Altamaha Healthcare Center

Inspectors wroteBased on resident and staff interviews, record review, review of the facility documents titled, PBJ (payroll-based journal) Staffing Data Report, and review of the facility policy titled, Staffing Policy, the facility failed to ensure Registered Nurse (RN) coverage was available in the facility for eight consecutive hours daily. This failure had the potential to negatively impact all residents at the facility.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies titled Safe Smoking Standard and Fall Management, the facility failed to ensure an environment free from accident hazards for two of 42 sampled residents (R) (R51 and R6). Harm was identified to have occurred on 7/30/2025, when Certified Nursing Assistant (CNA)12 was independently providing a bed bath for R51, and the resident fell from the bed. It was determined that R51 required two-person assistance for bed mobility (turning from left to right in the bed).

Inspectors wroteBased on staff interviews and review of the facility's policy titled Grievance Policy, the facility failed to develop a grievance policy that met all regulatory requirements. This failure had the potential to affect all 56 residents who resided in the facility.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure that two of two medication carts were locked when out of the sight of a licensed nurse.

Inspectors wroteBased on resident and staff interviews and review of the facility's policy titled Resident Rights & Dignity Management, the facility failed to ensure mail was delivered to residents on Saturdays. Specifically, mail was delivered to a locked box outside the facility on Saturdays; however, no staff retrieved and delivered the mail to the residents until Monday morning. This had the potential to affect all residents who might have received mail on Saturdays.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure the medication error rate was five percent (%) or less. There were six medication errors out of 27 opportunities, which yielded a medication error rate of 22.2% for three of five residents (R) (R5, R10, and R45) observed for medication administration.

Inspectors wroteBased on interview, record review, review of the Healthcare Professional Operator's Manual and review of the facility's policies titled, Glucometer Cleaning, and Respiratory Management, the facility failed to ensure that infection control practices were followed for five of five of 42 sampled residents (R) (R30, R45, R49, R24 and R47). Specifically, the nurse failed to ensure that the glucometer was cleaned and disinfected between use for R30, R45, and R49; the facility also failed to ensure that staff did not touch medication with their bare hands for R45 during medication administration; and the facility failed to ensure that respiratory equipment was cleaned and stored appropriately for R24 and R47.

Inspectors wroteBased on staff and resident interviews, record review, and review of the facility's policy titled Behavior Management Standard, the facility failed to discuss the risks and benefits and obtain informed consent before the administration of a psychotropic medication for one of five residents (R) (R4) reviewed for unnecessary medications.

Inspectors wroteBased on staff and resident interviews, record review, and review of the facility's policy titled Freedom of Abuse - Abuse Prevention: Fast Alerts, the facility failed to report an allegation of abuse and neglect for two of two residents (R) (R66 and R14) reviewed for abuse out of a total sample size of 42 residents. Specifically, the facility failed to report an allegation of abuse/neglect made on 10/16/2024 by R66 that Certified Nursing Assistant (CNA)15 was rough during the provision of care and did not check on the resident or provide incontinence care from 6:00 pm to 6:00 am on 10/16/2024. Also, the facility failed to report an allegation of verbal abuse made on 10/22/2024 by R14 that CNA15 yelled at them.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Freedom of Abuse - Abuse Prevention: Fast Alerts, the facility failed to investigate an allegation of abuse and neglect for two of two residents (R) (R14 and R66) reviewed for abuse out of a total sample size of 42 residents.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I was updated and resubmitted following the onset of a new mental illness diagnosis for one of 42 sampled residents (R) (R46) reviewed for PASARR.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Resident Hygiene, the facility failed to ensure nail care was provided for one of two residents (R) (R39) reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to follow up on outside physician recommendations, which caused a delay in treatment for one of two residents (R) (R47) reviewed for skin conditions.

Inspectors wroteBased on observation, staff and resident interviews, record review, and review of the facility's policy titled Respiratory System Management, the facility failed to ensure respiratory equipment was available and functioning properly for one of four residents (R) (R24) reviewed for respiratory services.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the medical records were complete and accurate for two of 14 sampled residents (R) (R10 and R47).

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure food was not stored on the floor, expired foods were disposed of in a timely manner, ready-to-eat food was not touched with bare hands, and moldy food was not stored for use in accordance with professional standards for food service safety as required for 52 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among facility residents.

