Woods At Sparta Of Journey Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Sparta, Georgia.
- Location
- 60 Providence Street, Sparta, Georgia 31087
- CMS Provider Number
- 115397
- Inspections on file
- 17
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Woods At Sparta Of Journey Llc, The during CMS and state inspections, most recent first.
A resident sustained a burn from an unsupervised e-stim treatment, and the facility failed to report or document the incident promptly. Additionally, power strips were improperly placed on the floor and bedside tables, posing hazards to residents. Staff interviews revealed a lack of awareness and communication regarding safety protocols.
A resident suffered a burn on the right leg due to improper use of an e-stim device by physical therapy staff who were not adequately trained. The staff member applied the device and left the room, resulting in the resident experiencing intense burning and removing the device to find burn marks. Interviews revealed that the facility did not provide training or competency checks for the e-stim device, relying on staff's prior schooling. The facility began training after the incident, but the delay in education was unexplained.
The facility's dietary staff failed to follow proper food safety protocols, including preventing wet nesting of steam table pans, storing food off the floor, and correctly using the three-compartment sink for sanitizing dishware. These deficiencies were confirmed by the Dietary Manager and observed during a survey.
A facility failed to maintain a dumpster, resulting in liquid waste leaking onto the ground due to a missing plug. Despite being aware of the issue, the facility's staff, including the DM and IMD, confirmed the ongoing leakage over several days. The Administrator noted the dumpsters were city-owned and lacked a specific waste disposal policy.
The facility failed to maintain effective infection control in its laundry operations. Observations revealed that laundry staff did not use PPE and transported clean linens uncovered, violating facility policies. Interviews indicated a lack of training and awareness among staff and management regarding infection control procedures, leading to potential cross-contamination risks.
A resident in a long-term care facility developed sores on the right lower leg, believed to be from an e-stim machine used during physical therapy. Despite the resident's denial of the sores' origin, the Physical Therapy Assistant documented the observations but failed to communicate them to the nursing staff or the Administrator. Consequently, the physician or Nurse Practitioner was not notified until 11 days later, when the resident's condition had worsened, requiring antibiotic treatment. Interviews revealed a breakdown in communication and documentation, with staff failing to complete an incident report or ensure proper notification.
The facility was found deficient in maintaining a safe, clean, and comfortable environment, with issues such as missing floor tiles, a bare lightbulb, chipped and peeling paint, and discolored ceiling tiles. Interviews revealed a lack of awareness and documentation of these maintenance issues, with the facility in the process of recruiting a permanent Maintenance Director.
The facility did not conduct pre-employment reference checks for eight employees, including key staff like the Administrator and DON, as required by their policy on Abuse, Neglect, and Exploitation. This oversight was confirmed through interviews and a review of employee files, although no abuse or neglect concerns were identified at the time.
Two residents with serious mental disorders were not referred for a PASARR Level II assessment upon admission or within 30 days of a new diagnosis. One resident with PTSD had an incomplete PASARR Level I, and no Level II assessment was conducted. Another resident with multiple diagnoses, including anxiety disorder, had an incomplete PASARR Level I, and no Level II assessment was completed. The responsibility for ensuring these assessments lies with the social worker, who was unavailable for comment.
A resident with schizophrenia was admitted to a facility without a required PASARR Level II assessment, despite facility policy mandating such coordination for mental disorders. The resident's PASARR Level I status was marked as Pending, indicating the need for further assessment, but this was not completed, as confirmed by the DON and Business Office Manager.
The facility failed to develop and implement comprehensive care plans for two residents. One resident did not have a care plan for pain management despite having diabetes with neuropathy and documented pain. Another resident's care plan for oxygen therapy was not followed, despite their need for respiratory support due to conditions like COPD and sleep apnea. These deficiencies were confirmed by the MDS/Care Plan Coordinator and the DON.
A facility failed to update a resident's care plan to reflect a change in code status from Full Code to DNR, as indicated by the POLST document. The MDS Coordinator acknowledged the oversight, and the DON explained that the SSD was responsible for reporting code status changes to the MDS Coordinator.
The facility failed to provide proper respiratory care for two residents. One resident did not receive continuous oxygen as ordered, with the equipment left exposed. Another resident's nebulizer mouthpiece was improperly stored, increasing infection risk. Staff were aware of the protocols but did not comply.
