Douglasville Center for Nursing and Healing LLC

Inspectors wroteBased on observations, staff interviews, and the facility policy titled, Food Receiving and Storage, the facility failed to ensure food was not expired. This had the potential to affect 183 of 213 residents receiving food out of the kitchen. This failure had the potential to spread food borne illness.

Inspectors wroteBased on observations, resident and staff interviews, record review, and the review of the facility policies titled, Oxygen Safety and Safe and Homelike Environment, the facility failed to: (1) maintain the laundry services area in a clean, sanitary, and safe condition; (2) maintain the [NAME] Shower tile grout in a clean and sanitary condition; (3) secure empty oxygen tanks to prevent potential hazards; (4) maintain metal Intravenous (IV) stands in a clean and sanitary condition for two of three residents (R) (R22 and R13) reviewed for enteral feedings; and (5) repair leaking air conditioning units, resulting in basins being placed on the floor in two of two rooms observed (rooms [ROOM NUMBERS]) over multiple days. [...]

Inspectors wroteBased on record review, interviews, and facility policy titled, Use of Psychotropic Medications, the facility failed to ensure psychotropic medication risks versus benefits/ or consents were completed for two of five residents (R) (R16 and R30) of 61 sample residents reviewed for unnecessary medications. This failure had the potential for oversedation and lack of understanding by the residents and/or representatives. Findings Include: 1. Review of R16's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R16 had been admitted on [DATE], with an initial admission on [DATE], with diagnoses of schizophrenia, anxiety, mood disorder, and major depressive disorder. [...]

Inspectors wroteBased on interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans the facility failed to provide the opportunity for residents and/or their representatives to participate in their quarterly care plan meetings for four of 54 sampled residents (Resident (R) 56, R158, R214, and R132) reviewed for care planning. The residents were not invited to their scheduled care plan conferences, and there was no documented evidence of invitations. This failure had the potential to limit residents' rights to be involved in decisions regarding their care and treatment. Findings Include: 1. Review of R56's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated R56 had been admitted to the facility on [DATE] with a diagnosis of a tracheostomy. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled Resident Self-Administration of Medication, the facility failed to ensure medications were not left at bedside unless the proper self-administration of medication assessment was completed for two of 61 sample residents (Resident (R) 47 and R56) reviewed for medication at the bedside. This deficient practice had the potential to place R47 and R56 at risk for medication errors, including incorrect dosing, omission, or unsupervised ingestion, which may result in adverse drug events, injury, or decline in condition.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to respect the right to personal privacy for two of three residents (R) (R34 and R235) reviewed for privacy. Specifically, respiratory treatments were conducted in public view without any privacy measures in place, which could have negatively affected the quality of life of affected residents. The facility also failed to ensure unauthorized family members did not have access to one of one sampled (R) (R132) current status, resulting in a breach of the resident's right to privacy and confidentiality.

Inspectors wroteBased on interviews, observations, record review, and policy review, the facility failed to protect the residents' right to be free from physical abuse by a resident for one of 11 residents (R) (R214) reviewed for abuse. This failure had the potential to cause serious physical injury or emotional distress to residents.

Inspectors wroteBased on interview, record review, and a review of the facility policy titled, Use of Psychotropic Medications, the facility failed to ensure two of five residents (Resident (R) 233 and R30) reviewed for unnecessary medications, was ordered to receive as needed (PRN) psychotropic medication beyond 14 days, without an evaluation and documentation of the clinical indications to use the medication beyond the 14 days. This failure had the potential to place the residents at risk of adverse consequences.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to obtain verification of nursing license background checks before the date of hire for two of nine newly hired nurses (Licensed Practical Nurse (LPN) 13 and Registered Nurse (RN) 5) and failed to update the abuse policy regarding the new state guidance regarding verification of nursing license background checks via NURSYS. The deficient practice could result in a staff member with an unknown criminal background having access to residents.

Inspectors wroteBased on interviews, record review, and facility policy titled Abuse, Neglect, and Exploitation, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime and reporting of all alleged abuse violations to the State Agency (SA) for one of 11 residents (R) (R53) reviewed for abuse. The deficient practice had the potential for continued episodes of unreported abuse, which posed the potential for physical harm and/or mental anguish.

Inspectors wroteBased on interviews, record review, and review of the facility's policy, the facility failed to complete a thorough investigation of an allegation of sexual abuse for one of 11 residents (R) (R53) reviewed for abuse. The facility's failure to complete a thorough investigation placed residents at risk of being unprotected from abuse.

