Woodstock Center For Nursing And Healing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodstock, Georgia.
- Location
- 105 Arnold Mill Road, Woodstock, Georgia 30188
- CMS Provider Number
- 115421
- Inspections on file
- 22
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Woodstock Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
A resident with paranoid schizophrenia and known behavioral disturbances verbally threatened another resident with violent, profane language in the activities room, leaving the threatened resident confused. The aggressor resident had a documented history of potential for verbal abuse related to mental illness and psychotropic medication use, as well as non‑compliance with medications, yet was still able to direct a specific threat toward another resident. The facility’s investigation substantiated this as an incident of verbal abuse, despite an existing policy prohibiting abuse, neglect, and exploitation.
An LPN signed out controlled medications for three residents in the narcotic log as if administered, but the residents either reported not receiving their scheduled pain or anxiety medications or had documentation indicating late or missing doses. For one resident with chronic back pain on scheduled morphine and another with vertebral fracture and arthritis on scheduled tramadol, the MAR showed the drugs initialed as given, yet there was no clear documentation of the actual administration time or explanation for the missed or delayed doses, and one resident’s pain scores were inconsistently charted. A third resident with anxiety on scheduled alprazolam had the drug signed out in the narcotic book and initialed on the MAR, but progress notes indicated it was not properly signed off in the EMAR. The LPN later stated that, after being asked to leave the facility because she was not formally assigned to the shift, she discarded the medications without a witness, contrary to facility policy requiring two licensed staff to witness and document controlled substance disposal, resulting in discrepancies between the narcotic log and MAR.
Staff did not consistently keep garbage dumpster lids closed and failed to maintain cleanliness around the dumpsters, leaving debris such as used gloves on the ground. Multiple observations confirmed that dumpster doors were left open when not in use, contrary to facility policy, and staff interviews acknowledged responsibility for these tasks.
A review of facility records and staff interviews revealed that the facility did not maintain a surety bond sufficient to cover all resident personal funds on deposit, with account balances exceeding the bond amount for several months. This failure affected the security of personal funds for multiple accounts managed by the facility.
Staff did not consistently provide or document required ADL assistance for three residents with significant cognitive and physical impairments. One resident was left in soiled linens without timely incontinence care, another had persistently dirty and untrimmed fingernails despite documentation suggesting care was provided, and a third had no records of receiving showers or bed baths for an extended period, even after a family grievance. Interviews revealed inconsistent practices and incomplete documentation among CNAs and nursing staff.
A resident with severe cognitive impairment and multiple medical conditions did not consistently receive physician-ordered TED hose as required, despite documentation in the MAR indicating otherwise. Observations showed the resident without the compression stockings during required times, and staff interviews revealed that LPNs sometimes documented the task as completed without actually applying the hose, with one LPN unaware of the order. The DON confirmed that documentation should reflect real-time care provided.
The facility had a medication administration error rate of 6.45%, exceeding the acceptable limit of 5%. An LPN failed to administer furosemide to a resident and did not perform required respiratory assessments for another resident receiving a nebulizer treatment. The DON confirmed these lapses in protocol.
The facility failed to protect residents from sexual abuse by other residents. One resident was groped by another in a common area, and another resident placed their hand down a different resident's shirt in the dining room. Both incidents involved residents with cognitive impairments and dependency on staff for ADLs. Despite regular staff training on abuse prevention, the facility's measures were insufficient to prevent these occurrences.
A resident with significant medical conditions and dependence on staff for personal hygiene did not receive adequate shower assistance, as documented in the EMR and confirmed through interviews. The DON acknowledged the lack of a dedicated shower team and inconsistent adherence to shower schedules.
A resident with respiratory failure was observed receiving O2 at 3.5 LPM despite a physician's order for 1 LPM. This discrepancy was confirmed by both an LPN and an RN/UM, who acknowledged the physician's order and the current O2 setting. The resident was alert and had no complaints about the care received.
The facility failed to secure resident medications as two medication carts and an IV cart were found unlocked and unattended. Staff confirmed that the carts should not have been left unlocked, and the DON reiterated that medication carts must always be locked when not attended.
The facility failed to properly perform infection control practices during medication administration. One LPN did not disinfect an electronic blood pressure cuff between uses on different residents, and another LPN handled medication with ungloved hands. The DON confirmed that these actions were against the facility's infection control policies.
