Winder Center For Nursing And Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Winder, Georgia.
- Location
- 263 E May Street, Winder, Georgia 30680
- CMS Provider Number
- 115536
- Inspections on file
- 17
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Winder Center For Nursing And Healing during CMS and state inspections, most recent first.
A resident with multiple diagnoses and severe cognitive impairment was at risk for pressure ulcers, but the facility failed to follow the care plan for skin assessments. Despite a physician's order for weekly assessments, documentation ceased after a CNA reported an open area on the sacrum. The lack of follow-up led to an unstageable wound, highlighting a significant deviation from the facility's care plan policy.
A resident at risk for pressure ulcers developed a sacral wound that was not properly assessed or treated, leading to a severe deterioration in their condition. Despite facility policies requiring weekly skin assessments, these were not consistently completed, and the recommended treatment for the wound was not implemented. Communication and documentation failures among staff contributed to the resident's condition worsening to septic shock, resulting in hospitalization.
A facility failed to accurately document a resident's advanced directive in the EMR. The resident, with multiple diagnoses and a BIMS score indicating cognitive intactness, had a POLST form signed for DNR status. However, the care plan inaccurately listed the code status as FULL CODE. This error was confirmed by the DON and the resident.
The facility failed to provide the required NOMNC and SNF ABN to two residents discharged from Medicare Part A coverage. One resident remained in the facility, while the other returned home. The Business Office Manager indicated that new Social Services and Therapy employees did not provide these documents upon discharge.
A facility failed to monitor blood glucose levels for a diabetic resident receiving insulin, as there were no specific orders for glucose monitoring upon admission. Despite daily insulin administration, no glucose monitoring was documented until the resident was transferred to the hospital with an altered mental status. Interviews revealed a lack of communication and oversight in ensuring blood glucose monitoring was conducted, as per professional standards.
A facility failed to obtain a physician order for colostomy care for a resident with a history of ulcerative colitis and intestinal obstruction. Despite the facility's policy requiring a licensed nurse to determine the type of ostomy and collaborate with the attending physician, the resident's EMR and MAR lacked orders for colostomy care. Interviews with the DON and an LPN confirmed the absence of these orders, leading to inadequate care management for the resident, who was at risk for skin breakdown.
Failure to Follow Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R145, who was at risk for pressure ulcers. R145 was admitted with multiple diagnoses, including encephalopathy due to subdural hematoma, chronic kidney disease, and cerebrovascular accident with hemiplegia. The resident was cognitively impaired and dependent on staff for all activities of daily living. The care plan for R145, dated 11/29/2023, included interventions for daily skin assessments, keeping the skin dry, and monitoring nutrition. However, the facility did not follow through with these interventions, as evidenced by the lack of documented skin assessments after 2/16/2024, despite a physician's order for weekly skin assessments. On 2/16/2024, a CNA reported an open area on R145's sacrum to an LPN, but there was no documented follow-up or additional skin assessments recorded in the medical record. The facility's failure to document and address the skin condition led to the development of an unstageable wound on the sacrum, which was identified by a Wound Nurse Practitioner on 3/27/2024. This oversight in care and documentation was a significant deviation from the facility's policy on comprehensive, person-centered care plans, which should include measurable objectives and timetables to meet the resident's needs. Interviews with facility staff revealed a lack of adherence to the care plan and communication breakdowns. The Corporate Wound Nurse indicated that CNAs are responsible for examining the skin during bathing and reporting changes to the unit nurse, while the MDS Coordinator emphasized the importance of following care plan interventions. Despite these protocols, the facility's staff did not consistently perform or document the required skin assessments, contributing to the resident's deteriorating condition.
Removal Plan
- R145 was discharged from the facility to the hospital for a septic wound and did not return to the facility.
- An AD-HOC meeting was held with the Administrator, Director of Nursing, Regional Director of Operations, Regional Director of Clinical Operations, and Chief Medical Officer to address the concerns identified related to the Immediate Jeopardy Citations.
- The RDO, RDCO, and CMO reviewed the center policy on Developing a Comprehensive Care Plan. No policy changes or recommendations were made because of this review.
- A Root Cause Analysis of the wound management system breakdown was completed by RDO, RDCO, CMO, Administrator and DON. Documentation of analysis was put on the RCA Tool and was included in the Ad Hoc Quality Assurance Performance Improvement QAPI meeting. The Root Cause for the immediate jeopardy was identified as staff not following the center's policy for Pressure Ulcer Prevention and Management secondary to education deficit.
