Sadie G. Mays Health & Rehabilitation Center

The facility failed to ensure activities of daily living (ADLs) were provided for one of three residents (Residents (R)9) who was dependent on staff for assistance with ADLS out of a total sample of 21. This failure placed R9 at risk of a diminished quality of life.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R9 was admitted to the facility with diagnoses that include but not limited to vascular dementia, stroke, and right-sided paralysis.Review of the 6/7/2024 ADLs Care Plan located in the Care Plan tab of the EMR revealed, The resident has an ADL self-care performance deficit r/t (related to) Hemiplegia [paralysis], Limited mobility, Limited ROM [range of motion]. Interventions included, Bathing/Showering: The resident requires assistance by (2) staff with bathing/showering 3 times weekly and as necessary. Dated 6/7/2024.Review of the EMR under the Task tab revealed, a shower was documented in the EMR on 3/7/2025. 3/29/2025, 4/10/2025, and 4/15/2025 (refusal). There was no other documentation in the Task…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and review of facility policy, the facility failed to ensure adequate supervision to potentially prevent accidents for two of four residents (Residents (R)9 and R11) reviewed for accidents in a total sample of 21. These failures placed the residents at risk of injury and unmet care needs.Findings include:Review of an undated facility policy titled Falls and Injury Program revealed, .Each resident's care plan will include specific fall prevention and management strategies tailored to their individual needs and risk factors.1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R11 was admitted to the facility with diagnoses that included but not limited to Alzheimer's disease, dementia.Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 1/21/2025 revealed R11 had a Brief Interview of Mental Status (BIMS) score of zero out of 15, which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview, and review of facility policy, the facility failed to properly position urinary drainage bags to promote adequate drainage and to potentially prevent recurring urinary tract infections (UTIs) for two residents (R)16 and R14 from four residents with urinary drainage bags out of a total sample of 21 residents. This failure has the potential for residents to develop recurring UTIs.Findings include:Review of the facility policy titled, Urinary Catheter Care Policy (undated) revealed, .Proper catheter care is essential to prevent infections, promote comfort, and maintain the dignity of residents.Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of R16's Medical Diagnosis sheet located in the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record reviews, and review of the facility policy titled, Standard Precautions, Administering Oral Medications, and Glucometer Cleaning, the facility failed to ensure nebulizers were bagged, dated, and labeled for two of three residents (R) (R20, R68); ensure the oxygen concentrator tubing was dated and the filter in the concentrator was clean for one resident (R20); and ensure bed pans were properly bagged, labeled, and stored for one resident (R607); and (5) to properly clean and disinfect the medication cart and provide a clean barrier for accu-checks for one resident (R74). Findings included: A review of the facility policy titled, Standard Precautions revealed under the Policy Statement standard precautions are used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interviews, and review of the facility policies titled, Antibiotic Stewardship, Antibiotic Stewardship - Orders for Antibiotics, and Antibiotic Stewardship - Review and Surveillance of Antibiotic Use the facility failed to maintain review of antibiotic prescribing practices and the documentation of the programs efforts to follow up on antibiotic usage data for all nine months (January 2024 to September 2024) that were reviewed. The deficient practice had the potential to affect any resident who was prescribed an antibiotic. Findings included: A review of the policy titled, Antibiotic Stewardship detailed the Policy Statement Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The Policy Interpretation and Implementation section details 1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name b.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating the facility failed to report an alligation of sexual abuse for two of four residents (R10 and R108) reviewed for abuse. Findings included: A review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Reporting and Investigating with revised date of September 2022, all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating the facility failed to complete a thorough investigation of abuse for three of four residents (R) (R98, R96, and R3) investigated for abuse. Findings included: A review of the facility policy entitled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating states, dated September 2022, revealed that all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 1. A review of the Electronic Medical Record (EMR) revealed that R98 was admitted to this facility on 7/1/2017 with diagnoses of cognitive communication deficit, hemiplegia, vascular dementia with behavioral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed quarterly for two residents (R) (R33) and (R405) of 58 sampled residents. Findings included: A review of the Electronic Medical Records (EMR) revealed that R33 was admitted on [DATE]. There was no updated MDS assessment in the resident clinical record. A review of the EMR revealed that R405 was admitted on [DATE]. There was no updated MDS assessment in the resident clinical record. During an interview on 10/24/2024 at 12:20 pm, the Minimum Data Set Coordinator (MDSC) NN revealed she worked at the facility for 27 years and is responsible for completing the comprehensive MDS assessments. The MDSC confirmed that an updated MDS assessment was not completed for R33 as she overlooked completing it. During an interview on 10/24/2024 at 3:43 pm, MDSC OO revealed she has worked at the facility for 10 years. MDSC OO confirmed that R405 did not have an updated assessment. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and a review of the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to ensure that the baseline care plan was completed for one of 11 residents (R) (R355) admitted with a catheter. Findings included: A review of the facility policy titled Care Plans, Comprehensive Person-Centered with a revised date of March 2022 revealed that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. A review of the clinical record for R355 revealed resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, cerebral a neuromuscular dysfunction of bladder, fracture of the right lower leg, subsequent encounter for closed fracture with routine healing age-related nuclear cataract, bilateral dystrophies primarily involving the retinal pigment epithelium, urinary tract infection, and retention of urine. A review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and the facility's policy titled Activities of Daily Living (ADL), Supporting, the facility failed to provide preventative care consistent with professional standards of practice for one of 58 sampled residents (R) (R455) at risk for skin breakdown related to repositioning. Findings included: A review of the facility's policy titled Activities of Daily Living (ADL), Supporting, dated 2001 revealed the policy was: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL care. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral care. A review of the electronic medical record (EMR) revealed R455 was admitted to the facility initially on 6/16/2023 and readmitted on [DATE] with diagnoses of, but not limited to, Alzheimer's Disease, repeated falls, adverse effect of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, staff and resident interviews, and review of the facility policy titled, Call System, the facility failed to ensure that one of 58 sampled residents (R) (R23) had a functioning call light. Findings included: A review of the facility policy titled, Call System dated 7/1/2021 revealed, It is our policy that each resident will have a call light and that call lights are answered. The residents can gain access to staff via the call light system. If the call light system is not operational or if there is an isolated incident involving the call system, team members will make hourly rounds. Maintenance will be notified to assess the call system. A review of the Electronic Medical Record (EMR) revealed that R23 was admitted to the facility on [DATE]. A review of the most recent quarterly Minimum Data Set (MDS) assessment revealed R23 presented with a Brief Interview for Mental Status (BIMS) score of six, indicating sever cognitive impairment; has upper extremities impairment on one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and the State of Georgia Nurse Aide Registry Nurse Aide Certification Renewal the facility failed to ensure that two Certified Nursing Assistance (CNA) certifications were renewed out of ten employee files selected for review. One CNA TT worked six months with an expired certification and CNA UU worked thirty days with an expired certification. The facility's census was one hundred and fifty-five residents. Findings included: A review of the State of Georgia Nurse Aide Registry Nurse Aide Certification Renewal revealed that to remain on the Registry and to be eligible to work in a licensed Medicaid & Medicare facility, you must meet the requirements for Re-Certification. Failure to return the Application for Renewal as a Certified Nurse Aide will result in your name being removed from the Georgia Nurse Aide Registry and will not be eligible to work as a nurse aide by a licensed Medicaid facility. 1. A review of CNA TT's employee file revealed the original certification…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and review of the facility policies titled Cleaning and Disinfection of Resident-Care Items and Equipment, and Administering Medications, the facility failed to maintain infection control standards by not cleaning and disinfecting reusable items between residents, and not performing hand hygiene after assisting a resident and picking paper up off the floor during a medication observation. The facility census was 150 residents. Findings included: A review of the policy titled Cleaning and Disinfection of Resident-Care Items and Equipment with a revised date of September 2022, revealed that resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. It is further noted that reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, and durable medical equipment). A review of the policy titled Administering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident and staff interviews, and review of the facility policies titled, 7 Step Cleaning Process, and Maintenance Service, the facility failed to maintain a safe, clean, and comfortable, homelike environment in five of 30 sampled resident rooms related to a buildup of dirt and grime inside the air discharge grille of the Packaged Terminal Air Conditioner (PTAC) units; a large hole under the sink in one bathroom; missing sheetrock in one resident's room; and by not ensuring an adequate supply of linen for nine days. Findings included: 1. A review of the undated facility policy titled 7 Step Cleaning Process, revealed the policy was to establish an efficient cleaning process unless noted otherwise and that it can be used as a checklist or guide. It is intended that all these steps be completed during each cleaning process. The purpose of this policy is to educate and guide all staff in daily cleaning procedures. The procedures and guidelines of the policy revealed to dust all horizontal and vertical surfaces including ledges and sills, to inspect the room area,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and a review of the facility's policies titled Pest Control and Maintenance Service, the facility failed to maintain an effective pest control program on one of four units (Unit B) related to an infestation of black gnats. Findings included: A review of the facility policy titled Pest Control dated May 2008 revealed that it is the facility's policy that it shall maintain an effective pest control program. It is noted that the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Maintenance services assist, when appropriate and necessary, in providing pest control services. A review of the facility policy titled Maintenance Service with a revised date of December 2009 states that maintenance service shall be provided to all areas of the building, grounds, and equipment and that the maintenance department will monitor and oversee the pest control program. 1. A review of the quarterly Minimum Data Set (MDS) assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to ensure reasonable accommodation of needs was provided for two of 16 sampled residents (R) (R6 and R8) related to providing wheelchair accessibility to accommodate R6 in getting out of bed and related to honor accommodations for bathing for R8. Findings included: 1. A review of the electronic medical Record (EMR) revealed that R6 was admitted to the facility on [DATE] with multiple diagnoses of, but not limited to, chronic pain, gout, and rheumatoid arthritis (RA). A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R6 presented with a Brief Interview for Mental Status (BIMS) score of 15, which indicated R6 was cognitively intact. During an observation on 5/2/2024 at 11:30 am, R6 was observed lying flat in the bed, the room was dark with the blinds closed, and the television was off. There was no bed on the side of the room by the door and there was no wheelchair, Geri-chair, or any type…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record review, and review of the facility's policies titled Abuse, Neglect, and Exploitation, the policy titled Background Screening Investigations, and the Director of Human Resource job description, the facility failed to ensure that a criminal background check was conducted for two Registered Nurse's (RN) of ten employee files selected for review (RN GG and RN HH). The facility census was one hundred and fifty residents. Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated April 2021 revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Conduct team member background checks and not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interviews, and review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, the facility failed to report a situation involving misappropriation of a controlled drug (Oxycodone) to the State Survey Agency (SSA) for two of 18 sampled residents (R) (R17 and R18). Findings included: A review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated September 2022 revealed that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policies titled Care Plans, Comprehensive Person-Centered and Activities of Daily Living (ADL), Supporting, the facility failed to develop a comprehensive, person-centered care plan for five residents (R) (R3, R7, R8, R9, and R16) of sixteen reviewed for care plan. This failure had the potential for these residents not to receive treatment and/or care according to their needs. Findings included: A review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated March 2022, revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record reviews, and a review of the facility policy titled Activities of Daily Living (ADL), Supporting, the facility failed to provide ADL assistance to one of eight residents (R) (R9) reviewed. This failure had the potential to cause R9 to be unclean and feel self-conscious of his appearance. Findings included: A review of the facility policy titled Activities of Daily Living (ADL), Supporting, with a revised date of March 2018 revealed that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL care independently, with the consent of the resident, and in accordance with the plan of care,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record review, and review of the facility's policies titled Background Screening Investigations and Hiring Process, the facility failed to ensure that one of three staff members (Registered Nurse (RN) HH) had the required licensure to provide nursing care to the residents. The facility census was 150 residents. Findings included: A review of the facility policy titled Background Screening Investigations dated April 2021, revealed that any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board is contacted to determine if any sanctions have been assessed against the applicant's license. A review of the facility policy titled Hiring Process dated 1/21/2024 revealed that this policy provides guidance for the hiring of team members. The Human Resources Director is responsible for overseeing all aspects of the hiring process, which includes: Human Resources will obtain copy of two forms of identification and will verify license or certification prior to an offer being made. A review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interviews, and the facility policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents, the facility failed to obtain vaccination consent before administering COVID-19 vaccines on two of five Residents (R) (R1 and R10) reviewed for vaccination status. Findings included: A review of the policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents with a revised date of May 2023 revealed the following: Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident is fully vaccinated. The resident's medical record includes documentation that indicates, at a minimum, the following: a. That the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine including (1) samples of the educational materials used; (2) the date the education took place; and (3) the name of the individual who received the education. b. Signed consent. 1. A review of R1 Electronic Medical Record (EMR) revealed an admission date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, it was determined that the facility failed to provide a privacy curtain to ensure personal privacy for two of 45 sampled residents (R) (R#16 and R#47). Findings included: A review of R#16's most recent Minimum Data Set (MDS) assessment, dated 8/10/22, indicated that R#16 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. A review of R#47's most recent MDS assessment, dated 7/1/22, indicated that R#47 had a BIMS score of 13, indicating R#47 was cognitively intact. Observation on 8/15/22 at 9:42 a.m. and 3:20 p.m., and on 8/18/22 at 3:21 p.m. revealed the name plate outside the door to the room with two resident names on it (R#16 and R#47). There was no privacy curtain between the A and B beds. In an interview on 8/18/22 at 3:21 p.m., R#16 stated the curtain had been gone forever. The resident could not provide a specific time frame. R#16 stated the maintenance director was aware that the curtain was missing. R#16 stated they would like to have some privacy. In an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, observations, and review of the facility's policy titled, Oxygen Administration, it was determined the facility failed to follow physician orders related to oxygen administration for two of two residents (R) (R#44 and R#134) reviewed with oxygen. Findings include: A review of the facility policy, titled, Oxygen Administration, revised October 2010, revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. Under Preparation, revealed, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. 1. A review of R#44's Face Sheet revealed the facility admitted the resident with diagnoses that included acute on chronic diastolic (congestive) heart failure, acute respiratory failure with hypoxia, and atherosclerotic heart disease of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of the facility's policy titled, Administering Medications, it was determined that the facility failed to maintain a medication error rate of 5% or less. There were two errors out of 27 opportunities, which resulted in a 7.4% medication error rate for two of three residents (R) (R#105 and R#106) observed during medication pass. Findings include: A facility policy, titled, Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 10. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1. A review of R#106's face sheet revealed the facility admitted R#106 on 12/16/20 with a diagnosis of atherosclerosis of the coronary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, observations, and review of the facility's policy titled, Storage of Medications and Administering Medications, it was determined the facility failed to maintain a secure, locked medication cart for one out of six medication carts. Findings include: A review of the facility policy, titled, Storage of Medications, revised November 2020, revealed, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. A review of the facility policy, titled, Administering Medications, revised April 2019, revealed, 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observation on 8/15/22 at 12:39…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.