Wynfield Park Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Albany, Georgia.
- Location
- 223 W.third Avenue, Albany, Georgia 31701
- CMS Provider Number
- 115625
- Inspections on file
- 19
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Wynfield Park Health And Rehabilitation during CMS and state inspections, most recent first.
A registered nurse assisted a resident with their meal while standing and not interacting, contrary to facility policy requiring staff to sit at eye level and engage with residents during meals. Interviews confirmed that staff are expected to provide dignified and respectful meal assistance by sitting and interacting with residents.
A resident with severe cognitive impairment and mobility limitations was found physically restrained in bed by a Geri-chair and regular chair placed against the bed, blocking her ability to exit. Staff interviews confirmed the chairs were used to prevent the resident from climbing out, but this was not documented as a restraint, and the care plan did not indicate restraint use.
A resident with quadriplegia, aphasia, and a neck contracture did not have the use of a neck pillow/support included in their care plan, despite an order for its use. The care plan only addressed general assistance with ADLs and safety, omitting this specific intervention. The DON confirmed the omission, and staff were expected to follow care plans and document refusals, but the neck pillow was not documented as an intervention.
A resident with quadriplegia and a neck contracture did not receive a physician-ordered neck pillow for head support, as observed during multiple checks. The care plan lacked documentation of this intervention, and staff confirmed the expectation to provide the device. The neck pillow was not present in the resident's room, indicating a failure to follow orders and care planning for range of motion support.
A kitchen aide was observed serving food without a required hair restraint, contrary to facility policy mandating hairnets or beard restraints in food service areas. The aide acknowledged forgetting to wear the hair net, and the Dietary Manager confirmed the expectation for staff to use hair restraints to prevent contamination. This failure had the potential to impact 54 residents receiving oral diets.
A resident with severe cognitive impairment, a stage 4 pressure ulcer, an indwelling urinary catheter, and a feeding tube did not receive proper infection control measures when a CNA failed to wear a gown during bathing and wound care, despite clear EBP signage and facility policy requiring gown and glove use for high-contact activities. The deficiency was observed during care, and the CNA acknowledged the lapse.
A resident with a documented history of hypersexual behavior was admitted without a care plan to address her risks, leading to multiple incidents of inappropriate sexual contact with four male residents who had cognitive impairments. Staff were not informed of her behaviors or provided with interventions, and some incidents were not reported or investigated, with leadership assuming consent without proper assessment.
The facility did not report allegations of sexual abuse involving two severely cognitively impaired male residents who were unable to consent, after a female resident with a history of sexually inappropriate behavior engaged in hypersexual actions. The Administrator did not recognize the incidents as abuse and relied on staff input to determine consent, despite the residents' cognitive status, resulting in a failure to follow required reporting procedures.
The facility did not investigate incidents where a resident with a history of sexually inappropriate behavior was observed sitting on the lap of one male resident and stroking the face of another, both of whom were severely cognitively impaired and unable to consent. Staff and administration failed to recognize or assess these incidents as potential abuse, contrary to facility policy.
A resident with Myasthenia gravis and a history of unsteady gait was placed in a Geri-chair without a documented therapy assessment or inclusion in the care plan as a fall prevention measure. Staff interviews confirmed the resident was frequently observed in the Geri-chair, and concerns were raised by the Director of Rehabilitation and RN supervisor about the potential accident hazard. The decision to use the Geri-chair was made by nursing staff for comfort, not through interdisciplinary assessment, resulting in a deficiency related to accident hazards and inadequate supervision.
A resident with dementia was not provided a timely urinalysis after a physician order was received, as the RN failed to enter the order promptly. The delay was confirmed through grievance review and interviews, with the administrator and NP both stating that staff are expected to enter and follow physician orders.
A facility failed to obtain laboratory tests as ordered by a physician for a resident with multiple diagnoses, including CKD and hypertension. Despite orders for a Vitamin D Panel, CBC, CMP, and Uric Acid level, there was no evidence that these tests were conducted. The Administrator confirmed that the laboratory service did not draw the samples, and the facility did not follow up to ensure completion.