A facility failed to implement a 14-day stop date for a resident's PRN Ativan prescription, as required by their policy. The medication, used for anxiety, was administered multiple times over an extended period without a documented rationale for extending the order. The DON admitted the oversight despite audits to ensure compliance.
The facility did not follow established menus and failed to notify the RD of meal substitutions, affecting residents on mechanical soft ground and puree diets. Instead of the posted menu, residents received meals with unapproved substitutions, such as brown gravy on chicken and mashed potatoes instead of puree cabbage. The RD was not informed of these changes, contrary to facility policy.
The dietary staff failed to follow the standardized recipe for fried chicken, affecting nine residents who required puree and mechanical soft ground consistencies. Instead of using fried chicken as indicated on the menu, plain steamed diced chicken was used, compromising the nutrient value of the meal. The Dietary Manager and Registered Dietitian were unaware of this substitution, leading to a deficiency in meal preparation.
Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to ensure the safety of three residents, resulting in actual harm to one resident, R14, who sustained a burn from an electrical stimulation (e-stim) treatment. The physical therapy staff did not adequately supervise the e-stim treatment, leading to a burn on R14's right leg. Despite the resident's report of the burn to the physical therapy assistant, the incident was not communicated to the nursing staff or documented in the resident's medical record until 11 days later. The resident continued to receive e-stim treatments even after the burn was identified, and the physician was not notified promptly. Additionally, the facility did not maintain a safe environment for residents R14, R15, and R30, as power strips were found on the floor and bedside tables, posing potential hazards. These power strips were used with medical equipment, such as oxygen concentrators and electrical beds, without being properly secured or mounted. Staff interviews revealed a lack of awareness and communication regarding the proper placement and safety requirements for surge protectors. The facility's failure to adhere to its own policies on incident reporting and safety precautions contributed to the deficiencies. The lack of immediate action and communication among staff members regarding the burn incident and the improper use of power strips demonstrated a significant oversight in ensuring resident safety and compliance with established protocols.
Lack of Training Leads to Resident Harm from E-Stim Device
Penalty
Summary
The facility failed to ensure that physical therapy staff were adequately informed or educated before applying an electronic medical device for electrical stimulation treatment (e-stim) on a resident, resulting in actual harm. The incident involved a resident who sustained a burn on the right leg with 100% slough in the wound bed after a physical therapy staff member applied the e-stim device and left the room. The resident, who was cognitively intact, reported that the device began to burn intensely, prompting him to remove it and discover three burn marks. The resident expressed concern that staff were using residents as test subjects without proper training. Interviews with facility staff revealed a lack of training and competency checks for the e-stim device. The Physical Therapy Manager admitted that the therapy staff had not received training or education on the device within the facility, assuming that their schooling sufficed. The Physical Therapy Assistant confirmed the absence of formal training, relying on her school training and personal experimentation. The Administrator acknowledged the need for skill checks to ensure staff competency, and the Regional Rehabilitation Manager confirmed that no training was provided before the incident. The facility began educating the physical therapy department after the incident, but the reason for the delay was not provided.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The dietary staff at the facility failed to adhere to proper food safety and sanitation protocols, as observed during a survey. The staff did not prevent wet nesting of steam table pans, which can lead to bacterial growth. During an inspection, it was found that the inside of the top pans in stacks of steam table pans were wet, indicating they were not completely air-dried before stacking. The Dietary Manager confirmed this observation and acknowledged that the pans should have been air-dried completely before being stacked. Additionally, the facility did not store food items properly in the dry storage area, as cases of food were found directly on the floor. The Dietary Manager admitted that the food items were left on the floor due to a recent grocery delivery and a lack of time to store them properly. Furthermore, the staff did not follow the correct procedure for using the three-compartment sink for sanitizing dishware. A dietary staff member was observed not immersing dishware in the sanitizing solution for the required 60 seconds, which was confirmed by the staff member and the Dietary Manager.
