Dawson Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility policy titled, Housekeeping, the facility failed to ensure that it was maintained in a safe, clean, comfortable environment for one of five bathrooms (Shared with room [ROOM NUMBER]-room [ROOM NUMBER]) on C Hall. Findings include:Review of the facility policy titled Housekeeping with a review date of 12/27/2025 revealed under Intent: it is the intent of this center to maintain a clean and sanitary center that is free from odor and other environmental factors that may affect the quality of life of our patients.Observations on 03/3/2026 at 9:45 AM, 03/4/2026 at 9:40 AM, and 03/5/2026 at 11:55 AM in the bathroom shared between room [ROOM NUMBER] and room [ROOM NUMBER] revealed the following:The ceiling vent was covered in a brownish gray substance. The bathroom linoleum floor on each day had a pool of clear liquid substance that resembled water (moisture). The linoleum was placed approximately 3.5 inches up the wall where baseboards would normally…

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 review of the facility policy titled, Best Practices for PASSR, the facility failed to submit a Preadmission Screening and Resident Review (PASARR) Level II for one of two residents (R) (R3) reviewed for PASARR. This deficient practice had the potential to affect the appropriate level of care and services provided for R3. Review of policy titled, Best Practices for PASRR, revealed, . There are two areas a person can be a PASSR patient: SMI (Significant Mental Illness or ID/DD Intellectual Disability/Developmental Disability. Review of the Electronic Health Record (EHR) under the Diagnosis tab revealed, that R3 was admitted to the facility on [DATE]. Diagnosis included, but not limited to, an onset psychosis in April 2021.Review of R3's quarterly Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment; Section I (Active Diagnosis) revealed depression, anxiety, and psychotic disorder;…

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's policy titled, Controlled Substance Medication Accountability, the facility failed to ensure the Controlled Drug Record was signed after narcotic administration for three of 33 sampled residents (R) (R47, R4, and R30) during review of three of five medication carts. This deficient practice had the potential to cause incorrect narcotic counts, missed or overdose of narcotic medication for residents. Findings include: Review of the facility's policy titled Controlled Substance Medication Accountability dated 12/31/2025 documented under Intent: To establish a method of accountability and reconciliation of controlled medications. Administration, reordering, and release of controlled medication at discharge or for leave of absence: When a routine controlled medication is administered, the licensed nurse administering the medication will promptly enter the following information on the Medication Administration Record (MAR) and 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 observation, staff interviews, record review and review of the facility's policy titled Hand Hygiene, the facility failed to practice proper infection control protocol by not sanitizing hands between glove change for one of three sampled residents (R) R47 with foley catheter. This deficient practice had the potential to cause infection to R47. Findings include: Review of the facility's policy titled Hand Hygiene dated 12/27/2025, documented under INTENT: It is the intent of this facility to promote and facilitate appropriate hand washing as set forth by the guidelines of CDC. Under PURPOSE: Hand Hygiene is the single most important means of preventing the spread of infection. The use of gloves does not replace hand washing. Under GUIDELINE: Associates should use alcohol based hand rub or wash hands with soap and water for the following indications. Immediately after glove removal. Glove use: Gloves should not be used as a substitute for hand hygiene. If your task requires gloves, perform hand hygiene…

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, interviews, and facility policy review, the facility failed to assess for self-administration of medication for one of one resident (Resident (R) 11) reviewed for self-administration of medication out of a total sample of 19 residents. This had the potential to affect resident medication safety at the facility. Findings include: Review of R11's admission Record in the Profile tab of the electronic medical record (EMR) revealed an admission date of 01/27/21. The admission Record revealed R11's diagnoses included centrilobular emphysema and malignant neoplasm of bronchus/lung. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/24 and located in the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. Review of R11's physician order written 07/28/22 located in the Orders tab revealed, Creon [lipase/protease/amylase], 36,000 unit-114,000 unit-180,000-unit capsule delayed release take two capsules, by mouth with meals. During…

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, and policy review, the facility failed to ensure the accurate code status was documented in the medical record to ensure the resident/family's wishes would be honored for one of 24 residents (Resident (R)23) reviewed for code status in the initial pool. This failure could result in a resident receiving cardiopulmonary resuscitation in the event they coded when their wishes were to not receive cardiopulmonary resuscitation. Findings include: Review of R23's code status revealed there was a discrepancy in the documentation between the physician's order, electronic medical record (EMR), and the Physician Orders for Life-Sustaining Treatment (POLST). Review of R23's current physician's order located under the Orders tab of the EMR revealed she had an order for a full code. The order had a start date of [DATE]. The top section of the EMR stated R23 was a full code. Review of a document located in the Document tab of the EMR titled Georgia Department of Public Health Physician…

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 interview, record review, and review of the facility's policy, the facility failed to notify the physician for one of two residents (Resident (R) 29) reviewed for change of condition out of 19 sampled residents. R29 was ordered medication as an intervention for pain; however, the resident missed three doses of medication, and the physician was not notified. Additionally, R29 could not fully complete an x-ray due to pain and the nurse failed to notify the physician. This failure prevented the medical provider the opportunity to make changes to the plan of care. Findings include: Review of the facility's policy titled, Changes in a Patient's Condition, reviewed 12/27/24 revealed .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 .Nursing services is responsible for notifying the patient's attending physician when: .There is a significant change in the patient's physical,…