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse when one resident threatened another with violent language. One resident (R7), who had paranoid schizophrenia, used a wheelchair, and had a BIMS score of 15/15 indicating little to no cognitive impairment, told another resident (R8), "I will blow your brains out" with profanity while in the activities room. R8, who had type 2 diabetes, leg pain, unilateral primary osteoarthritis, and a BIMS score of 8/15 indicating moderate cognitive impairment, reported hearing R7 rambling, not understanding what was said, and then hearing the explicit threat directed at her. R8 stated she felt confused afterward. The facility’s own investigation, as documented in the Incident Summary Report, substantiated the allegation of verbal abuse. R7’s care plan, in place prior to the incident, documented that she used psychotropic medications with potential effects on mood and behavior and that she had the potential to demonstrate verbal abuse related to her mental and emotional illness, including paranoid schizophrenia. The NP noted that R7 continued to demonstrate behavioral disturbances, was verbally abusive at times, and was non‑compliant with her medication regimen, though she had not been physically threatening. The DON confirmed familiarity with R7’s history of increased hallucinations, paranoia, and verbal abuse when medication adjustments were needed. Despite this known risk and the facility’s written policy prohibiting abuse, neglect, and exploitation, R7 was able to verbally abuse R8, resulting in a substantiated incident of resident‑to‑resident verbal abuse.
Misappropriation and Poor Accountability of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of medications, specifically controlled substances, and to ensure accurate administration and documentation for three residents. For one resident with chronic pain, muscle spasm, spinal stenosis, osteoarthritis, hypertension, and Alzheimer’s disease, the MDS showed moderate cognitive impairment and ongoing pain requiring scheduled Morphine Sulfate ER 15 mg twice daily. On the date in question, an incident report documented that the DON was notified that this resident and others had not received their scheduled 9:00 AM narcotic medications. The narcotic book showed that an LPN had signed out the Morphine as if administered, but the resident later verbalized that the morning dose had not been received. For a second resident with cerebral infarction, vertebral fracture, arthritis, and hypertension, the MDS indicated moderate cognitive impairment and frequent, almost constant pain that interfered with daily activities, with an order for Tramadol 50 mg twice daily. The incident report again showed that the DON was notified that this resident had not received the scheduled 9:00 AM narcotic medication, while the narcotic book reflected that the LPN had signed out the Tramadol as administered. Review of the MAR for that date revealed conflicting pain scores of 0 and 9 and showed Tramadol initialed as given at 9:00 AM, but there was no documentation of the actual time of administration or explanation for the delayed or missed dose. A progress note indicated that Tramadol was signed out in the narcotic book but not signed off on the MAR. For a third resident with major depressive disorder, anxiety, gout, and psoriasis, the MDS showed little to no cognitive impairment and frequent pain, and the resident had an order for Alprazolam 0.5 mg once daily for anxiety. The incident report documented that the DON was notified that this resident had not received the scheduled 9:00 AM anxiety medication, even though the narcotic book showed the LPN had signed out the Alprazolam as if given. The MAR showed Alprazolam initialed as administered at 9:00 AM, but there was no documentation of the actual time of administration or any accounting for the delayed or missed dose. Progress notes for this resident stated that the medication was not signed off on the EMAR but was signed off in the narcotic book as given at 9:00 AM. Across all three residents, the LPN initially confirmed administration of the medications but later stated that, after being asked to leave the facility because she was not formally assigned to the shift, she discarded the medications without a witness, contrary to facility policy requiring two licensed staff to witness and document any controlled substance disposal. The facility’s written policy on Controlled Substance Administration & Accountability stated that the Controlled Drug Record serves the dual purpose of recording both narcotic disposition and patient administration and, together with the MAR, is the source for documenting any patient-specific narcotic dispensed from the pharmacy. The policy also required that two licensed staff witness any disposal or destruction of a controlled substance and document it on the Drug Disposition Record. In these incidents, controlled substances were signed out in the narcotic log as if administered, residents reported or were documented as having missed or late doses, and there was no proper witnessing or documentation of disposal, resulting in discrepancies between the narcotic log, MAR, and resident reports.
Improper Disposal and Maintenance of Garbage Dumpsters
Penalty
Summary
Staff failed to properly dispose of garbage and refuse in accordance with the facility's policy, which requires dumpsters to be kept covered when not being loaded and the surrounding area to be kept clean. During multiple observations, surveyors noted that the sliding lids of both garbage dumpsters were left open when not in use, and there was debris, including used gloves and other materials, on the ground around the dumpsters. Interviews with the Administrator and Dietary Manager confirmed that staff were responsible for closing the dumpster doors and maintaining cleanliness, but these procedures were not consistently followed, as evidenced by repeated observations of open dumpster doors and debris present in the area. No information about residents or their medical conditions was included in the report, and the deficiency was based solely on staff actions and facility practices related to waste disposal.