Improper Dumpster Maintenance Leads to Waste Leakage
Penalty
Summary
The facility failed to properly maintain one of its two dumpsters, leading to a deficiency in waste management. Observations revealed that the dumpster closest to the building was missing a plug at the bottom, resulting in a liquid substance actively dripping onto the asphalt ground. This issue was first observed on 8/9/2024 and continued to be present during subsequent observations on 8/10/2024 and 8/11/2024. The Dietary Manager confirmed the absence of the plug and the active leakage during interviews conducted on these dates. The facility's Administrator and Interim Maintenance Director were made aware of the issue, with the Administrator noting that the dumpsters were city-owned and maintained, and that there was no existing policy regarding dumpsters or waste disposal. The Interim Maintenance Director confirmed that the plug likely dislodged during the last garbage pick-up and had contacted the waste management company to request a replacement. Despite these communications, the issue persisted over several days, indicating a lapse in timely corrective action.
Infection Control Deficiency in Laundry Handling
Penalty
Summary
The facility failed to maintain an effective infection control program, particularly in the handling, storage, and processing of linens. During a tour of the laundry area, it was observed that the industrial washer had accumulations of chemical residue and dust, and the laundry staff was not using personal protective equipment (PPE) while handling both dirty and clean laundry. Additionally, clean clothing was found hanging on an uncovered rack, ready for distribution, which is against the facility's infection control policies. Interviews with the laundry staff and management revealed a lack of awareness and training regarding infection control procedures. Laundry Aide GG admitted to not wearing PPE and was unaware of the requirement to cover clean clothing racks. The Laundry Manager, who was new to the position, also lacked training and was unaware of the need to cover clean clothing racks or the requirement for staff to wear PPE. The Director of Nursing confirmed that all linen should be covered before leaving the laundry and that staff should wear gloves and gowns when handling soiled linen. Further observations showed that clean linen was transported in uncovered baskets and placed next to dirty linen carts, which violates the facility's policy of keeping clean and dirty linens separate. Interviews with other laundry aides confirmed that they had never covered laundry during transport and did not wear PPE when handling contaminated or clean linen. The Infection Prevention Nurse and the Administrator reiterated the importance of separating clean and dirty linen and the requirement for PPE, highlighting a systemic issue in the facility's infection control practices.
Failure to Timely Notify Health Agent of Resident's Burn
Penalty
Summary
The facility failed to timely notify the health agent of a significant change related to a burn for a resident, identified as R14, which was a deficiency found during the survey. The facility's policy requires notifying the resident, their physician, and a family member or legal representative when there is a significant change in the resident's condition. In this case, R14, who was cognitively intact with a BIMS score of 14, developed sores on the right lower leg, believed to be from an e-stim machine used during physical therapy. Despite the resident's denial of the sores' origin, the Physical Therapy Assistant (PTA) documented the observations but failed to communicate them to the nursing staff or the Administrator. Consequently, the physician or Nurse Practitioner was not notified until 11 days later, when the resident's condition had worsened, requiring antibiotic treatment. Interviews with facility staff revealed a breakdown in communication and documentation. The PTA informed the Physical Therapy Manager of the burn, but neither completed an incident report nor ensured the nursing staff was aware. The Assistant Director of Nursing confirmed the absence of documentation or an event report related to the burn in the electronic medical record. The Physical Therapy Manager admitted to assuming the PTA had reported the incident to nursing and acknowledged the oversight in not following up. The Medical Director was aware of the burn but uncertain about the timeliness of the notification, emphasizing the need for immediate reporting and frequent monitoring of such injuries.
Deficiencies in Facility Maintenance and Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in several resident rooms and a common area, as observed during a survey. Specific deficiencies included missing floor tiles in multiple rooms, a bare lightbulb without a cover in a shared restroom, chipped paint on baseboards, peeling paint exposing drywall, and discolored ceiling tiles in the Resident Dining Room. These issues were identified through observations conducted on different dates and times, highlighting the facility's inability to adhere to its own policies on maintenance and preventative maintenance. Interviews with the facility's Administrator, Interim Maintenance Director, and Corporate Director of Procurement, Information Technology, and Maintenance revealed a lack of awareness and documentation regarding the maintenance issues. The Administrator confirmed the need for repairs and expressed expectations for a home-like environment, while the Interim Maintenance Director admitted to conducting daily observational rounds without documentation. The Corporate Director acknowledged the need for timely repairs and was in the process of finding matching tiles for the missing ones. The facility was also in the process of recruiting a permanent Maintenance Director.