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 interview, the facility failed to ensure one of one resident (Resident) (R) 40) out of a total sample of 19 residents comprehensive social assessments were completed accurately to reflect diagnoses of mental illness and/or intellectual disability (ID). Failure to accurately identify diagnosis of mental illness or ID had the potential to result in the resident not receiving additional specialized services. Findings include: Review of R40's electronic medical record (EMR) revealed an admitting and current diagnosis located under the Diagnosis tab of Undifferentiated Schizophrenia and mild intellectual disabilities. Review of the Admission section of the EMR revealed R40 was admitted to the facility on [DATE]. Review of the Comprehensive Social Assessment V2.0 located in the Assessment tab of the EMR with completion dates of 02/3/25, 11/08/24, 07/31/24, 05/9/24, 02/5/24, and 11/13/23 revealed no diagnoses of Undifferentiated schizophrenia and/or Mild intellectual disability. Each of these…

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 an accurate Level I screening prior to admission for one of one resident (Resident (R)40) reviewed for Preadmission Screening and Resident Review (PASRR) out of a total sample of 19 residents. This failure resulted in R40 not receiving a Level II screen for specialized services for mental illness (MI) and/or intellectual disability (ID). Findings include: Review of R40's electronic medical record (EMR) revealed his admitting and current diagnosis located under the Diagnosis tab included Undifferentiated Schizophrenia and mild intellectual disabilities. Review of the Admission section of the EMR revealed he was admitted to the facility on [DATE]. Review of the Comprehensive Social Assessment V2.0 located in the Assessment tab of the EMR with completion dates of 02/3/25, 11/08/24, 07/31/24, 05/9/24, 02/5/24, and 11/13/23 revealed no diagnoses of Undifferentiated schizophrenia and/or Mild intellectual disability. Each of the assessments were…

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 interview, record review, and review of the facility's policy, the facility failed to ensure a baseline care plan was developed within 48 hours of a resident's admission for one of one resident (Resident (R) 45) reviewed for baseline care plans out of 19 sampled residents. Findings include: Review of the facility's policy titled, Baseline Care Plan, reviewed 12/27/24 revealed .To promote person-centered continuity of care and communication with the resident and representative, if applicable, regarding the initial plan for delivery of care and services .The center will complete and implement a baseline care plan within 48 hours of a resident's admission in collaboration with the resident and the representative, if applicable . Review of R45's undated Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R45's entire electronic medical record (EMR) revealed no documented evidence a baseline care plan was developed for R45. 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 interview, record review, and review of the facility's policy, the facility failed to ensure the care plan was revised to address pain for one of 19 sampled residents (Resident (R) 29). This deficient practice placed the resident at risk for her pain not to be effectively managed. Findings include: Review of the facility's policy titled, Patient's Plan of Care, reviewed 12/27/24 revealed Intent .To promote person-centered patient care through a comprehensive care plan. Guideline. Each patient will have a person-centered comprehensive care plan developed and implemented to address the patients' medical, physical, mental, and psychosocial needs .Procedure .The comprehensive care plan should also be updated as ongoing clinical assessments identify changes . Review of the facility's policy titled, Pain Assessment, reviewed 12/27/24 revealed .Each patient identified with pain should have a care plan addressing pain management . Review of R29's undated Face Sheet, provided by the facility revealed 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.

Based on observations, record review, interviews, and policy review, the facility failed to consistently implement a low bed and fall mats for one of four residents (Resident (R) 48) reviewed for accidents out of a total sample of 19 residents. Failing to consistently implement measures when the resident transfers self out of bed and/or chair increased the risk of R48 sustaining an injury. Findings include: Review of R48's Care Plan located in the Care Plan tab of the electronic medical record (EMR) revealed a care plan area titled fall risk with a review date of 12/17/24. The Care Area/Problem section of the care plan stated the resident will get out of bed or chair unassisted related to always being incontinent, right below the knee amputation, fall in the past six months, highly impaired vision, unsteady gait, fall within last 2 to 6 months and fall with in past month. The interventions included frequent checks, frequent observations, low bed, mat at both sides of bed, and place the resident in open area for maximum observation opportunities as tolerated. His care plan for…

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 interview, record review, and review of the facility's policy, the facility failed to ensure pain medication was procured from the pharmacy and administered as ordered by the physician for one of 19 sampled residents (Resident (R) 29). The facility's failure increased the potential for R29 to have untreated pain when three doses of the pain medication were not available from the pharmacy. Findings include: Review of the facility's undated policy titled, Pharmacy Services Medication Unavailable for Administration, revealed .DEA [drug enforcement agency] Schedule II through V controlled substance medications require a signed prescription from the physician. At times, medications may become unavailable due to no prescription on file. The administering nurse should contact the dispensing pharmacist for further instruction on the necessary steps needed to obtain the medication .At any time a medication is not available for a specified time of administration, the nurse notifies the prescriber that 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 record review, staff interviews, and review of the facility policy titled, Bed Hold During Hospital Stays and Therapeutic Leaves, the facility failed to provide a written bed hold agreement for one of 11 Residents (R1) who was sent to a behavioral facility for medication stabilization. The facility census was 59. Findings include: Review of the policy titled, Bed Hold During Hospital Stays and Therapeutic Leaves review date [DATE], Under Intent: It is the intent of this nursing center to offer all residents and/or his / her designee the choice of either paying the appropriate amount to hold the bed when the resident goes to the hospital or on therapeutic leave or releasing the bed and being readmitted to their previous room if available or to the first available bed. Closed Record Review Review of the Face Sheet revealed Resident 1 was admitted to the facility with the following diagnoses that include but not limited to Schizophrenia, type 2 diabetes mellitus, hypertension, depression, and…

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.