Citations in Georgia
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Georgia.
Statistics for Georgia (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Georgia
A resident with severe cognitive impairment and significant physical limitations required two-person assistance for bed mobility per their care plan. A CNA provided care alone, resulting in the resident falling from the bed and sustaining a head injury. Documentation and staff interviews confirmed the care plan was not followed.
A resident with severe cognitive impairment and significant physical limitations, requiring two-person assistance for bed mobility and personal care, was injured when a CNA provided care alone and the resident fell from the bed, sustaining a head injury. Staff interviews confirmed the care plan was not followed, leading to the accident.
The facility did not maintain an effective pest control program, as evidenced by repeated documentation of mice and roach sightings in multiple resident rooms over several months, ongoing complaints from residents and families, and confirmation from maintenance staff of a persistent infestation despite policy and monitoring efforts.
A deficiency was cited for not ensuring that each resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report does not provide further details about the specific events or individuals involved.
Staff did not consistently keep garbage dumpster lids closed and failed to maintain cleanliness around the dumpsters, leaving debris such as used gloves on the ground. Multiple observations confirmed that dumpster doors were left open when not in use, contrary to facility policy, and staff interviews acknowledged responsibility for these tasks.
Surveyors found that the facility did not ensure the dietary ice machine was free from dark brown and black buildup, despite staff attempts to clean it. The Maintenance Director, responsible for cleaning the machine, was unaware of the buildup until the survey, and the issue was confirmed by the Administrator. This deficiency had the potential to impact 76 residents receiving nutrition or hydration from the kitchen.
A review of facility records and staff interviews revealed that the facility did not maintain a surety bond sufficient to cover all resident personal funds on deposit, with account balances exceeding the bond amount for several months. This failure affected the security of personal funds for multiple accounts managed by the facility.
A resident with upper extremity impairment and total dependence for care was not provided with a call device she could use, despite staff awareness of her inability to activate the standard call light. The care plan did not address her needs, and no appropriate assessment or device was provided, leaving her unable to independently request assistance.
Staff did not consistently provide or document required ADL assistance for three residents with significant cognitive and physical impairments. One resident was left in soiled linens without timely incontinence care, another had persistently dirty and untrimmed fingernails despite documentation suggesting care was provided, and a third had no records of receiving showers or bed baths for an extended period, even after a family grievance. Interviews revealed inconsistent practices and incomplete documentation among CNAs and nursing staff.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement a resident's care plan requiring two-person assistance for bed mobility. The resident, who had diagnoses including spinal cord disease, rheumatoid arthritis, and cervical spondylosis with myelopathy, was severely cognitively impaired and dependent on staff for most activities of daily living. The care plan specified that two staff members were needed for bed mobility due to the resident's physical limitations and chronic pain. Despite this, a Certified Nurse Aide (CNA) provided care alone and attempted to turn the resident without assistance. During this solo care, the resident fell from the bed, resulting in a hematoma and laceration to the head, necessitating transfer to the emergency room. Documentation and interviews confirmed that the CNA did not request help before the incident, and the care plan's requirements were not followed. The Director of Nursing and the Administrator both stated that staff were expected to adhere to care plans, especially for residents requiring extensive assistance.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to follow the established plan of care for a resident who required extensive assistance with activities of daily living due to conditions such as disease of the spinal cord, rheumatoid arthritis, and spondylosis with myelopathy. The resident was documented as needing two-person assistance for bed mobility, turning, repositioning, and use of a bedpan, as well as being severely cognitively impaired and dependent on staff for most care. Despite these documented needs, the CNA provided care alone, without the required second staff member present. During the provision of care, the CNA attempted to turn the resident onto her left side and, while cleaning her, the resident rolled off the bed, resulting in a fall that caused a hematoma and laceration to the right side of the head. The incident required the resident to be transferred to the emergency room for further evaluation. Interviews with facility staff confirmed that the CNA did not request assistance as required by the care plan, and the Director of Nursing and Administrator both stated that staff are expected to follow care plans for residents needing extensive assistance.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective, facility-wide pest control program for its population of 89 residents. Review of the pest control policy and resident council minutes revealed ongoing concerns about rodents and insects, with repeated complaints and documentation of pest sightings over several months. The pest control checklist documented multiple instances of mice and roaches in various resident rooms across different units, with frequent sightings particularly on the South 2 unit. Residents and their families reported seeing rodents, and these concerns were discussed in resident council meetings as both unresolved and ongoing issues. Interviews with facility maintenance leadership confirmed that the facility had been experiencing an infestation of field mice and had recently changed pest control contractors, with an intensive eradication effort and increased monitoring. Despite these efforts, the pest control checklist continued to show recurring sightings of mice and insects in resident rooms over several months. During the survey, residents who had previously witnessed mice reported that it had been a couple of weeks since the last sighting, and no pests were observed by surveyors during their visit.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all individuals in their care. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Improper Disposal and Maintenance of Garbage Dumpsters
Penalty
Summary
Staff failed to properly dispose of garbage and refuse in accordance with the facility's policy, which requires dumpsters to be kept covered when not being loaded and the surrounding area to be kept clean. During multiple observations, surveyors noted that the sliding lids of both garbage dumpsters were left open when not in use, and there was debris, including used gloves and other materials, on the ground around the dumpsters. Interviews with the Administrator and Dietary Manager confirmed that staff were responsible for closing the dumpster doors and maintaining cleanliness, but these procedures were not consistently followed, as evidenced by repeated observations of open dumpster doors and debris present in the area. No information about residents or their medical conditions was included in the report, and the deficiency was based solely on staff actions and facility practices related to waste disposal.
