Wrightsville Manor Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Wrightsville, Georgia.
- Location
- 337 West Court Street, Wrightsville, Georgia 31096
- CMS Provider Number
- 115406
- Inspections on file
- 20
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Wrightsville Manor Health And Rehab during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, vascular dementia, and independent mobility, who was care-planned as an elopement risk, exited the building unsupervised through a side door that had been left unsecured while staff were attending a Christmas party. The door, previously held open with a latch to move a shower bed, was not secured after use, and the resident apparently followed someone out and left the premises. A community member later notified the facility after seeing the resident walking down the street, and staff confirmed the elopement and the circumstances under which the resident had been able to leave.
An LPN was observed administering medications to several residents without performing hand hygiene between each resident, handling medication carts, water cups, and door handles without cleaning hands. Although facility leadership expected hand hygiene between residents, the LPN only performed it before certain treatments, leading to a failure to prevent cross-contamination during medication administration.
A resident with severe cognitive impairment and an indwelling urinary catheter was not treated with dignity during meal service and catheter care. A CNA stood while feeding the resident instead of sitting, and the resident's catheter drainage bag was repeatedly left uncovered and visible in both private and common areas, contrary to facility expectations for privacy and dignity.
The facility did not provide required written transfer notices, including appeal rights and ombudsman contact information, to residents or their responsible parties when residents were transferred to the hospital. Bed hold notices were incomplete or missing, and notifications were not sent to the Ombudsman. Staff interviews confirmed that written notifications were not consistently provided, resulting in noncompliance with regulatory requirements.
A resident with an indwelling urinary catheter, severe cognitive impairment, and recent UTI hospitalization was observed multiple times with their catheter drainage bag and tubing lying on the floor, both in bed and in a chair. Staff confirmed this placement was inappropriate and not in line with infection control practices, and the facility's policy did not address proper catheter bag placement.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility did not ensure that dialysis care was provided according to the resident's requirements.
Surveyors identified that the medication error rate in the facility was 5 percent or greater, indicating that medication administration was not performed with sufficient accuracy and exceeded regulatory standards.
A resident with diabetes experienced a hypoglycemic episode that was confirmed and treated by an LPN, but the incident was not documented in the medical record. Interviews with the resident, LPN, and ADON confirmed the event and the lack of documentation, despite facility expectations for such events to be recorded.
A resident with severe cognitive impairment was found standing over another resident with Alzheimer's Disease, leading to a sexual abuse investigation. Blood was found on the female resident's brief, and she was later treated at a hospital for vaginal tears. The facility's policy lacked a definition of sexual abuse, contributing to staff uncertainty. The male resident was arrested but returned to the facility due to mental capacity, and was later transferred to a behavioral health facility.
A resident was sexually abused by another resident, and the facility failed to conduct a thorough investigation. Staff observed the alleged perpetrator entering and leaving the victim's room, and the victim was later found with signs of sexual assault. The DON and Administrator did not take immediate action to prevent further harm, and the facility's inaction led to a situation of immediate jeopardy.
Resident Elopes Through Unsecured Side Door During Staff Party
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free of accident hazards and to provide adequate supervision to prevent elopement for one resident identified as at risk. The facility had an elopement policy stating it would identify, prevent, detect, and respond promptly to resident elopement, and the resident’s care plan documented that he was at risk for elopement due to independent ambulation, paranoid schizophrenia, anxiety, and hallucinations/delusional thoughts. The care plan goals included that the resident would not leave the facility unsupervised and that staff would take appropriate steps to prevent and detect elopement, including use of electronic door locks, staff education, and staff control of door access. The resident had diagnoses including schizoaffective disorder, vascular dementia, psychotic disturbances with hallucinations and delusions due to a known physiological condition, muscle weakness, and dysphagia. A recent MDS showed he was cognitively intact with a BIMS score of 15, had disorganized thinking that did not fluctuate, and was independent with mobility and had no range-of-motion limitations. Progress notes documented that on the day of the incident, a community member called the facility reporting that he believed a facility resident was walking down the street. Facility staff went to the location, verified the resident’s identity, and found him unharmed, but he refused to get into the vehicle to return and stated, “ya’ll are trying to kill me,” demanding that police be called and agreeing to return only with an officer. Interviews and record review showed that the resident was able to exit the building without staff supervision during a staff Christmas party. Staff reported that the resident likely went out behind someone when a door was opened, and that the exit door on the 200 Hall had previously been equipped with a latch/hook used to hold it open for moving a shower bed. The DON and Administrator stated that at the time of the elopement, the side door used for the shower bed was not secured after a staff member brought the shower bed in, allowing the resident to leave the facility. The Administrator confirmed that this occurred while all staff were present at the Christmas party and stated that staff assigned to residents were expected to be accountable to them.
