Heritage Inn Of Barnesville Health And Rehab

Based on observations, staff interviews, and review of the facility's policy titled Skilled Nursing Services: Cleaning and Sanitizing, the facility failed to ensure the kitchen workplace and equipment were clean and sanitized to reduce the risk of foodborne illnesses. This deficient practice had the potential to place the residents who received an oral diet from the kitchen at risk of foodborne illness. Findings Include: Review of the facility's policy titled, Skilled Nursing Services: Cleaning and Sanitizing, dated 12/27/2024, revealed the Intent section included, It is the intent of this center to clean and sanitize utensils, dishware, pots and pans, workspace, and equipment to minimize the risk of food-borne illnesses. The Guideline section included, . Work surfaces and equipment should be cleaned and sanitized as needed. Fixed equipment: Items should be cleaned and sanitized appropriately. Removable parts may be cleaned and sanitized separately. Items should air dry as needed. Stationary equipment should be covered when fully cleaned and sanitized. Observation on 4/9/2025 at…

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, staff interviews, record review, and review of the facility's policy titled, Medication Administration-General, the facility failed to ensure the medication error rate was less than five percent. There were two errors with 26 opportunities for two of five residents (R) (R33 and R28) observed for a medication error rate of 7.69 percent. This deficient practice had the potential to place R33 and R28 at risk of avoidable medical complications due to not receiving medications as prescribed by the physician. Findings Include: Review of the facility's undated policy titled, Medication Administration- General, revealed the Intent section stated, To facilitate that medications are administered as prescribed, in accordance with good nursing principles. 1. Review of R33's Consolidated Orders revealed diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD). Observation on 4/9/2025 at 8:15 am revealed Certified Medication Assistant (CMA) AA administering morning medications to R33. The medications included citalopram 20 milligrams (mg)…

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 reviews, and a review of the facility policies titled Change in a Patient's Condition, and Fall Management, the facility failed to notify the physician and family of a change in condition for three residents (R) (R1, R3, and R9) of 11 sampled residents reviewed for notification of a change in condition. Specifically, when R1 refused dialysis treatment, and when R3 and R9 sustained falls. Findings include: Review of the policy titled Change in a Patient's Condition, with a review date of 12/30/2022, indicated the Intent section stated: It is the intent of this center to notify the patient, his/her attending physician, and responsible party/patient representative of changes in the patient's condition and/or status. The Guideline section stated: Nursing services is responsible for notifying the patient's attending physician when: Deemed necessary or appropriate in the best interest of the patient. Nursing services is responsible for notifying the patient, his/her next-of-kin, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and family interviews, staff interviews, record review, and review of the policies titled Abuse Prohibition, and A Comprehensive Patients' Rights Program, the facility failed to protect two residents' (R) (R3 and R10) right to be free from verbal abuse and neglect by staff. Specifically, the facility failed to protect R10's right to be free from verbal abuse when she asked for assistance with removing her clothes and staff called the resident lazy and failed to protect R3's right to be free from neglect when he requested staff to assist him to the bathroom and the staff refused. As a result of R3 attempting to go to the bathroom by himself, he fell and sustained an injury to the head. The sample size was 11 residents. Findings include: Review of the facility policy titled Abuse Prohibition, with a review date of 12/30/2022, revealed the section titled Intent stated: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, 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 and staff interviews the facility failed to maintain medical records accurately on six out of eleven resident (R) records reviewed (R3, R6, R7, R8, R9, R11). Findings include: 1. Review of R3's Electronic Health Record (EMR) Face Sheet revealed a discharge date of 3/24/2023. Review of the resident's Minimum Data Set (MDS) discharge assessment revealed a date of 3/20/2023. Further review of R3 EMR Nurses Note dated 3/20/2023 revealed the resident was sent to the hospital. There was no documentation that R3 returned to the facility. 2. Review of R6's EMR Face Sheet revealed a discharge date of 2/23/2023. Review of the resident's MDS discharge assessment revealed a date of 2/23/2023. Further review of R6 EMR Nurses Note dated 2/22/2023 revealed the resident was sent to the hospital. There was no documentation that R6 returned to the facility. 3. Review of R7's EMR Face Sheet revealed a discharge date of 6/29/2023. Review of the resident's MDS death in the facility assessment revealed a date of 6/28/2023. Further review of R7's EMR Nurses Note dated 6/28/2023 at…

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 and resident representative (RR) interviews, record review, and review of the facility policy titled, Skilled Inpatient Services, Pain Assessment, the facility failed to notify the physician of a resident's pain for one of two residents (R) (R#283) reviewed for pain management. Specifically, the pain reliever for R#283 was not working, they experienced frequent pain, and the physician was not notified. This failure had the potential to delay or prevent treatment for R#283. Findings include: Review of the facility policy titled, Skilled Inpatient Services, Pain Assessment, dated 12/04/2021, revealed there was no information in the policy regarding notifying the physician about a resident's uncontrolled pain. A review of the Face Sheet for R#283 indicated diagnoses that included sepsis following a procedure, muscle weakness (generalized), pain in left leg, pain in left knee, effusion in left knee, need for assistance with personal care, dementia, psychotic disturbance, mood…

