Westbury Center Of Mcdonough For Nursing & Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcdonough, Georgia.
- Location
- 198 Hampton Street, Mcdonough, Georgia 30253
- CMS Provider Number
- 115463
- Inspections on file
- 23
- Latest survey
- January 24, 2026
- Citations (last 12 mo.)
- 5 (2 serious)
Citation history
Health deficiencies cited at Westbury Center Of Mcdonough For Nursing & Healing during CMS and state inspections, most recent first.
Administration failed to provide protective oversight and enforce abuse‑prevention policies, allowing an EVS housekeeper to enter resident rooms at unusual times without cleaning supplies and engage in sexual contact with a resident on a locked behavioral unit. The Administrator conducted a biased, leading interview with the involved resident in front of law enforcement, repeatedly framing the encounter as consensual despite the resident’s dementia and memory concerns. Another resident reported feeling uncomfortable when the same staff member entered her room twice while she was dressing, but the SSD did not file a grievance or investigate further. A CNA later reported directly witnessing the EVS housekeeper with his pants down and his penis in a resident’s mouth, and leadership subsequently characterized the incident as consensual while acknowledging such conduct violates the abuse policy.
A cognitively impaired resident with vascular dementia, anxiety, and major depressive disorder, care planned for poor decision-making and need for monitoring, was left vulnerable when an EVS housekeeper entered the resident’s room, closed the door, and remained inside for several minutes. Video footage showed the housekeeper entering the room after previously entering another room without knocking. A CNA later entered and reported seeing the housekeeper standing with his pants down while the resident lay in bed with his penis in her mouth, after which he reacted and fled to the bathroom. In a subsequent police-recorded interview, the resident stated that her mind was gone and that she did not enjoy the encounter, indicating the housekeeper did. These events show the facility failed to protect the resident from sexual abuse by staff.
A cognitively intact resident with anxiety reported to the SSD that an EVS housekeeper had entered her room on two early-morning occasions while she was dressing, which made her feel uncomfortable. Facility policy designates the SSD and Administrator as Grievance Officials and requires that any verbal complaint to staff be documented on a grievance form, investigated, and tracked through resolution, with the resident kept informed. The SSD acknowledged she did not treat the resident’s report as a grievance, did not complete grievance documentation, and did not initiate an investigation, resulting in noncompliance with the facility’s grievance policy and federal requirements.
Multiple residents with cognitive and physical impairments were subjected to physical abuse by peers, including being pushed, struck, and pinned to the floor, resulting in injuries such as a sprained ankle and facial scratches. Staff and medical records confirmed that aggressive behaviors were known and recurring, but interventions such as redirection and care plan updates did not prevent repeated harm. The facility's actions were insufficient to protect vulnerable individuals from abuse, as required by policy.
Multiple residents experienced unclean and poorly maintained living conditions, including dirty floors, damaged bathrooms, malfunctioning toilets, and cluttered shower rooms. Housekeeping was inconsistent, with staff reporting high turnover and heavy workloads, leading to overflowing garbage and lack of basic supplies. Maintenance issues, such as broken fixtures and persistent grime, were not addressed promptly, and common areas were cluttered with equipment, detracting from a homelike environment.