Failure to Perform Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to administer medications in a manner that prevented cross-contamination for seven of thirteen residents observed during a medication pass. An LPN was observed repeatedly preparing and administering medications to multiple residents without performing hand hygiene between residents. The LPN handled the medication cart, medication cards, water cups, and touched door handles and other surfaces both inside and outside the building, as well as objects in the residents' environments, without cleaning her hands between each interaction. In one instance, the LPN only performed hand hygiene before administering eye drops, which she considered a treatment, but not between other medication administrations. The LPN acknowledged touching surfaces and objects that could contribute to cross-contamination and confirmed that she did not perform hand hygiene between residents unless a treatment was involved. During interviews, the Assistant Director of Nursing stated that staff were expected to perform hand hygiene before starting the medication pass and between each resident, and that handwashing should be repeated if hands became soiled. However, the facility did not have a specific handwashing policy, relying instead on a skills check for staff. Documentation showed that the LPN had been assessed as competent in handwashing, with instructions to perform hand hygiene between each resident's medication pass. Despite this, the observed practice did not align with these expectations, resulting in a failure to prevent potential cross-contamination during medication administration.
Failure to Maintain Resident Dignity During Feeding and Catheter Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity during meal service and the care of an indwelling urinary catheter. The resident, who was admitted with diagnoses including pseudobulbar affect, generalized anxiety disorder, and abnormal weight loss, was noted to have severe cognitive impairment and was dependent on staff for most activities of daily living. During meal service, a CNA stood at the resident's bedside while feeding her, rather than sitting, which is considered a dignity concern. The CNA stated she was unaware that standing while feeding a resident was an issue related to dignity, and the Assistant Director of Nursing confirmed that staff had not been in-serviced on this expectation. Additionally, the resident's urinary catheter drainage bag was observed on multiple occasions to be uncovered and visible, both in the resident's room and in a common area, with urine visible in the bag. The drainage bag was also found lying on the floor under the resident's chair without a dignity cover. Staff interviews confirmed that the use of dignity covers for catheter bags was an expectation, but the cover was not in place at the time of observation. These actions and inactions resulted in a failure to maintain the resident's dignity during care and daily activities.
Failure to Provide Required Written Transfer Notices and Bed-Hold Information
Penalty
Summary
The facility failed to provide required written transfer notices, including information on appeal rights and ombudsman contact details, to residents and/or their responsible parties (RPs) when residents were transferred to the hospital. Additionally, the facility did not send copies of these notices to the Long Term Care Ombudsman for any of the five residents reviewed for hospitalizations. The facility's policy required that residents and their RPs be informed of transfer reasons, appeal rights, and bed-hold policies, but documentation showed these steps were not followed. Record reviews for multiple residents revealed that while verbal notifications were made to RPs regarding hospital transfers, there was no evidence of written notifications being provided. Bed hold notices, when present, were undated, unsigned, and did not specify the daily bed hold rate for private or semi-private rooms. In several cases, there was no documentation that the resident or RP received any written notice regarding the transfer or the facility's bed-hold policy at the time of transfer. Progress notes and other EMR documentation confirmed the absence of these required notifications. Interviews with facility staff, including the Administrator and Social Services Director, confirmed that written notifications were not consistently provided to RPs or sent to the Ombudsman. The Administrator acknowledged that while residents were sent with bed hold notices, RPs were not provided with this information, and the Social Services Director was unaware of the requirement to notify the Ombudsman for all hospital transfers. These actions and omissions resulted in a failure to comply with regulatory requirements for resident transfer notifications.
