Hygiene policy requires all staff to perform proper hand hygiene consistent with accepted standards of practice. The resident involved had diagnoses including contractures of both hands, UTI, and muscle weakness, with a BIMS score indicating moderately impaired cognition, and was care planned as bowel and bladder incontinent with staff responsible for cleaning the perineal area and changing briefs and clothing as needed after incontinence episodes. During observed incontinence care, a CNA did not perform hand hygiene between glove changes. The CNA acknowledged that she failed to sanitize her hands after removing used gloves and before donning a new pair and stated she should have done so. The SDC and DON both stated in interviews that staff are expected to wash or sanitize hands between glove changes and that failure to do so could result in spread of germs, cross-contamination, or infection to residents. These observations and interviews showed that staff actions during incontinence care did not comply with the facility’s established hand hygiene and infection control policies.
Failure to Provide Suitable Call Device for Dependent Resident
Penalty
Summary
A resident with a history of cervical spinal cord injury and schizophrenia, who was dependent for all activities of daily living and had upper extremity impairment, was not provided with a call device suitable for her use. Despite the call light being placed within her reach, the resident was unable to activate it due to her physical limitations, as observed on multiple occasions. Staff interviews confirmed awareness of the resident's inability to use the standard call button, and documentation revealed that the care plan did not address her inability to use the call device. The deficiency was further evidenced by the lack of an appropriate assessment upon admission to determine the resident's need for a specialized call device. Both nursing and administrative staff acknowledged that the resident required a different type of call light, but no suitable device was provided during the period reviewed. The resident had to wait for staff to check on her for assistance, as she could not independently call for help.
Failure to Provide Written Bed Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice or reason for transfer to a resident and their representative at the time of two separate hospital transfers. According to the facility's own policy, written information regarding bed hold practices must be given both in advance and at the time of transfer for hospitalization or therapeutic leave. Record review showed that the resident was not cognitively intact at the time of the transfers, and there was no documentation in the clinical record that the required notices were provided for either transfer. Interviews with the resident's representative confirmed that no written bed hold notice was received, and this was the first time the representative had heard of the term 'bed hold.' Staff interviews revealed confusion and lack of clarity regarding responsibility for providing and documenting the bed hold notice. Nursing staff believed the business office or admissions was responsible, while the business office manager stated it was the nursing staff's duty to provide the notice at the time of transfer. The unit manager indicated that providing the bed hold policy was part of the transfer process, but acknowledged there was no documentation of this action. The administrator was unable to locate any proof that the required written notice was given for the hospital transfers, despite expectations that nursing staff would provide and document the notice in the resident's record.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required by policy, resulting in a calculated error rate of 7.69 percent. This was determined through observations, staff and resident interviews, and record reviews. For one resident with diagnoses including hyperkalemia, acute kidney failure, and encephalopathy, an LPN crushed and administered atorvastatin calcium oral tablet, despite the medication not being approved for crushing. The LPN acknowledged the error, and the facility pharmacist confirmed that atorvastatin calcium tablets should not be crushed. The Director of Nursing also confirmed that nurses are expected to follow the facility's policy and reference materials regarding medication administration. In another instance, a resident with a history of hemiplegia, hemiparesis, dysarthria, anarthria, and muscle weakness was ordered to receive one scoop of polyethylene glycol powder daily for constipation. However, an LPN administered two scoops after the resident requested an additional dose, without provider approval. The LPN confirmed the deviation from the physician's order, and the Director of Nursing stated that any changes to medication administration require prior provider approval. These actions directly contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, R117, who was in distress and exhibiting signs of pain. Despite having an active order for a stronger pain medication, Tramadol, the staff only administered Tylenol and Zofran, which were ineffective. Observations on the day of the incident revealed that R117 was in significant pain, rocking, moaning, and vomiting, yet the staff did not assess her condition adequately or administer the stronger medication available. The resident, R117, had a history of conditions including gastroparesis, diabetes, and systemic inflammatory response syndrome. Her care plan included interventions for pain management, but these were not followed. On the day of the incident, the LPN on duty prioritized medication pass over attending to R117's immediate needs, despite her visible distress and requests for assistance. The resident's condition worsened throughout the day, and she was eventually sent to the hospital with a diagnosis of colitis. Interviews with staff revealed a lack of urgency in addressing R117's pain and distress. The LPN initially dismissed the resident's request for help, and the Director of Nursing only intervened after being informed by the surveyor. The facility's failure to adhere to its pain management policy and to respond promptly to the resident's needs resulted in actual harm to R117, who was left in pain and distress for several hours before being sent to the hospital.
Inaccurate Staffing Data Reporting Leads to One-Star Rating
Penalty
Summary
The facility failed to accurately report direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of Fiscal Year 2024. This deficiency was identified through a review of the Payroll Based Journal (PBJ) report, which indicated a One-Star Staffing Rating due to several issues: failure to submit PBJ data by the deadline, more than four days in the quarter without Registered Nurse (RN) staffing hours, and failure to respond to or pass a CMS audit designed to discover discrepancies in PBJ data. The facility's assessment tool indicated a licensed bed capacity of 173 beds with an average daily census of 145 residents, recommending four RNs based on resident acuity levels. Interviews with the Director of Nursing (DON) and the Administrator revealed awareness of the staffing rating issue, attributing it to high turnover rates and reliance on staffing agencies.