The facility failed to routinely assess and document pressure ulcers for two residents. One resident had a blister on the heel that was not measured or staged, and no further assessments were conducted until it was identified as a DTI. Another resident had a stage 2 pressure ulcer on the ankle, but no further assessments were recorded after a certain date, despite ongoing treatment. Interviews revealed a lack of consistent wound assessment and documentation, contributing to the deficiency.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
A deficiency was identified when a registered nurse (RN) assisted a resident with their meal while standing, rather than sitting at eye level as required by facility policy. During the meal observation, the RN was seen standing next to the resident, watching other activities in the dining room, and not interacting with the resident during the meal. The facility's policy on meal service specifies that associates should promote and maintain patients' dignity and respect during meal service. Interviews with the RN, Assistant Dietary Manager, and Dietary Manager confirmed that staff are expected to sit next to residents and interact with them while providing meal assistance. The RN admitted to not following this protocol, stating she had not received training in dining room protocol and preferred not to sit. Both the Assistant Dietary Manager and Dietary Manager agreed that standing while assisting a resident is not dignified and that staff should sit at eye level and engage with residents during meals.
Resident Restrained by Chair Placement Against Bed
Penalty
Summary
A deficiency was identified when a resident was found physically restrained in bed by the placement of a Geri-chair and a regular chair against her bed, blocking her ability to get out on one side. The facility's policy states that residents have the right to be free from physical restraints unless required for medical treatment, and that assessment and consent are required prior to restraint use. The resident in question was severely cognitively impaired, had an impairment in one lower extremity, required substantial to maximum assistance with activities of daily living, and had a history of falls. There was no documentation in the care plan indicating a need for restraint. Multiple staff interviews confirmed that the chairs were intentionally placed to prevent the resident from climbing out of bed, but this was not reported or documented as a restraint. Observations on several occasions showed the chairs blocking the resident's exit from bed. Some staff recognized this as a potential restraint, while others did not report it. The Health Information Manager and other staff had previously noticed and moved the chairs, but the practice continued. The DON stated she had not observed this before and expected staff to report such situations.
Failure to Include Neck Pillow Intervention in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan with measurable goals and interventions for one resident, as required by their own policy and federal regulations. Specifically, the care plan for a resident with quadriplegia, aphasia, and dysphagia did not include documentation or interventions related to the use of a neck pillow/support, despite the resident having a neck flexion contracture and an order for the neck pillow. The care plan only addressed assistance with activities of daily living and promoting safety, omitting the specific intervention of the neck pillow. Staff interviews and record reviews confirmed that the resident's care plan did not reflect all necessary interventions for the contracted neck, as the use of the neck pillow was not included. The DON acknowledged that staff were expected to follow orders and care plans, and to document refusals, but confirmed the omission of the neck pillow from the care plan. This lack of comprehensive care planning placed the resident at risk for unmet care needs and not achieving their maximum practicable level of functioning.
Failure to Provide Ordered Neck Support for Resident with Contractures
Penalty
Summary
A resident with quadriplegia, aphasia following nontraumatic intracranial hemorrhage, and dysphagia following cerebrovascular disease was admitted to the facility and identified as being at risk for contractures, specifically a neck flexion contracture. Physician orders directed staff to apply a neck pillow for head support, and the resident's care plan noted limited range of motion and the need for assistance with activities of daily living. However, there was no documentation in the care plan regarding the neck pillow intervention. Multiple observations over two days revealed that the resident was not provided with the neck pillow, and the device was not present in the resident's room. Staff interviews confirmed that the resident was supposed to have a neck pillow for support, and both the ADON and DON stated that staff were expected to follow physician orders and care plans unless the resident refused, with refusals to be documented. The facility failed to provide the required equipment to prevent further decrease in range of motion, as ordered and care planned.