Inspectors wroteBased on observation, interview, record review, personnel file review, and policy review, the facility failed to 1. follow manufacturer's instructions regarding the cleaning and disinfecting of one of one glucometer between residents' use. 2. follow pre-employment and annual purified protein derivative (PPD) (skin test that determines if you have tuberculosis) guidelines of obtaining PPD 1st and 2nd step at the time of employment for six of nine personnel files (Administrator, Director of Nursing (DON), Certified Nurse Aide (CNA) 2, Licensed Practical Nurse (LPN) 2, Dietary Aide (DA) 1, and LPN3) reviewed, 3. obtain annual PPD test for two of nine personnel files (LPN1 and CNA1) reviewed, and 4. maintain a current infection surveillance program for 2024. Failure to follow infection control guidelines could result in the residents acquiring a blood-borne pathogen or infectious disease.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to provide written information to five residents (Resident (R) 48, R18, R12, R24, and R4) and/or their resident representative concerning the right to formulate an advance directive of 28 sample residents. The failure to discuss advance directive information with the resident and resident representative could potentially affect their ability to make informed decisions about their care.

Inspectors wroteBased on personnel file review, interview, and policy review, the facility failed to follow their policy to obtain background and criminal checks at time of employment for four of nine employee files (Certified Nurse Aide (CNA) 1, CNA2, Licensed Practical Nurse (LPN) 2, and Dietary Aide (DA) 1) reviewed for background checks. The failure to obtain background and criminal checks had the potential to allow facility staff with criminal backgrounds to work with the residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure seven of seven residents and their representatives (Resident (R) 27, R29, R38, R48, R116, R112, and R44) reviewed for facility initiated emergent hospital transfer, from a total sample of 28 residents, were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, other information regarding the transfer, and information on the right to appeal the transfer. This failure had the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure seven of seven residents (Resident (R) 27, R29, R38, R48, R116, R112, and R44) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information of 28 sample residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's room following a hospitalization for residents transferred to the hospital.

Inspectors wroteBased on observation, interview, record review, Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI) review, and policy review, the facility failed to revise the care plan to include fall interventions and ensure care conferences were held for one resident (Resident (R) 48) of 28 sample residents reviewed for care planning. The failure to revise the care plan could affect staff implementing interventions to prevent a future fall. Failure to conduct care plan conferences with the resident and/or their resident representatives could cause the resident to not be informed of care interventions as well as for the resident and/or the resident representative to ask questions about the resident's care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that three of three residents (Resident (R) 5, R38, and R3) reviewed for bed rail use out of a total of 28 sampled residents had bed rail assessments and attempted alternatives with documented reasons for the failure of the alternative prior to the use of the bed rails. This failure increased the potential risks associated bed rail use and could put the residents at risk for injury, entrapment, and/or death.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure pharmacy provided medications timely and residents received medications as ordered by the physician for one of six residents (Residents (R) 113) reviewed for medication administration out of 28 sample residents. The failure of the facility to ensure medications were provided from the pharmacy had the potential to affect all residents requiring administration of medications.

Inspectors wroteBased on record review, interview, and policy review, the facility nurses failed to document the behaviors that were occurring and what nonpharmacological interventions were attempted prior to the administration of antipsychotic medication, Seroquel Intramuscularly (IM) for one of five residents (Resident (R) 48) reviewed for unnecessary medications of 28 sample residents. The failure could result in the resident receiving unnecessary medication.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility nurse failed to follow the physician order and provide the resident his insulin per the sliding scale order for one of seven residents (Resident (R) 3) reviewed during medication administration of 28 sample residents. Specifically, the resident did not have the insulin available for medication administration. This failure caused a significant medication error which could affect the management of R3's diabetes and glucose levels.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the daily nurse staffing was posted to accurately reflect the actual staff hours to care for the 52 current residents for three of four survey days. This failure had the potential to inaccurately inform any resident, family member, or visitor of the available nursing staff caring for residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the level one Preadmission Screening and Resident Review (PASRR) accurately reflected diagnosed mental illnesses for three (Resident [R] #3, R#44, and R#50) of six sampled residents who were reviewed for PASRR.

Inspectors wroteBased on observation, staff interviews, record review, and review of policy titled Medication Administration Guidelines, the facility failed ensure the medication error rate was less than 5%. There were six medication errors with 25 opportunities, which resulted in a 24% medication error rate. This failure affected two residents, Resident (R) #41 and R#15.

Inspectors wroteBased on interviews, record review, and review of policy titled Advance Directives/DNRO [Do Not Resuscitate Order] Log, the facility failed to ensure the resident's code/advanced directive status was promptly determined and documented in an easily accessible location in the medical record to facility staff's ability to honor the resident/responsible party's wishes for one (Resident [R] #154 of three sampled residents reviewed for advance directives.