Failure to Conduct Pre-Employment Reference Checks
Penalty
Summary
The facility failed to conduct pre-employment reference checks for eight out of 60 employees, as required by their policy on Abuse, Neglect, and Exploitation. This policy mandates that potential employees undergo background, reference, and credentials checks to screen for any history of abuse, neglect, exploitation, or misappropriation of resident property. The absence of these checks was discovered during a review of employee files, which revealed that key staff members, including the Administrator, Director of Nursing, and several nurses, were hired without the necessary reference checks. Interviews with the Business Office Manager and the Administrator confirmed the lack of documentation for these reference checks. The Business Office Manager, who was temporarily covering for the Human Resource Director, was unable to locate the required documents. The Administrator acknowledged that the Human Resource Director was responsible for ensuring the completion and maintenance of new hire documents, including reference checks. Despite the deficiency, there were no identified concerns related to abuse or neglect within the facility at the time of the report.
Failure to Conduct PASARR Level II Assessments
Penalty
Summary
The facility failed to ensure that two residents with serious mental disorders were referred for a Level II PASARR assessment upon admission or within 30 days of a new diagnosis. Resident R34 was admitted with a diagnosis of PTSD, but the PASARR Level I request did not document this diagnosis, and no PASARR Level II assessment was conducted. The Director of Nursing confirmed the absence of a PASARR Level II in R34's clinical record and acknowledged that the PASARR Level I should have included the PTSD diagnosis. The Social Service Director, responsible for reviewing PASARR Level I and resident diagnoses, was unavailable for comment. Resident R35 was admitted with diagnoses including dementia, depression, anxiety disorder, and delusional disorder. However, no PASARR Level II assessment was completed, and the PASARR Level I assessment was incomplete, with sections left blank. Interviews with the Business Office Manager and the Director of Nursing revealed that the responsibility for ensuring a PASARR Level II assessment lies with the social worker, who was also unavailable for an interview. The Director of Nursing noted that R35's diagnosis of anxiety disorder warranted a PASARR Level II assessment.
Failure to Complete PASARR Level II Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that a resident with a serious mental disorder was referred for a Level II PASARR assessment upon admission or within 30 days of a new diagnosis. The resident, identified as R19, was admitted with a diagnosis of schizophrenia, which was documented in the electronic medical record and the Minimum Data Set (MDS). Despite this, the facility did not have a PASARR Level II assessment on file for the resident, as confirmed by the Director of Nursing (DON) and the Business Office Manager. The facility's policy requires coordination with the PASARR program to ensure appropriate care for residents with mental disorders. However, the Social Services Director, responsible for tracking PASARR screening status, did not ensure a Level II assessment was completed for R19. The PASARR Level I request, dated 5/5/2017, indicated a diagnosis of schizoaffective disorder, and the status was marked as Pending, suggesting the need for a Level II assessment. The absence of this assessment was verified by the DON, who acknowledged the potential risk of the resident not receiving necessary services.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, R14 and R15, as required by their policy. For R14, the facility did not create a care plan addressing pain management despite the resident's documented diagnoses of type 2 diabetes mellitus with diabetic neuropathy and generalized muscle weakness. The resident's quarterly MDS indicated the presence of pain, and a physical therapy evaluation outlined a treatment plan to manage this pain. However, the care plan lacked any mention of pain management or the specific diagnosis, which was confirmed by the MDS/Care Plan Coordinator and the Director of Nursing (DON). For R15, the facility failed to implement the care plan for oxygen therapy. The resident's medical record included diagnoses such as acute and chronic respiratory failure, COPD, and obstructive sleep apnea, with the quarterly MDS documenting the receipt of oxygen therapy. Although the care plan noted the risk of respiratory decline and included interventions for respiratory treatments, it was not followed as the resident did not receive oxygen as ordered. This oversight was verified by both the MDS/Care Plan Coordinator and the DON, who acknowledged the care plan was not being adhered to.