Inspectors wroteBased on interview, record review, and review of facility policies, the facility failed to maintain evidence the resident and resident representative (RR) were provided with a written transfer notification of the reason for the transfer and send a copy of the notice to the ombudsman and notify the resident and RR of the facility policy for bed hold for two of seven residents (Resident (R)14 and R59) reviewed for hospitalization. This failure had the potential for the residents and RR to be misinformed of the transfer out of the facility.

Inspectors wroteBased on staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of one resident, (R) (R233), had an accurately coded Minimum Data Set (MDS) assessment. Failure to accurately code the MDS has the potential to result in inaccurate federal reimbursement and inaccurate resident assessment and care planning.

Inspectors wroteBased on interviews, record review, and review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and plans for one of 54 sampled residents (R) R 200. The failure to develop a care plan increased the risk of incomplete and/or inconsistent care related to the resident's risk of developing pressure ulcers.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure Activities of Daily Living (ADLs) were conducted for five of 61 sampled residents (R) (R47, R247, R200, R10, and R151). The facility failed to ensure timely incontinence care was provided for one resident (R47); ensure showers and/or baths were conducted for three residents (R247, R200, and R151); and ensure facial hair was trimmed and nails clipped for one resident (R10). This failure had the potential to compromise residents' hygiene and quality of life.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to provide an ongoing activity program to meet the individual interests and needs to enhance the quality of life for four of 61 sampled residents (R) (R251, R233, R200 and R7). Residents were observed idle for extended periods with no engagement, individualized programming, or staff led activities that reflected their cognitive abilities, interests, or past life roles. This had the potential to cause psychosocial decline, including social isolation, depression, decreased quality of life, and cognitive and functional deterioration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pressure-relieving air mattress was set according to manufacturer specifications for two of ten residents (Resident (R) 122 and R40) reviewed for pressure ulcers. This failure placed the resident at risk for skin breakdown and compromised pressure injury management. 1. Review of R122's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R122 was admitted to the facility on with diagnoses that included tracheostomy and diabetes mellitus. Review of R122's Care Plan, located under the Care Plan tab of the EMR and dated 10/24/2205, indicated that the resident had an actual skin impairment related to wound on the sacrum. The Care Plan did not address the use of an air mattress as a pressure ulcer prevention/healing device. [...]

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Care and Treatment of Feeding Tubes, the facility failed to properly administer enteral formulas for three of 10 residents (Resident (R)132, R13, and R22) reviewed for tube feedings out of a total sample of 61. The facility failed to administer the correct enteral formula to R132 and failed to record the time on the enteral formula bottle when administration began for R13 and R22. These failures had the potential to cause gastrointestinal issues and/or weight loss for residents who require tube feedings.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Oxygen Administration and Tracheostomy Care, the facility failed to administer oxygen to one of one resident (Resident (R) 15) and provide tracheostomy care to one of five residents (R265) per physician order out of six residents reviewed for respiratory care out of a total sample of 61 residents. The deficient practice had the potential to place R15 and R265 at increased risk of respiratory complications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure communication took place between the facility and the dialysis center for one of one resident (R) (R9), reviewed for dialysis services out of a total sample of 61. This deficient practice could result in residents who are on dialysis not receiving the needed care or services.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Use of Psychotropic Medications, the facility failed to provide the prescribing provider with pharmacy recommendations, take actions, or document the rationale if no action was taken for psychotropic medications for one of five residents (Resident (R) 30) reviewed for unnecessary medication in a total sample of 61 residents. This failure resulted in the provider not having the opportunity to respond to the recommendations for psychotropic medications.

Inspectors wroteBased on observation, interview, record review, and review of the Epilepsy Foundation, National Library of Medicine, and the Food and Drug Administration (FDA) websites, the facility failed to ensure three of 61 Residents (R) (R47, R9, and R200), whose medications were reviewed were free of significant medication errors when medications were not administered as ordered, including at the correct time, in the correct manner, and with accurate documentation. The facility failed to administer anti-seizure medication, anticoagulants, and insulin within acceptable timeframes, administer narcotic medications in accordance with physician orders, and accurately document medication administration and maintain complete and consistent controlled substance records. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the documented Dietary Meal Start Times, the facility failed to serve meals on time for ten residents (R) (R59, R117, R50, R183, R208, R29, R203, R56, R122, and R200) out of a total sample of 61. This failure had the potential to negatively affect 183 residents who were served meals that were prepared from the facility's kitchen.