Failure to Use Hair Restraint During Meal Service
Penalty
Summary
A deficiency was identified when a kitchen aide was observed serving the noon meal in a second-floor dining room without wearing a hair restraint, as required by the facility's Personal Hygiene policy. The policy, dated 12/27/24, specifies that all dining and nutritional services associates must wear a hairnet or beard restraint in food preparation, production, and serving areas to promote personal hygiene and infection control. During the observation, the kitchen aide admitted to forgetting to put on a hair net. The Dietary Manager confirmed that staff are expected to wear hair restraints to prevent hair follicles from contaminating food served to residents. This lapse had the potential to affect 54 residents receiving an oral diet.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to adhere to the facility's infection control practices and policies for a resident who was on Enhanced Barrier Precautions (EBP). During wound care and bathing, a Certified Nursing Assistant (CNA) did not wear a gown as required, despite an EBP sign posted on the resident's door indicating the need for gown and glove use during high-contact activities such as bathing and wound care. The Registered Nurse (RN) performing wound care did wear the appropriate personal protective equipment (PPE), but the CNA, who was assisting with positioning the resident and providing a bed bath, did not. The CNA later acknowledged awareness of the EBP requirements but admitted to not wearing a gown during the care activities. The resident involved had significant medical needs, including a stage 4 pressure ulcer, an indwelling urinary catheter, a feeding tube, and severe cognitive impairment. Review of the resident's care plan and medical orders revealed no documentation or orders for Enhanced Barrier Precautions, although the infection prevention nurse maintained a separate list and ensured signage was present. The Director of Nursing confirmed that EBP was not typically documented in the care plan or as a physician order, but expected staff to follow posted EBP instructions.
Failure to Protect Residents from Sexual Abuse by Known Offender
Penalty
Summary
The facility failed to protect four male residents from sexual abuse by another resident with a known history of hypersexual and inappropriate behaviors. Upon admission, the resident's family member informed staff of her history of sexually inappropriate behaviors towards men and requested specific precautions, including restricting her access to male residents' rooms and requesting male staff not provide her care. Despite this information, no care plan was developed to address or alert staff to her hypersexual behaviors. Multiple incidents occurred in which the resident engaged in inappropriate sexual contact with male residents, all of whom had moderate to severe cognitive impairment. These incidents included lying on top of a resident in his bed, kissing and touching his face, slapping another resident on the thigh/groin area, and sitting in the laps of other residents while stroking their faces. Some incidents were reported and investigated, while others were not, with facility leadership determining without proper assessment that the behaviors were consensual and caused no harm. Interviews with staff revealed that they were not informed of the resident's history of inappropriate sexual behaviors, nor were they provided with education or interventions to prevent such incidents or increase supervision. Staff members expressed that they would consider the behaviors to be sexual abuse and would have reported them if they had been aware. The Social Services Director was also not informed of the incidents, and nursing staff did not recognize or report the behaviors as abuse, failing to assess the affected residents for harm or consent.
Failure to Report Alleged Sexual Abuse of Cognitively Impaired Residents
Penalty
Summary
The facility failed to report allegations of sexual abuse involving two male residents who were severely cognitively impaired and unable to consent. According to the facility's policy, all allegations of abuse or those involving serious bodily injury must be reported immediately, but no later than two hours. Despite this, incidents involving inappropriate hypersexual behaviors by a female resident with a known history of such behaviors were not reported to the State Agency. The female resident had a documented history of sexually inappropriate behaviors towards men and was assessed as having moderately impaired cognition. The two male residents involved had severe cognitive impairment, as indicated by their low BIMS scores, making them unable to consent. The Administrator acknowledged that the incidents were reported to her by a registered nurse but were not reported to the State Agency. She stated that the incidents were not recognized as sexual abuse, believed there was no harm, and considered the behavior consensual based on staff input, despite the residents' inability to consent. The Administrator could not provide a rationale for determining consent and did not know which staff member observed the incidents. This failure to report the allegations as required by facility policy and regulatory requirements constitutes the deficiency.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse involving two male residents with severe cognitive impairment after another resident, who had a known history of sexually inappropriate behaviors, was observed engaging in potentially abusive conduct. Specifically, the resident with a history of hypersexual behaviors was seen sitting on one male resident's lap and stroking and rubbing another male resident's face. Both male residents were documented as being severely cognitively impaired and unable to consent, yet no investigation was initiated following these incidents. Staff interviews revealed that the incidents were not recognized as potential abuse, and the administrator stated that no investigation was conducted because the incidents were perceived as consensual and harmless. However, there was no documented assessment to determine the ability of the involved residents to consent or whether any harm had occurred. The facility's own policy required immediate response and investigation of alleged abuse, including assessment of the alleged victims, but these steps were not taken.