Failure of Administration to Prevent, Recognize, and Properly Investigate Staff‑to‑Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility administration’s failure to provide protective oversight and to administer the facility in a manner that effectively prevents abuse, specifically staff‑to‑resident sexual abuse. The Administrator did not ensure appropriate supervision of an Environmental Services (EVS) housekeeper who entered and remained in resident rooms at unusual times without cleaning supplies or a housekeeping cart, causing residents to feel uncomfortable and afraid. The facility’s abuse policy required assigning responsibility for supervision of staff on all shifts to identify inappropriate staff behaviors, and the Administrator’s job description required protecting residents from abuse, ensuring reportable events are reported, and promoting an environment of trust and abuse prevention. Surveyors reviewed a police body‑worn camera recording of an interview conducted by the Administrator with a resident in the presence of a police officer. During this interview, the Administrator used leading and suggestive questions that implied the resident consented to sexual contact with the EVS housekeeper, including asking whether the resident “enjoyed” the act and whether it was something the resident “consent[ed]” to and “like[d]” to happen. The resident, who resided on a locked behavioral unit and referenced memory problems, responded that her “mind is gone” and could not state how long the conduct had been occurring, while also indicating the EVS housekeeper’s penis had been in her mouth several times. The Administrator later stated that this questioning style came from her professional training and that she believed the resident was alert, oriented, and communicating clearly during the interview. The five‑day follow‑up submitted by the facility concluded that staff‑to‑resident sexual contact was substantiated but characterized the incident as consensual and framed the EVS housekeeper’s responsibility as needing to inform administration of the resident’s desire for a sexual encounter. Additional findings showed that another resident on the same locked behavioral unit reported that the same EVS housekeeper had entered her room on two early‑morning occasions while she was dressing, without cleaning supplies, which she found odd and which made her feel uncomfortable; she reported this to the Social Service Director (SSD). The SSD acknowledged that she asked the resident if the EVS housekeeper had touched her, was told no, and did not file a grievance or conduct further investigation. A CNA reported that on the day of the incident she entered the first resident’s room while passing ice water and observed the EVS housekeeper standing with his pants down and his penis in the resident’s mouth; the CNA stated the EVS housekeeper exclaimed and ran into the bathroom, and that video review showed he had been in the room for fifteen minutes with a resident who has dementia. The Regional Director of Operations stated that the resident initiated the contact, that the incident was consensual, and simultaneously acknowledged that an employee receiving fellatio from a resident would violate the abuse policy. These actions and inactions by administration and leadership compromised the integrity of the abuse investigation and minimized the seriousness of staff‑to‑resident sexual abuse.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Housekeeping Staff
Penalty
Summary
The facility failed to protect a resident from sexual abuse by an Environmental Services (EVS) housekeeper, in violation of its abuse, neglect, and exploitation policy, which prohibits sexual abuse defined as non-consensual sexual contact of any type with a resident. The resident involved had diagnoses including anxiety, major depressive disorder, and vascular dementia, and her most recent MDS assessments showed moderately impaired cognition with poor decision-making skills, need for cueing and reminders, and cognitive loss/dementia as an area of concern. Her care plan identified poor decision-making and required staff monitoring and redirection as needed. On the day of the incident, facility camera footage showed the resident leaving her room briefly and then returning and closing the door, with no further exit observed. Later that afternoon, the EVS housekeeper entered another resident’s room without knocking, then exited and shortly thereafter knocked on the involved resident’s door and entered, closing the door behind him. He remained in the room for approximately 12 minutes before a CNA entered the room while passing ice water. The CNA reported observing the EVS housekeeper standing with his pants down and the resident lying in bed with his penis in her mouth; the CNA stated she gasped, the housekeeper said “Oh shit,” and ran into the bathroom with a “scary look” in his eyes. The facility’s incident report documented that a staff member walked into the resident’s room and observed the staff member with his pants down and it appeared the resident was engaged in oral sex. Review of police body camera footage from the same day captured the resident stating, “My mind is gone,” and telling the Administrator and a police officer, “I am not saying I enjoyed it. He enjoyed it,” and, “It ain’t about me, it is about him.” These observations and statements, combined with the resident’s documented cognitive impairment and need for supervision, demonstrate that the facility did not ensure the resident’s right to be free from sexual assault by facility staff.