Improper Management of Urinary Catheter and Drainage Bag
Penalty
Summary
A deficiency was identified regarding the management of a urinary catheter and drainage bag for one resident with an indwelling urinary catheter. The facility's Foley Catheter Policy did not address the proper placement of urinary catheter drainage bags and tubing. The resident, who had diagnoses including pseudobulbar affect, generalized anxiety disorder, abnormal weight loss, and was severely cognitively impaired, was dependent on staff for most activities of daily living. The care plan for this resident included interventions to position the catheter bag and tubing below the level of the bladder and to check for kinks to ensure proper urine flow. The resident had a recent hospitalization for a urinary tract infection. During multiple observations, the resident's urinary catheter drainage bag and tubing were found lying on the floor, both while the resident was in bed and when seated in a geriatric chair in the common area. Staff interviews confirmed that the catheter bag and tubing should not be on the floor due to infection control concerns. Both a CNA and the ADON acknowledged that the observed placement of the catheter bag and tubing was inappropriate and not in accordance with infection control practices.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Failure to Document Hypoglycemic Episode
Penalty
Summary
A deficiency occurred when the facility failed to document an episode of hypoglycemia for a resident with type 2 diabetes mellitus. The resident was admitted with orders for fingerstick blood sugar checks before meals and at bedtime, with instructions to notify the physician if levels were below 80 or above 400. On the day in question, the resident experienced symptoms of low blood sugar, which was confirmed by an LPN who measured a blood sugar level of 61. The LPN administered orange juice and sugar, and a subsequent check showed the blood sugar had risen to 91. Despite this event, there was no documentation of the incident in the resident's electronic medical record. Interviews with the resident, the LPN involved, and the Assistant Director of Nursing (ADON) confirmed that the hypoglycemic episode occurred and that it was not documented. The ADON and facility administration both stated that it was their expectation for such episodes to be documented according to current standards of practice. The lack of documentation was verified through review of the entire electronic medical record and direct staff interviews.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, resulting in an incident involving two residents. One resident, who had severe cognitive impairment, was found standing over another resident, who was legally blind and had Alzheimer's Disease, in her room. Blood was noted on the resident's brief, and upon examination at the hospital, she was found to have vaginal tears and was given STI prophylaxis. The incident was witnessed by a nurse who saw the male resident standing over the female resident, and blood was later found on his pants. The facility's policy on abuse prevention did not include a definition of sexual abuse, which may have contributed to the staff's uncertainty about the nature of the incident. Interviews with staff revealed that the male resident had a history of inappropriate behavior, such as exposing himself, but was not considered to have sexually inappropriate behaviors towards other residents. The Director of Nursing and other staff expressed doubt about the male resident's capability to perform a sexual act, suggesting that any assault would have been with his hands. The incident was reported to the police, and the male resident was arrested but returned to the facility due to his mental capacity. The facility placed him on 15-minute checks and moved him to a locked unit until he could be transferred to a behavioral health facility. The female resident was transferred to the hospital for examination and returned to the facility after the incident. The facility's response to the incident included interviews with staff and residents, but the initial failure to prevent the abuse and the lack of a clear policy definition of sexual abuse were significant factors in the deficiency.
Removal Plan
- Abuse Prevention education is ongoing with staff by Administrator, Staff Development Coordinator or Director of Nursing. All employees have received education. Prevention education is provided upon hire by HR director and periodically throughout employment by regulation guidelines. No new staff will be able to work without receiving the education.
- Social Service Director interviewed all residents with BIMS 13 or above, asking if anyone injured them, came in their room, or sexually abused them. For residents unable to answer, skin assessments are performed on all residents weekly by treatment nurse. Weekly skin assessments were completed with no injuries found per treatment nurse.
- A camera was placed in R1's room and the monitor placed at nurses' station, with family's permission for closer observation and residents' inability to communicate related to potential abusive encounters.
- R1 was assessed upon return by nurse S.T. with no new findings/bleeding observed.
- Social Service Director began interviewing all residents, asking them if a person has been in their room touching or hurting them.
- Medical Director was notified of 3 Ij's.
- Medical Director reviewed the abuse policy and made no changes.