Insufficient Surety Bond for Resident Personal Funds
Penalty
Summary
The facility failed to assure the security of all personal funds deposited by residents by not maintaining a sufficient surety bond to cover the total amount of resident funds managed. Review of the facility's policy on Resident Personal Funds indicated that a surety bond or other satisfactory assurance must be in place to secure all resident funds. Examination of bank statements over a six-month period showed that the facility held resident funds exceeding $100,000, with balances ranging from $106,898.12 to $133,831.89 during several months. However, the surety bond in effect during this period was only $100,000, which was not adequate to cover the highest balances held in resident accounts. Interviews with the Administrator and the Director of Regulatory Compliance (DRC) confirmed that the surety bond should be sufficient to cover the total balance of resident funds. The DRC later provided documentation of an increased surety bond amounting to $150,000, but this updated bond only became effective after the period in question and did not retroactively cover the higher balances previously held. As a result, the security of personal funds for 56 accounts managed by the facility was not fully assured during the months when the resident fund balances exceeded the surety bond amount.
Failure to Provide Required ADL Assistance and Documentation
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who required support due to various medical conditions. One resident with dementia, diabetes, and limited mobility was observed sitting on soiled linens with urine-soaked clothing, despite care plans indicating the need for regular incontinence care and staff checks every two hours. The Director of Nursing confirmed that all nursing staff were responsible for providing this care. Another resident with a history of cerebral infarction, hemiplegia, and vascular dementia was found to have untrimmed and dirty fingernails on multiple occasions, even though documentation on shower sheets indicated that nail care was performed. Interviews with CNAs revealed inconsistencies in nail care practices and documentation, with one CNA expressing discomfort in trimming nails and deferring the task to nursing staff, but without clear follow-up or documentation. A third resident with severe cognitive impairment, Alzheimer's disease, and a history of falls had no documented evidence of receiving showers or bed baths for two months, despite care plans and a grievance from the resident's daughter regarding the resident being wet and needing clean linen. Staff interviews indicated that showers and bed baths were to be provided and documented, but records for the relevant months were missing, and there was no confirmation that the required ADL care was delivered.
Failure to Apply and Accurately Document Physician-Ordered TED Hose
Penalty
Summary
Facility staff failed to follow a physician's order for a resident requiring TED hose (compression stockings) to be applied to both lower extremities each morning when out of bed and removed at bedtime. Despite documentation in the Medication Administration Record (MAR) indicating that the TED hose were applied daily, multiple observations revealed that the resident did not have the TED hose on during the required times. The resident, who was severely cognitively impaired and had diagnoses including cerebral infarction, hemiplegia, and lower leg atrophy, was observed attempting to communicate the need for the TED hose and was seen retrieving them from a drawer himself. Staff interviews confirmed that the TED hose were not consistently applied as ordered. Further review of facility policies showed requirements for accurate and objective documentation, and for staff to sign the MAR only after administration of care or medication. However, interviews with LPNs revealed that staff sometimes documented the application of the TED hose without actually performing the task, with one LPN admitting to marking the MAR without having put on the hose and another stating she was unaware of the order for the TED hose. The Director of Nursing confirmed that it was expected for staff to document care in real time and not to mark tasks as completed if they had not done them.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to ensure that the medication administration error rate was less than 5%, resulting in an observed error rate of 6.45%. During medication administration, an LPN prepared medications for a resident but did not administer furosemide because it was not available. The LPN stated that the medication could be pulled from the automated medication dispensing system but did not do so, leading to the resident missing a dose. The Director of Nursing confirmed that the medication was available in the system and should have been administered to the resident. Another incident involved the same LPN administering medications to a different resident, including a nebulizer treatment. The LPN used a Flonase nasal spray that was not labeled with the resident's name and left the resident unattended during the nebulizer treatment. Additionally, the LPN did not assess the resident's respiratory status before and after the nebulizer treatment, contrary to the facility's policy. The Director of Nursing confirmed that respiratory assessments should be conducted and documented for nebulizer treatments.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from sexual abuse by other residents. Specifically, one resident (R52) was groped by another resident (R51) in a common area, and another resident (R270) placed their hand down a different resident's (R8) shirt in the dining room. Both incidents were documented in Facility Incident Report Forms and involved residents with varying degrees of cognitive impairment and dependency on staff for activities of daily living (ADLs). The facility's policy on abuse prevention was not effectively implemented to prevent these incidents from occurring. The first incident involved R51, who has severe cognitive impairment and requires substantial assistance with ADLs, groping R52, who also has severe cognitive impairment and is dependent on staff for most ADLs. The second incident involved R270, who has little or no cognitive impairment but is dependent on staff for ADLs, placing their hand inside R8's shirt. Both incidents were reported to the state and investigated per facility policy. Staff interviews confirmed that they received regular training on abuse prevention and dementia care, and were aware of the procedures for reporting abuse. However, the facility's measures were insufficient to prevent these occurrences of resident-to-resident sexual abuse.