- All residents had a pressure ulcer risk assessment performed. Care plans were reviewed and updated by the MDS Coordinators for 139 of 140 residents to ensure that the weekly skin check was listed as an intervention under the at-risk skin care plan.
- The center MDS Coordinator, Wound Care Nurse, and Regional Wound Care Specialist conducted an audit for 5 of 5 residents with pressure ulcers/injuries to ensure that all residents have a comprehensive wound care plan that is being implemented.
- Nursing employees, 6 of 7 RN's, 27 of 29 LPN's and 43 of 46 CNA's were educated by the RWCS, Staff Development Coordinator, and DON on implementation of the care plan for pressure ulcer prevention and management including location of the care plan in the electronic health record and viewing the care plan prior to the start of the shift. LPNs were educated regarding following physicians orders and the person-centered care plan. Any staff not educated during the initial education will have the education prior to the start of their shift or during the orientation period.
- Review of the root cause analysis showed LPNs and CNAs were educated to ensure weekly skin assessments will be completed on a weekly basis and documented. DON will ensure the completion of assessments in a timely manner. The DON verified the DON in-serviced staff along with RN PP. The DON stated CNAs were re-educated on how to fill out shower sheets (and give a copy to the charge nurse and DON), as soon as a skin condition was identified and to notify the nurse immediately.
- Review of a Daily Census revealed 139 of 140 residents were reassessed for risk for pressure ulcers and that residents had a care plan to include weekly skin assessments. This was verified by review of the pressure ulcer risk assessments and care plans for R12, R395, R400, R402 and R403.
- Review of the pressure Ulcer/Injury Care Plan Update Tool revealed 5 of 5 residents care plans were reviewed for accuracy of wound location and care plan reflective of care provided. Review of five residents, R12, R395, R400, R402 and R403, showed the residents had comprehensive care plans for pressure ulcers.
- Review of in-service sign in sheets revealed 27 of 29 LPNs, 43 of 46 CNA's and 6 of 7 RN's were in-serviced by the RWCS on care plans for pressure ulcer prevention and management.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure ulcers for a resident, identified as R145. The resident was admitted with diagnoses including encephalopathy due to subdural hematoma, chronic kidney disease, and cerebrovascular accident with hemiplegia. The resident was at risk for pressure ulcers but had none at the time of the initial assessment. However, an open area on the sacrum was reported by a CNA on 2/16/2024, but there was no documented follow-up or treatment for this wound. The facility's policy required weekly skin assessments and documentation of any pressure injuries, but these were not consistently completed for R145. The last documented skin assessment was on 3/1/2024, and there was no mention of a sacral wound. Despite a CNA reporting the sacral wound, it was not documented or treated until it was identified as an unstageable wound by a Wound NP on 3/27/2024. The recommended treatment by the NP was not implemented, and the wound worsened significantly, leading to the resident's hospitalization. Interviews with staff revealed a breakdown in communication and documentation processes. The LPN on duty did not recall being informed about the sacral wound, and the wound nurse was not notified in a timely manner. The facility's system for reporting and documenting skin issues was not followed, contributing to the resident's condition deteriorating to septic shock and necessitating hospitalization.
Removal Plan
- An Ad-Hoc meeting was held with the Administrator, Director of Nursing, Regional Director of Operations, Regional Director of Clinical Operations, and Chief Medical Officer to address the concerns identified related to the Immediate Jeopardy Citations.
- The RDO, RDCO, and CMO reviewed the facility policy regarding Pressure Ulcer Prevention and Management. Facility did not make any policy changes or recommendations on this review.
- A Root Cause Analysis regarding the pressure ulcer prevention and skin management system was completed by RDO, RDCO, CMO, Administrator and DON. Documentation of the RCA was put on the RCA Tool and was included in the Ad-Hoc Quality Assurance Performance Improvement meeting. The Root Cause for the immediate jeopardy was identified as staff not following the center's policy for Pressure Ulcer Prevention and Management secondary to education deficit.
- The facility Unit Managers and Wound Care Nurse conducted skin assessments on 131 of 140 residents residing in the center. Audit revealed no new in-house acquired pressure ulcers/injuries.
- Five of five residents residing in the center identified with pressure ulcers/injuries were reassessed including measurements and documented on by the wound care nurse practitioner.
- Orders were verified for five of five Residents with pressure injuries by the Regional Skin Management Specialist to ensure orders in the electronic medical administration record matched the recommendations of the wound care nurse practitioner. The facility implemented an audit conducted by the DON after each wound care nurse practitioner visit to ensure the orders match the recommendations of the wound care nurse practitioner. This audit will be conducted once a week.