Failure to Maintain Cleanliness of Dietary Ice Machine
Penalty
Summary
Surveyors observed that the facility failed to maintain the dietary ice machine in a clean and sanitary condition, as required by facility policy and professional standards. During an inspection in the kitchen area, the interior of the ice machine was found to contain dark brown and black buildup. The Dietary Manager confirmed the presence of this buildup and stated that both she and the kitchen staff had attempted to remove it without success. The facility's policy specifies that ice machines must be cleaned according to manufacturer instructions or as needed to prevent soil or mold accumulation, and assigns responsibility for cleaning to the Maintenance Director or a designee. Interviews with the Dietary Manager and Maintenance Director revealed that the Maintenance Director was responsible for cleaning the ice machine and reported doing so monthly. However, the Maintenance Director was unaware of the buildup prior to the surveyor's observation and confirmed the presence of the dark brown substance inside the machine. The Administrator also confirmed the buildup and stated that both the Maintenance Director and kitchen staff are expected to clean the ice machine regularly and thoroughly. This deficiency had the potential to affect the 76 residents who received nutrition or hydration from the kitchen.
Insufficient Surety Bond for Resident Personal Funds
Penalty
Summary
The facility failed to assure the security of all personal funds deposited by residents by not maintaining a sufficient surety bond to cover the total amount of resident funds managed. Review of the facility's policy on Resident Personal Funds indicated that a surety bond or other satisfactory assurance must be in place to secure all resident funds. Examination of bank statements over a six-month period showed that the facility held resident funds exceeding $100,000, with balances ranging from $106,898.12 to $133,831.89 during several months. However, the surety bond in effect during this period was only $100,000, which was not adequate to cover the highest balances held in resident accounts. Interviews with the Administrator and the Director of Regulatory Compliance (DRC) confirmed that the surety bond should be sufficient to cover the total balance of resident funds. The DRC later provided documentation of an increased surety bond amounting to $150,000, but this updated bond only became effective after the period in question and did not retroactively cover the higher balances previously held. As a result, the security of personal funds for 56 accounts managed by the facility was not fully assured during the months when the resident fund balances exceeded the surety bond amount.
Failure to Provide Suitable Call Device for Dependent Resident
Penalty
Summary
A resident with a history of cervical spinal cord injury and schizophrenia, who was dependent for all activities of daily living and had upper extremity impairment, was not provided with a call device suitable for her use. Despite the call light being placed within her reach, the resident was unable to activate it due to her physical limitations, as observed on multiple occasions. Staff interviews confirmed awareness of the resident's inability to use the standard call button, and documentation revealed that the care plan did not address her inability to use the call device. The deficiency was further evidenced by the lack of an appropriate assessment upon admission to determine the resident's need for a specialized call device. Both nursing and administrative staff acknowledged that the resident required a different type of call light, but no suitable device was provided during the period reviewed. The resident had to wait for staff to check on her for assistance, as she could not independently call for help.
Failure to Provide Required ADL Assistance and Documentation
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who required support due to various medical conditions. One resident with dementia, diabetes, and limited mobility was observed sitting on soiled linens with urine-soaked clothing, despite care plans indicating the need for regular incontinence care and staff checks every two hours. The Director of Nursing confirmed that all nursing staff were responsible for providing this care. Another resident with a history of cerebral infarction, hemiplegia, and vascular dementia was found to have untrimmed and dirty fingernails on multiple occasions, even though documentation on shower sheets indicated that nail care was performed. Interviews with CNAs revealed inconsistencies in nail care practices and documentation, with one CNA expressing discomfort in trimming nails and deferring the task to nursing staff, but without clear follow-up or documentation. A third resident with severe cognitive impairment, Alzheimer's disease, and a history of falls had no documented evidence of receiving showers or bed baths for two months, despite care plans and a grievance from the resident's daughter regarding the resident being wet and needing clean linen. Staff interviews indicated that showers and bed baths were to be provided and documented, but records for the relevant months were missing, and there was no confirmation that the required ADL care was delivered.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
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