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 interviews, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) for one of three residents (R) (R#24) who were being discharged from Medicare Part A services. Specifically, the facility failed to provide a SNF ABN for R#24 when they were discharged from therapy services and remained in the facility. Findings include: A copy of the Notice of Medicare Non-Coverage (NOMNC) and SNF ABN notifications were requested from the Administrator on 2/20/2023 for three residents who were required to have notifications. No SNF ABN notification was located for R#24. A review of the Face Sheet for R#24 revealed diagnoses that included Parkinson's disease, compression fracture of lumbar vertebrae, polyneuropathy, and unsteadiness on feet. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated the assessment was a 5-day Prospective Payment System (PPS) scheduled assessment for a Medicare Part A stay. The MDS indicated R#24…

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, resident and staff interviews, and review of the facility policy titled, Abuse Prohibition, the facility failed to implement their abuse policy related to reporting and investigating an allegation of abuse and protecting the resident during the investigation for one of four residents (R) (R#24) reviewed with allegations of abuse. Specifically, these failures created the potential for continued abuse toward R#24 and other facility residents. Findings included: A review of the facility policy titled, Abuse Prohibition dated 2020, indicated in the section titled, Investigation and Follow Up, the policy indicated, After an allegation/incident has been reported to the state, incident should be investigated including but not limited to the following: Description of the event to include any identified injuries. Additional excerpts from this section of the policy included, Interviews will be conducted of pertinent parties. Written statements from any involved parties will be obtained if possible or a witnessed, signed interview would be an appropriate alternative.…

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, resident and staff interview, and review of the facility policy titled, Abuse Prohibition, the facility failed to report an allegation of abuse to the Administrator and to other appropriate agencies for one of four residents (R) (R#24) with allegations of abuse reviewed. Findings include: A review of the facility's Abuse Prohibition policy, dated 2020, indicated in the section titled, Reporting that It will be the responsibility of any department leader receiving the complaint of alleged abuse, corporal punishment, involuntary seclusion, neglect, mistreatment of patient property, or exploitation should inform the Administrator or designee immediately. All allegations of abuse or allegations involving serious bodily injury must be reported immediately but no later than 2 hours. Allegations that do not involve abuse or allegations with serious bodily injury must be reported immediately but no later than 24 hours. The policy also indicated, The administrator or designee will notify the Complaint Investigation Intake and Referral Unit and the legal representative…

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, resident and staff interviews, and review of the facility policy titled, Abuse Prohibition, the facility failed to thoroughly investigate an allegation of abuse and to protect the resident during the investigation for one of four residents (R) (R#24) reviewed for allegations of abuse. Findings included: A review of the facility's Abuse Prohibition policy, dated 2020, indicated the following in the section titled, Investigation and Follow Up: After an allegation/incident has been reported to the state, incident should be investigated including but not limited to the following: Description of the event to include any identified injuries. Physical assessment of the patient may be required based on the nature of the allegation. Additional excerpts from this section of the policy included, Interviews will be conducted of pertinent parties. Written statements from any involved parties will be obtained if possible or a witnessed, signed interview would be an appropriate alternative. Information…

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 a review of the facility's policy titled, Skilled Inpatient Services, Pain Assessment, the facility failed to ensure pain management was provided for 1 of 2 residents (R) (#283) reviewed for pain management. Observations revealed that R#283 experienced pain during a procedure and during care and the facility staff failed to assess the pain and provide pain management. Findings included: A review of a facility policy titled, Skilled Inpatient Services, Pain Assessment, dated 12/04/2021, specified, Upon admission, patients will be evaluated for pain utilizing the Pain Risk Assessment. Patients should be evaluated for pain, using the Pain Risk Assessment, quarterly, annually, and with a significant change of condition such as illness, decline in function or change in mood or cognition. Observation for the recognition of pain using the 0-10 pain scale should be completed every 8 hours and before and after the administration of PRN [as needed] analgesic…

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, record review, facility policy review titled Hand Hygiene-Center for Disease Control and Prevention (CDC) Guidelines, and staff interviews, the facility failed to ensure that catheter care was performed in a way to prevent cross-contamination by changing gloves when going from dirty to clean for one resident (R) (R#44), who has a history of urinary tract infections (UTI), from a total sample of 32 residents. Findings include: Review of facility policy titled Hand Hygiene-CDC Guidelines dated 1/12/18 revealed that staff are to change gloves when moving from a contaminated body site to a clean body site on the same patient. R#44 was admitted to the facility on [DATE] with diagnoses including but not limited to neuromuscular dysfunction of the bladder. During observation of catheter care with Certified Nursing Assistant (CNA) AA and CNA BB, on 9/2/21 at 9:15 a.m., CNA AA laid out all necessary supplies (one pair of purple gloves, package of wipes, clean diaper, and plastic bag) on a covered…

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.