Failure to Assess Geri-Chair Use Leads to Accident Hazard
Penalty
Summary
The facility failed to properly assess a resident for the use of a Geri-chair, which resulted in a deficiency related to accident hazards and inadequate supervision. The facility's Fall Management policy requires that each resident's risk for falls be evaluated and that appropriate interventions, including assistive devices, be implemented based on interdisciplinary assessment. However, for a resident with a diagnosis of Myasthenia gravis and a history of unsteady gait and fall risk, there was no documented therapy assessment for the use of a Geri-chair, nor was its use included in the resident's care plan as a fall prevention measure. Multiple staff interviews confirmed that the resident was observed in a Geri-chair on several occasions, and the resident's family member reported frequent falls. The Director of Rehabilitation and the RN supervisor both stated that therapy should assess residents for Geri-chair use, and expressed concerns that using a Geri-chair for a resident who is able to stand could pose an accident hazard. Despite this, the resident was placed in a Geri-chair without a documented therapy assessment or interdisciplinary team involvement. Documentation reviewed, including comprehensive nursing assessments and the care plan, did not reflect any evaluation or plan regarding the Geri-chair as an intervention. The DON indicated that the decision to use the Geri-chair was made by nursing staff for comfort, rather than based on a formal assessment. This lack of proper assessment and care planning for the use of the Geri-chair created the potential for falls and injuries for the resident.
Failure to Timely Complete Physician-Ordered Urinalysis
Penalty
Summary
A resident with a diagnosis of dementia with behavioral disturbance was admitted and later discharged from the facility. During the resident's stay, a grievance was filed indicating that a registered nurse (RN) received an order for a urinalysis (UA) but did not follow through with entering the order into the system. The order was eventually entered and the specimen was sent for stat processing, with results returning negative. However, the delay in entering and processing the UA order was confirmed through interviews and document review. The facility was unable to provide relevant policies when requested. Interviews with the administrator confirmed that the RN had not entered the physician's order as expected, and the nurse practitioner stated that staff are expected to enter and follow physician orders. The failure to timely complete the UA had the potential to delay treatment for abnormal laboratory results.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained as ordered by the physician for a resident. The resident, who was admitted with chronic kidney disease, hypertension, atrial fibrillation, chronic right hip pain, gout, and osteoarthritis, had physician orders for several laboratory tests, including a Vitamin D Panel, Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Uric Acid level, to be conducted every six months. Despite these orders, there was no evidence in the clinical record that the blood samples for these tests were obtained. The facility's Administrator confirmed that the laboratory service did not draw the samples, and the facility did not follow up to ensure the laboratory tests were completed.
Failure to Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure thorough and routine assessment of pressure ulcers for two residents, R8 and R9. R8 was admitted with multiple diagnoses including type 2 diabetes mellitus and chronic kidney disease. On 3/30/2024, a nurse noted a blister on R8's heel with purple discoloration, indicating a potential pressure ulcer. Despite initial treatment and notification of the physician, the ulcer was not measured or staged, and no further assessments were conducted until 4/19/2024, when it was identified as a Deep Tissue Injury (DTI). The treatment continued without further assessments until R8 was hospitalized, and there was no additional wound tracking documentation. R9, admitted with paraplegia and type 2 diabetes mellitus, had a wound on the left ankle upon admission. On 5/20/2024, it was assessed as a stage 2 pressure ulcer, and treatment orders were documented. However, after 6/21/2024, no further assessments were recorded, although treatment continued. An observation on 7/10/2024 confirmed the presence of a stage 2 pressure ulcer with a granulation wound base and bloody drainage. Interviews with the Regional Nurse Consultant and Treatment Nurse BB revealed a lack of consistent wound assessment and documentation. Treatment Nurse BB admitted to not measuring R8's wound weekly, believing it was not necessary, and confirmed the absence of further assessments for R9's wound after 6/21/2024. This lack of routine assessment and documentation contributed to the deficiency in pressure ulcer care for both residents.
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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