Failure to Treat Resident’s Verbal Complaint as a Grievance
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and federal requirements when a resident voiced a concern about staff behavior. The facility’s policy titled “Resident and Family Grievances” states that the Director of Social Services and the Administrator are designated Grievance Officials responsible for overseeing the grievance process, receiving and tracking grievances, leading investigations, maintaining confidentiality, issuing written grievance decisions, and coordinating with state and federal agencies as needed. The policy further specifies that grievances may be voiced verbally to any staff member or Grievance Official, and that the staff member receiving the grievance must record the nature and specifics of the grievance on the designated grievance form or assist the resident in completing the form, take any immediate actions needed to prevent further potential violations of resident rights, and keep the resident apprised of progress toward resolution. Resident 6 was admitted with a diagnosis that included anxiety, and her most recent PPS Part A MDS showed a BIMS score of 15, indicating she was cognitively intact. During an interview, the resident reported that on two occasions an Environmental Services Housekeeper entered her room early in the morning while she was dressing, and that this made her feel uncomfortable; she stated she reported this to the Social Worker. The Social Service Director confirmed that she spoke with the resident, who told her it was odd that the housekeeper had been in her room twice, and when asked, the resident said the staff member had not touched her. The Social Service Director acknowledged that she did not file this concern as a grievance and no further investigation was conducted at that time, resulting in the resident’s verbal complaint not being treated, documented, or investigated as a grievance in accordance with the facility’s policy and federal requirements.
Failure to Protect Residents from Physical Abuse by Peers
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, resulting in both physical and psychosocial harm. One resident with severe neurocognitive disorder and a history of aggressive behaviors physically assaulted several other residents on multiple occasions. In one incident, this resident grabbed another resident by the neck and pushed her, and in another, pushed a resident to the floor, causing a sprained ankle that required an ER visit and immobilization. A third incident involved the same resident dragging another resident out of his room and pinning her to the floor, resulting in visible discoloration and distress. These incidents occurred despite the known behavioral risks and cognitive impairments of both the aggressor and the victims, who were all severely cognitively impaired and prone to wandering into other residents' rooms. Another incident involved a resident with paraplegia and no cognitive impairment who was physically assaulted by his roommate. The aggressor verbally threatened and then struck the resident on the face, causing scratches and distress. The assaulted resident was unable to defend himself due to his physical limitations. Staff observed the injuries and confirmed the account, and the incident was reported to the appropriate authorities. The aggressor denied the physical assault but admitted to a verbal altercation. In all cases, the facility's actions and interventions prior to the incidents were insufficient to prevent the abuse, despite documented behavioral risks and prior aggressive incidents. The facility's policies required the protection of residents from abuse, but the measures in place did not prevent repeated harm to vulnerable residents. Staff interviews confirmed that the aggressive behaviors were known, and interventions such as redirection of wandering residents were inconsistently effective. The facility did not implement increased supervision or one-to-one monitoring for the resident with repeated aggressive incidents, and documentation of efforts to find alternative placement after discharge notices was lacking.
Failure to Maintain Clean, Homelike, and Well-Maintained Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents across several units, as required by its own policy and federal regulations. Observations revealed numerous deficiencies in cleanliness and maintenance, including crumbs and soiling on floors, unclean and damaged bathrooms, toilets that were difficult to flush or not functioning, and cracked or loose toilet seats. Residents reported that housekeeping was inconsistent, with rooms sometimes not cleaned, garbage cans overflowing, and a lack of basic supplies such as toilet paper and paper towels. Maintenance issues, such as clogged toilets and broken shower heads, were not addressed in a timely manner, with some repairs taking weeks to complete. Resident council minutes documented ongoing concerns over several months, including unswept floors, dirty windows, insufficient trash bags, un-mopped floors, malfunctioning lights, and persistent plumbing issues. Observations in various rooms and common areas found dust accumulation on ceiling tiles, water damage, peeling baseboards, soiled and discolored flooring, missing or damaged tiles, mildew, and non-functioning light fixtures. Shower rooms were cluttered with stored equipment, further detracting from the homelike environment and limiting usable space for residents. Interviews with housekeeping staff revealed high turnover and heavy workloads, with each housekeeper responsible for cleaning up to 35 rooms. Staff confirmed that some areas, such as the blackened floors, could not be adequately cleaned with routine methods and required more intensive maintenance. The Maintenance Director and Environmental Services staff verified many of the observed deficiencies and acknowledged that some issues, such as lack of storage space and persistent grime, had not been properly addressed. Residents affected by these deficiencies included individuals with intact cognition as well as those with moderate cognitive impairment and complex medical needs.
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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