Inspectors wroteBased on staff interviews, record review, and the facility policy titled, Documentation in Medical Record, the facility failed to ensure the medical record was complete for urinary and bowel incontinence care for two of three residents (R) (R170 and R266) reviewed for incontinence care. This failure had the potential to contribute to inaccurate reflection of resident care.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure Respiratory Therapist changed Personal Protective Equipment (PPE) between residents (R) for tracheostomy care for R34 and R235; failed to ensure staff donned PPE when providing care to R251; failed to ensure staff changed gloves and perform hand hygiene during perineal care between removing soiled brief and applying clean brief and adjusting bed linens for R188 and failed to ensure R40's urinary catheter collection bag remained off the floor. The facility's failure to ensure proper infection control during care created the potential for cross contamination and infection for the total survey sample of 61.

Inspectors wroteBased on observations, record reviews, staff and resident interviews, and review of the facility policy Discharge and Transfer Policy, the facility failed to ensure that treatment was provided in a timely manner following a right hip fracture for one of three residents (R1). Actual harm was identified on 8/24/2025 when R1 fell and suffered a right hip fracture that was not recognized until 8/25/2025 when the resident was sent to the hospital and had to undergo surgery for an intertrochanteric fracture of the right hip.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Self-Administration Protocol, the facility failed to adequately assess two of 72 sampled Residents (R) (R65, R54) for self-administration of medication. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a clean, comfortable, homelike environment as evidenced by broken wall molding trim in three of 31 resident rooms (room [ROOM NUMBER], 320, and 324) on Unit 30. In addition, two wall tiles were broken in room [ROOM NUMBER].

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled, Abuse Prevention, the facility failed to ensure that the hiring of staff was proceeded by a completed background check to ensure that individuals who have been hired have not been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment in a court of law. Specifically, the Dietary Manager (DM) was allowed to continue working at the facility after two unsatisfactory criminal background checks.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Abuse Prevention, the facility failed to report injuries of unknown origin to the State Survey Agency (SSA) within the required timeframe for one resident (R) (R512) reviewed for abuse and neglect. The deficient practice had the potential for future unreported injuries of unknown origin, with the potential to affect residents' quality of life.

Inspectors wroteBased on staff interviews, record review, and a review of the facility policy titled, PASRR (Preadmission Screening and Resident Review) Screening for Mental Disorder or Intellectual Disability, the facility failed to submit a PASARR Level II for one of two residents (R) (R153) reviewed for a mental illness diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R153.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Oxygen Therapy, the facility failed to deliver oxygen (O2) per physician order for one of 37 residents (R) (R76) receiving O2 therapy. The deficient practices had the potential to cause respiratory distress.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled, Abuse Prevention, the facility administration failed to provide oversight to ensure one employee was free from adverse action on the criminal background check while working in the facility.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Telephone Orders, the facility failed to ensure accurate and complete medical records were maintained for one of three sampled residents (R) (R4).

Inspectors wroteBased on observations, staff interviews, record review, and review of the manufacturer's instructional sheet titled, How to clean and disinfect your Blood Glucose Meter, the facility failed to ensure proper cleaning technique for a glucometer during routine fasting blood sugar checks on one resident (R) (R44). The deficient practice had the potential to put residents at risk for a possible bloodborne pathogen.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Care Plans, the facility failed to include seizure medication in the care plan for one of nine sampled residents (R) (R1) reviewed. The deficient practice had the potential for R1 not to receive treatment and/or care according to their needs.

Inspectors wroteBased on complainant, family member and staff interviews, record review, and review of the facility policy titled, Prescriber Medication Orders, the facility failed to transfer a medication order and failed to give the medication as ordered for one of nine sampled residents (R) (R1). The deficient practice caused R1 not to receive ordered seizure medication.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide services with reasonable accommodation of needs for one of 28 sampled residents (R) (R6) related to scheduled appointments.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide toileting assistance and assessment and treatment of a bleeding right leg to one of three sampled residents (R) (R7).

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled Abuse Prevention, the facility failed to ensure that an allegation of sexual abuse was thoroughly investigated to rule out abuse for two of 28 sampled residents (R) (R11 and R12).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to ensure that the resident environment remained free of accident hazards for one of four residents (R) (R16) related to receiving adequate supervision and assistance devices to prevent accidents.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to maintain a clean, comfortable, homelike environment as evidenced by dirty PTAC (packaged terminal air conditioner) filters and broken slats, loose call light panels, and oversized ceiling light fixtures which covered or partially covered the return air vents in six of 141 occupied resident rooms (TC101, TC104, W31, W33, W34, and W36).