Failure to Revise Care Plan for Code Status Change
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a change in code status. The facility's policy on Comprehensive Care Plans requires that care plans be reviewed and revised by the interdisciplinary team following each comprehensive and quarterly Minimum Data Set (MDS) assessment. However, a review of the resident's care plan revealed that it was not updated to reflect the change from Full Code status to Do Not Resuscitate (DNR), despite the Physician Orders for Life-Sustaining Treatment (POLST) document indicating a change to Allow for Natural Death. The MDS Coordinator acknowledged the oversight during an interview, and the Director of Nursing explained that the Social Service Director was responsible for handling code status changes and reporting them to the MDS Coordinator.
Deficient Respiratory Care Practices
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For one resident with acute and chronic respiratory failure, heart failure, COPD, and obstructive sleep apnea, the facility did not administer oxygen as ordered. Observations revealed that the resident was not receiving the prescribed continuous oxygen, and the oxygen tubing and nasal cannula were left exposed to the environment. There was no documentation of the resident refusing or removing the oxygen, despite the order for continuous administration. For another resident with dyspnea and COPD, the facility did not properly store the nebulizer mouthpiece. Observations showed that the nebulizer cup and mouthpiece were left unbagged and exposed to the environment. Interviews with staff confirmed awareness of the requirement to store respiratory equipment in a plastic bag to prevent infection, yet the equipment was not stored properly. The resident reported that the storage bag had been missing for a few days, and staff interviews confirmed the lack of compliance with storage protocols.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure a stop date was implemented for psychotropic medications, specifically for a resident prescribed Ativan for anxiety. The facility's policy requires that PRN psychotropic drugs have a stop date not exceeding 14 days unless the attending physician documents a rationale for extending the order. However, a review of the resident's physician orders revealed an indefinite end date for Ativan, which was administered multiple times over a period exceeding 14 days. The Director of Nursing acknowledged that the oversight occurred despite audits conducted to ensure compliance with the policy.
Failure to Follow Established Menus and Notify RD of Substitutions
Penalty
Summary
The facility failed to adhere to established menus and did not notify the Registered Dietitian (RD) of meal substitutions, affecting residents on mechanical soft ground and puree diets. The facility's policy, titled Therapeutic Diet Orders, mandates that residents receive foods in the appropriate form and nutritive content as prescribed by a physician or assessed by the interdisciplinary team. However, during an observation, it was noted that the lunch meal served did not match the posted menu. Instead of fried chicken, black eye peas, collard greens, and cornbread, residents on a mechanical soft ground diet received ground plain chicken with brown gravy, boiled cabbage, blackeye peas, and cornbread. Residents on a puree diet received plain puree chicken with brown gravy, puree blackeye peas, and mashed potatoes. Interviews revealed that the Dietary Manager (DM) did not notify the RD of several menu changes, including the addition of brown gravy to the chicken, the substitution of mashed potatoes for puree cabbage, and the omission of pureed cornbread. The RD confirmed that she was only informed about the substitution of cabbage for collard greens. The DM admitted to not having the option to purchase chicken gravy and using brown gravy instead, as well as not having time to puree cabbage. The RD emphasized that dietary staff should serve the menu as posted and notify her of any modifications, which was not done in this instance.
Failure to Follow Recipe for Fried Chicken
Penalty
Summary
The dietary staff at the facility failed to follow the standardized recipe for fried chicken, compromising the nutrient value of the meal served to residents. The deficiency affected six residents who required puree consistency and three residents who required mechanical soft ground consistency from a total of 40 residents receiving an oral diet. The menu indicated that fried chicken was to be served, but instead, plain steamed diced chicken was used. This practice was observed during a survey, where Dietary [NAME] II was seen using steamed diced chicken instead of fried chicken for the puree consistency meal. The dietary staff member was unaware of the recipe requirements and had been using plain chicken, believing it was acceptable. The Dietary Manager (DM) confirmed the use of plain steamed chicken instead of fried chicken and admitted that the facility's Registered Dietitian (RD) had not been informed of this substitution. The RD expected the dietary staff to follow the recipes and indicated that actual fried chicken should have been used to ensure proper nutrient value and taste. The RD was not aware of the changes made by the dietary staff, and the DM assumed that using any form of chicken would suffice. This lack of communication and adherence to the recipe led to the deficiency in meal preparation.
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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