Failure to Provide Adequate Shower Assistance
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) assistance, specifically showers, for a resident (R35) who was dependent on staff for personal hygiene. R35, who had diagnoses including spina bifida, neurogenic bowel, neuromuscular dysfunction of the bladder, and Fournier gangrene, was documented as having little or no cognitive impairment and no behavioral issues. Despite being dependent on staff for bathing, the electronic medical record (EMR) and shower sheets revealed that R35 was only given a shower on five occasions between March and April 2024. Interviews with R35 confirmed that he had not received a shower for two weeks as of mid-May 2024. The Director of Nursing (DON) acknowledged that there was no dedicated shower team, but staff were assigned to give showers daily. However, there were no routine showers scheduled for the night shift unless requested by residents. The DON also stated that if a resident refused a shower, staff would document the refusal and offer the shower again at a different time. Despite these protocols, R35 reported not receiving a shower while his roommates did, indicating a failure in the facility's adherence to its own policies and the resident's care plan, which required extensive assistance with bathing.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician orders related to oxygen (O2) liter flow for a resident with respiratory failure. The resident, who had a physician's order for O2 at 1 liter per minute (LPM) via nasal cannula (NC) to keep O2 saturation above 92%, was observed on multiple occasions receiving O2 at 3.5 LPM. This discrepancy was confirmed by both a Licensed Practical Nurse (LPN) and a Registered Nurse (RN)/Unit Manager (UM), who acknowledged the physician's order and the current O2 setting. The resident was alert, oriented, and had no complaints about the care received during the observations. However, the facility's failure to adhere to the prescribed O2 flow rate was evident. The resident's electronic medical record (EMR) indicated a history of unspecified respiratory failure and a personal history of COVID-19. The care plan for the resident included O2 therapy to maintain O2 saturation above 92% and monitoring for abnormal breathing patterns. Despite these documented interventions, the resident was consistently provided with a higher O2 flow rate than ordered. The RN/UM mentioned that in cases where a resident needed more O2, the provider would be notified to adjust the order, but there was no indication that such a notification had occurred in this instance.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to safely secure resident medications as evidenced by the observation of two of six medication carts left unlocked and unattended. During an initial tour, the C-Hall (300 hall) medication cart was found unlocked and unattended in the hallway. Upon return, RN QQ admitted that the cart should not be left unlocked but explained it was due to the cart being shared between two charge nurses, with the key left in the narcotic count book for access. Similarly, the B-Hall (200 hall) medication cart was also found unlocked and unattended, and LPN NN confirmed that it should not have been left unlocked. Additionally, the IV cart was noted to be unlocked and this was verified by the Unit Manager. The Director of Nursing (DON) confirmed during an interview that medication carts should always be locked when not attended, especially during the night shift. The facility's policy titled 'Storage of Medications' mandates that all compartments containing drugs and biologicals must be locked when not in use and should not be left unattended if open or potentially available to others. The failure to adhere to this policy resulted in unauthorized access to resident medications, posing a potential risk to residents, staff, and visitors.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to properly perform infection control practices during medication administration, as observed in the actions of two Licensed Practical Nurses (LPNs). One LPN did not disinfect an electronic blood pressure cuff between uses on different residents. Specifically, the LPN checked the vital signs of one resident, placed the cuff back on the medication cart, and then used the same cuff on another resident without cleaning it. When questioned, the LPN admitted forgetting to clean the cuff, despite knowing it was required to prevent cross-contamination between residents. Another LPN was observed handling medication with ungloved hands. This LPN poured Tylenol pills into the lid of the bottle, used her bare hand to hold an extra pill, and then placed the extra pill back into the bottle. She also counted the pills by pouring them onto a tissue and then picked them up with her bare hand to place them back into the medication cup. When asked, the LPN believed it was acceptable to touch the pills with bare hands if hand sanitizer was used beforehand. The Director of Nursing confirmed that the staff were expected to clean the blood pressure cuff after each use and that nurses should not handle pills with bare hands, even if hand hygiene was performed.
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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