Inspectors wrote3. Review of R647's quarterly MDS dated [DATE] revealed section I (Active Diagnosis): chronic respiratory failure, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, shortness of breath (SOB), section O (Special Treatments, Procedures, Programs): receives oxygen therapy. Review of the care plan for R647 dated 6/9/2021 revealed a Focus of the resident uses oxygen/nebulizer for COPD. The Goal was that R647 will have the effectiveness of oxygen/nebulizers through the next review on 7/21/2023. Monitor for signs and symptoms of respiratory distress, and monitor vital signs as needed or according to the facility's policy. A review of the physician's orders for R647 revealed an order dated 11/3/2023 for O2 at 2 LPM via NC. Observation on 2/6/2024 at 12:39 pm revealed R647's O2 was set at 5 LPM. [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to maintain dignity by ensuring a urinary catheter dignity bag was provided for two of 45 sampled residents (R) (R654 and R657). This failure had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Comprehensive Person-Centered Care Plans, the facility failed to develop and implement a care plan for two of 45 Residents (R) (R82 and R126). Specifically, R82 had no care plan for psychotropic medication and R126 had no care plan for Hospice care or for oxygen (O2).

Inspectors wroteBased on record review, review of the facility policy titled Comprehensive Person-Centered Care Plans, and resident and staff interviews, the facility failed to implement the care plan for two of 56 sampled residents (R) (R19 and R36). Actual harm occurred on 3/14/2023 when R19 sustained an acute fracture of the proximal fibular diaphysis after falling from the bed when one Certified Nursing Assistant (CNA) failed to follow the plan of care for Activities of Daily Living (ADL) care interventions.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that three of 54 sampled residents (R19, R40, and R36) were free of accidents related to not following the plan of care for fall risk for R19 and R36 and not completing neuro checks for R40. Also, the facility failed to store chemicals in a safe and secure manner to prevent accidents. Actual harm occurred on 3/14/2023 when R19 sustained an acute fracture of the proximal fibular diaphysis after falling from the bed when one Certified Nursing Assistant (CNA) failed to follow the plan of care for ADL care interventions.

Inspectors wroteBased on record review, interviews, and review of the facility's policy titled Bowel Elimination Protocol the facility failed to implement interventions to prevent discomfort for one of 54 sampled residents (R) (R8). Actual harm was identified to have occurred on 6/28/2023 when R8 was sent out to an acute care hospital for fecal impaction.

Inspectors wroteBased on record review, observations, staff interviews, and the undated facility's policies titled, Controlled Medications Administrations and the undated Medication Administration General Guidelines revealed two of 56 sampled residents (R) (R8 and R7) medication was not administered timely.

Inspectors wroteBased on policy and record review, observations and resident and staff interview the facility failed to follow infection control processes and procedures to prevent the spread of infections and contamination on four of five units (300 Unit, Central Unit, Magnolia Terrace, and Transition Pulmonary Unit).

Inspectors wroteBased on observations and interviews, the facility failed to provide residents with a comfortable and homelike atmosphere on three of five Units (Transition Pulmonary Unit, Magnolia Terrace, and 300 Unit) related to not having an adequate supply of bed and bath linens, dirty rooms, used pest traps and trash on floors, soiled privacy curtains, and urine odors.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide Activities of Daily Living (ADL) care to seven of 54 sampled residents (R) (R7, R21, R26, R38, R30, R39, and R15) related to scheduled showers/baths, incontinence care, and nail care.

Inspectors wroteBased on observation, interview, and review of the facility's policy for food and nutrition, the facility failed to ensure opened food items were securely wrapped, labeled, and dated, failed to discard food items by the expiration date, failed to store food items properly in the freezer, and failed to maintain a sanitary functional kitchen equipment in the kitchen. The facility census was 199.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a Safe, Functional, Sanitary, and Comfortable Environment for three of five units (Magnolia Terrace, Central Unit, and 300 Unit).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an effective pest control program on two of five units (Magnolia Terrace and 300 Unit).

Inspectors wroteBased on policy reviews, record reviews and interviews, the facility failed to provide residents with a grievance process that provided residents with the solutions for grievances that were filed for three of 54 sample residents (R) (R16, R17, and R18).

Inspectors wroteBased on record review and interviews, the facility failed to fully investigate an allegation of abuse for one of 56 residents (R) (R32).

Inspectors wroteBased on record review, observations, interviews, and the facility's policy titled, Tracheostomy Care the facility Respiratory Therapist (RTs) failed to provide a safe and sanitary environment during tracheostomy (trach)care for three four residents (R) (R15, R31, and R33) reviewed for trach care.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure that one of six treatment carts (300 Unit Treatment Carts) were secured and inaccessible to residents.