- QA reviewed state report of incident with R1 and R2. R2 did not return to facility, resolving the situation, as R2 was admitted to a behavioral health facility.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility administration failed to protect a resident from sexual abuse by another resident and did not conduct a thorough investigation following the incident. On the night of the incident, a resident was observed by staff entering and leaving the room of another resident. The staff later found the resident in bed with signs of sexual assault, including blood in the vaginal area. The resident was subsequently transferred to the emergency room for evaluation, where a sexual assault exam confirmed injuries consistent with rape. The Director of Nursing (DON) and the Administrator were informed of the incident but did not take immediate and appropriate actions to prevent further harm. The DON expressed uncertainty about whether the incident constituted rape and suggested that the alleged perpetrator was not capable of such an act. Despite the severity of the situation, the facility did not implement one-on-one supervision for the alleged perpetrator, who was only placed on 15-minute checks until he could be transferred to a behavioral facility. The facility's failure to maintain a safe environment and adequately investigate the incident was identified as noncompliance with federal requirements, posing a likelihood of serious harm to residents. The administration's inaction and lack of oversight contributed to the immediate jeopardy situation, which was recognized by surveyors and communicated to the facility's leadership.
Removal Plan
- Director of operation reviewed Abuse Neglect and Exploitation misappropriation program in-serviced Administrator and DON.
- Administrator and DON signed job descriptions on hire date. Director of operations reviewed job descriptions.
- The facility held Ad Hoc QAPI meeting to review the Immediate Jeopardy findings Medical Director was over the phone. Administrator, DON, Adon, Treatment nurse, MDS, Social Service, Activity, Maintenance, Housekeeping, HR, Admissions, Dietary, IFP, CNA, Unit Manager.
- The allegations of sexual abuse of R1 have been reported and investigated by administrator and DON and the necessary corrective actions were taken to assure they do not happen again, R2 was removed from facility and is discharged. R1 has a room monitor with camera and it stays on at the nurse's station to allow staff to see R1.
- Abuse prevention is given by HR on hire. No new employee will be able to work without receiving education.
- Social Service director has called an emergency Abuse and prevention and resident rights meeting. The meeting was held with resident counsel.
- Social Service director completed interview with all residents asking them has a person been in their room touching or hurting them, all that could answer stated no. Residents that could not answer were reviewed on skin assessments for injury, tears, bruises.
- Skin assessments were started on all residents weekly by treatment nurse. Each hall is on a different day, treatment nurse observes for any skin tears, bruises, sores, etc. Skin assessments were completed.
- Confirmation via signed document stating Abuse, Neglect, exploitation misappropriation prevention program was reviewed and in-serviced by the Director of Operations. Signatures by the Director of Operations, Administrator, and the Director of Nursing.
- Review of signed statement indicating the Director of Operations reviewed Administrator and DON job descriptions. Copy of job descriptions attached and signatures by the Director of Operations, Administrator, and Director of Nursing.
- Review of document titled Quality Assurance/Performance Improvement Meeting Format indicated signatures for Administrator, DON, ADON, Treatment nurse, MDS, Social Service, Activity, Maintenance, Housekeeping, HR, Admissions, Dietary, IFP, and Unit Manager.
- Review of the Census of the electronic medical record (EMR) R2 discharged from the facility. Review of Progress Notes indicated that R2 was picked up by transportation and taken to a behavior health center.
- Observation a monitor was observed at the nursing station showing R1 in bed asleep.
- Review of signed document signed by Administrator and Human Resources (HR) indicating HR will be responsible for giving abuse prevention policy to new hires.
- Interview with HR, who confirmed there have been no new hires. She reported that she is responsible for reviewing the abuse policy with new hires and will get them to sign off on this during orientation.
- Review of document titled Resident Council Meeting indicated topics discussed of Resident Rights, Abuse Prevention, and Reporting Abuse. Policy reviewed Abuse Prohibition Policy and Procedures and Resident's Federal and State Rights.
- Interview with the Administrator who confirmed that an Emergency Resident Council meeting was held to discuss abuse prevention and resident's rights.
- Interviews with R3 and with R11 who both confirmed attending the resident council meeting.
- Review of document which listed total residents and their response (No or no response) to a question about anyone coming into their room unwelcomed making sexual advances or inappropriate touch. None of the residents reported yes to the question. This was completed by the Social Services Director.
- Review of skin assessment documentation confirmed skin assessments were completed for all residents.
- Review of the skin assessment documents indicated skin assessments completed weekly. This was also confirmed through a calendar that indicated the dates that skin assessments were completed for each hall.
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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