- Nursing employees 6 out of 7 registered nurses, 27 out of 29, licensed practical nurses and 43 out of 46 certified nursing assistants were educated by the Regional Wound Care Specialist Staff Development Coordinator, and DON on the pressure ulcer prevention and treatment. Specifically, CNAs received education to notify the licensed nurse anytime a new skin area was identified and to document the findings on the body sheet. The LPNs/RNs received education on conducting weekly skin assessments and notifying the Medical Provider or Wound Care Nurse Practitioner anytime a new skin area is identified as well as following physician orders and plan of care for wound care treatments. Anyone that was not educated during the Initial education sessions will be educated prior to start of their shift or during the orientation process.
- The Regional Skin Management Specialist educated three of three wound care nurses on ensuring pressure wounds are measured weekly and are assessed on the Weekly Wound Assessment Tool.
- 139 of 140 residents' charts were audited the DON will ensure staff have an order to perform a weekly skin check.
- The facility implemented a process to ensure that skin checks are monitored daily to ensure completion. The DON will conduct daily audits to ensure skin checks are completed daily and to ensure any newly identified pressure ulcer was reported to the MD or Wound Care Provider and an appropriate treatment ordered.
Inaccurate Documentation of Advanced Directive in EMR
Penalty
Summary
The facility failed to ensure the accurate documentation of an advanced directive in the Electronic Medical Record (EMR) for a resident, identified as R397. R397 was admitted with multiple diagnoses, including Sepsis, Chronic Diastolic Heart Failure, Acute Kidney Failure, Respiratory Failure with Hypoxia, Psoriatic Arthritis, and Hyperlipidemia. The resident was cognitively intact, as indicated by a BIMS score of 13. A POLST form dated 7/24/2024, signed by R397 and medical personnel, indicated a code status of Allow Natural Death - Do Not Attempt Resuscitation (DNR). However, the care plan dated 9/24/2024 inaccurately documented the resident's code status as FULL CODE. This discrepancy was confirmed by the Director of Nursing during an interview, and the resident also confirmed the correct DNR status during a separate interview.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents who were discharged from Medicare Part A coverage. Resident 94 was discharged from Medicare Part A skilled services and remained in the facility, while Resident 397 was discharged and returned home. There was no documented evidence that these notices were provided to either resident or their responsible parties. During an interview, the Business Office Manager revealed that the facility did not provide the necessary documents to the residents. The manager attributed this failure to the fact that the Social Services and Therapy employees were new to the facility and did not provide the documents upon discharge from Medicare Part A skilled services.
Failure to Monitor Blood Glucose in Diabetic Resident Receiving Insulin
Penalty
Summary
The facility failed to ensure professional standards were followed for blood glucose monitoring of a resident receiving insulin. The facility's policy on Blood Glucose Monitoring did not include a protocol for residents receiving insulin, and there was no documentation of blood glucose monitoring for the resident in question. The resident, who had a diagnosis of diabetes mellitus, was admitted with orders for insulin Glargine but without specific orders for blood glucose monitoring. Despite receiving insulin daily, there was no evidence of glucose monitoring from the time of admission until the resident was transferred to the hospital. The resident was transferred to the hospital due to an altered mental status, where they were diagnosed with a complicated urinary tract infection. Interviews with facility staff revealed a lack of clarity and communication regarding the need for blood glucose monitoring. The Chief Medical Officer stated that blood sugars should be monitored daily for residents on long-acting insulin, even if not specified in hospital discharge orders. However, the Licensed Practical Nurse and the Director of Nursing indicated that the omission of fingerstick orders was an oversight, and the admission nurse failed to clarify the need for such orders with the Nurse Practitioner.
Failure to Obtain Physician Order for Colostomy Care
Penalty
Summary
The facility failed to obtain a physician order for colostomy care for a resident who required such services. The facility's policy on ostomy care mandates that a licensed nurse should determine the type of ostomy through physical assessment and collaboration with the attending physician as part of the comprehensive assessment and care planning process. However, the resident's Electronic Medical Record (EMR) and Medication Administration Record (MAR) lacked any physician orders for colostomy care, including the necessary supplies and frequency for changing the colostomy drainage bag. This oversight was confirmed during interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN), who acknowledged the absence of the required orders on the MAR. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, had a history of ulcerative colitis and intestinal obstruction, and was at risk for skin breakdown due to the colostomy. The resident reported having to clean the stoma multiple times, indicating a lack of proper care management. The care plan initiated for the resident included colostomy care every shift and as needed, but without the necessary physician orders, the care was not documented or administered as required. This deficiency highlights a gap in the facility's adherence to its own policies and procedures for ostomy care management.
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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