Medication Administration Timing Error
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11.11% during the survey. This deficiency was identified through observations, record reviews, and staff interviews. Specifically, the error involved the administration of medications to a resident, R124, who had diagnoses including hypertension and cerebral infarction. The medications, which included carvedilol, baclofen, and apixaban, were ordered to be administered at 9:00 am but were given at 7:13 am by an LPN, outside the facility's policy of administering medications within 60 minutes of the scheduled time. The LPN acknowledged administering the medications too early and stated she had adjusted the timing for residents in the skilled hall due to varying needs, such as pain management before therapy. The Assistant Director of Nursing confirmed that the administration time was incorrect and noted that exceptions to the timing policy should be documented and approved by a physician. The failure to adhere to the scheduled medication administration times as per the physician's orders and facility policy led to the identified deficiency.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that the code status for one of the residents, identified as R111, was consistently documented and available to the staff responsible for the resident's care. The facility's policy on Residents Rights Regarding Treatment and Advanced Directives requires that any decision-making regarding a resident's choices be documented in the medical record and communicated to the interdisciplinary team. However, there was a discrepancy in the documentation of R111's code status. The Electronic Medical Record (EMR) and physician orders indicated a Do Not Resuscitate (DNR) status, while the Physician Orders for Life Sustaining Treatment (POLST) documented a Full Code status, signed by two physicians and the resident's responsible party. Interviews with staff, including a Certified Nurse Aide (CNA), a Licensed Practical Nurse (LPN), a Hospice Registered Nurse (RN), and the Director of Nursing (DON), revealed inconsistencies in the understanding and documentation of R111's code status. The CNA and LPN referred to the EMR for code status information, which showed a DNR status, while the Hospice RN confirmed a Full Code status as per the POLST. The DON acknowledged the expectation for the code status to be easily located and consistent across the EMR, orders, and miscellaneous documents, which was not the case for R111.
Inadequate ADL Care for Resident with Contracted Hands
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for a resident with contracted hands, resulting in poor nail care and hand hygiene. The resident, identified as R4, was admitted with multiple diagnoses including chronic respiratory failure, chronic kidney disease, Alzheimer's disease, hypertension, chronic obstructive pulmonary disease, and a psychotic disorder. Despite being cognitively intact with a BIMS score of 15, R4 was dependent on staff for ADL care. The care plan indicated a self-care deficit requiring assistance with ADL care due to physical limitations and multiple comorbidities, with a preference for bed baths. Observations and interviews revealed that R4 had dirty fingernails digging into her skin and expressed dissatisfaction with the frequency and quality of care. On multiple occasions, R4 was observed with unclean hands and nails, and her fingernails were untrimmed and contracted into her skin. A CNA confirmed that ADL care should include hand and nail care, and a LPN stated that the facility's ADL protocols should encompass comprehensive hand cleaning, with only nurses permitted to cut nails if the resident is diabetic. The LPN confirmed that R4 prefers her nails short and clean, indicating a failure to meet the resident's care needs.
Failure to Provide Urostomy Care
Penalty
Summary
The facility failed to provide appropriate urostomy care for a resident, identified as R262, who was sent to an outside appointment without a urostomy bag. R262 had a urostomy with an ileal conduit due to bladder cancer and was admitted with diagnoses including malignant neoplasm of the posterior wall of the bladder and surgical aftercare of the genitourinary system. The care plan for R262 included interventions such as educating the resident on the importance of keeping a urostomy bag and providing urostomy care as ordered. However, on the day of the appointment, the resident was sent out without the necessary urostomy appliance, which was covered with an adult brief and a disposable bed pad instead. The incident was reported by the resident's caseworker, who informed the facility that Adult Protective Services had been notified. The facility's staff explained that the resident had removed the appliance before leaving and that there were no additional supplies available to reapply it. The Director of Nursing, who was not employed at the time of the incident, confirmed that residents should not be sent out without the appropriate ostomy bag. The Administrator stated that the resident's supplies were special-order items not available through the facility's usual supply resources, and the shipment had not arrived in time for the appointment.
Infection Control Deficiencies in Respiratory and Medication Handling
Penalty
Summary
The facility failed to adhere to standard infection control practices, as evidenced by two specific incidents. In the first incident, a continuous positive airway pressure (C-PAP) mask belonging to a resident was observed unbagged and lying on a towel on the resident's bed. The resident mentioned that he cleans the machine himself daily. A Licensed Practical Nurse (LPN) confirmed that the mask was not bagged, which was against the facility's policy that requires respiratory equipment to be covered in a plastic bag when not in use. Both the Director of Nursing and the Administrator stated that it is the responsibility of the nursing staff to ensure that C-PAP masks are clean and bagged when not in use. In the second incident, an LPN was observed handling medications with her bare hands during medication administration. The facility's policy explicitly states that medications should not be touched with bare hands to prevent contamination or infection. The LPN admitted to handling the medications with her bare hands, citing that her hands were too big and she did not want to drop the medications. The Assistant Director of Nursing confirmed that the expectation is for nurses to avoid touching medications with bare hands and to use gloves if necessary. These actions were in direct violation of the facility's infection control protocols.
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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