Hartwell Health And Rehabilitation

Based on observations, staff interviews, and review of facility policy titled, Food Preparation and Distribution, the facility failed to ensure dietary staff properly washed hands in the dish room to prevent cross contamination. The facility census was 85 and all residents were receiving an oral diet. The deficient practice had the potential to affect all facility residents.Findings include:Review of the facility policy titled Food Preparation and Distribution revealed Cross contamination - hand washing should occur before putting on gloves and after removing gloves. Gloves should be changed between tasks, such as between handling raw meats or ready-to-eat foods and between handling soiled and clean dishes.Observation on 02/07/2026 at 12:35 PM of Dietary Aide EE revealed she was in the dish room washing soiled dishes and was wearing blue colored plastic gloves. Continued observation revealed the dietary aide placing soiled meal trays in a dish rack and pushed them through the conveyer belt style dish machine. Dietary Aide EE then placed six soiled small plastic gray bowls on a dish…

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 policy titled, Abuse Prohibition-Screening, Hiring, And Training Practices, the facility failed to complete and receive satisfactory background check screenings for one of 11 nursing staff reviewed. The deficient practice had the potential for staff with criminal backgrounds to care for vulnerable residents.Findings include:Review of the facility policy titled Abuse Prohibition-Screening, Hiring, And Training Practices reviewed date 12/04/2021 revealed it is the intent of this center to establish standards of practice for screening, hiring and training of associates. Guideline:Prospective Associate Screening and Hiring Practices: A background and criminal records history investigation is conducted for prospective associates that will include:Background and Criminal History Investigation. Non-licensed associates are completed through the Georgia Criminal History Check System (GCHECXS) and may include fingerprinting. The center will not employ individuals who have an unsatisfactory determination from the criminal…

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, resident and staff interviews, record review, and review of the facility policy titled, Foot Care, the facility failed to adequately provide Activities of Daily Living (ADL) care pertaining to foot treatment for one of 36 sampled residents (R) (R11). The deficient practice had the potential to place R11 at risk for unmet needs and a diminished quality of life.Findings include:Review of the facility policy titled Foot Care review dated 12/27/2024 revealed under Intent: To provide foot care in accordance with professional standards of practice as part of routine care to assist in identifying skin concerns, maintain mobility and sustain good foot health.Review of the electronic medical record (EMR) for R11 revealed she was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease, age-related physical debility, morbid (severe) obesity due to excess calories, lymphedema, repeated falls, iron deficiency anemia, diastolic (congestive) heart failure, chronic kidney disease, stage 3b.Review of an annual Minimum Data Set…

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 and resident interviews and record review, the facility failed to follow physician orders and to contact the physician for a change in condition for one of 16 residents (R) (R13) sampled with physician orders for daily weights. The deficient practice had the potential to place R13 at risk for medical complications, unmet needs, and a diminished quality of life.Findings include:Review of R13's electronic medical record (EMR) revealed R13 was admitted to the facility with pertinent diagnoses including but was not limited to acute and chronic respiratory failure with hypoxia, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, stage 3 chronic kidney disease, chronic diastolic (congestive) heart failure, paroxysmal atrial fibrillation, need for assistance with personal care, Parkinson's disease, dementia, and wheezing.Review of R13's 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS)…

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 review, staff interviews, and review of the facility's policy titled, Patient Smoking Guidelines, the facility failed to keep facility free of accident hazards for one of three sampled residents (R) (R22) who smoked. Specifically, smoking materials were not kept away from R22's bedside. This deficient practice had the potential to result in choking, aspiration, oral injury, and other avoidable harm to facility residents.Findings include:A review of the facility policy titled Patient Smoking Guidelines reviewed on 12/27/2024 revealed in section General Smoking Guidelines: No patient will be allowed to be in possession of smoking paraphernalia (i.e., cigarettes, lighters, e-cigarettes, matches, etc.) on their person, in their rooms or any other place in the Center or Center grounds other than the Center has identified location to keep patient smoking materials. All patient smoking materials will be kept in a designated location in the Center and dispensed at the time of the smoke…

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 review, staff interviews and review of the facility policies titled, Infection Prevention Plan and Transmission-Based Precautions, the facility failed to maintain effective infection control practices concerning contact precautions standards for one of 39 sampled residents (R) (R78). Additionally, the facility failed to prevent the risk of cross-contamination for one of 39 sampled residents (R) (R16). The deficient practices had the potential for cross-contamination of pathogens to other residents and staff.Findings include:Review of the facility's policy titled, Infection Prevention Plan last reviewed date 12/27/2024, revealed under Intent: The Infection Prevention Plan provides an overview of the infection prevention practices of the center that is charged with the promotion of a healthy and safe environment to reduce the risk of infections in patients, staff, visitors, and others in health care environment. Under Goals: . Maintain a sanitary environment for personnel 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.

Based on observations, record review, staff interviews, and review of the facility's policy titled Medication Beyond-Use and Expiration Dates, the facility failed to remove expired insulin pens from two of three medication carts observed. This failure had the potential for residents to be administered expired medications. Findings include: Review of the undated facility's policy titled Medication Beyond-Use and Expiration Dates, under the section titled Guidelines revealed, An expiration date indicates the last date at which the manufacturer guarantees a drug's full potency and safety Medication should not be stored, transported, or administered after beyond-use or expiration date. Observation on 10/24/2024 at 9:38 am of Licensed Practical Nurse (LPN) DD while working on Medication Hall Three cart, revealed one Humalog insulin pen with a sticker that indicated a discard date of 10/21/2024. There was no identifiable open date on the pen. Interview on 10/24/2024 at 9:44 am with LPN DD, while working on Hall Three medication cart, confirmed the Humalog insulin pen had a sticker with…

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, review of facility's policy titled, , Housekeeping, review of the documents titled, Patient Room Cleaning Standard and 10 Step Patient Room Cleaning, the facility failed to maintain clean exhaust fans for six shared bathrooms out of 35 bathrooms. This had the potential to compromise the hygiene and safety of the shared bathroom environments, increasing the risk of infection and negatively impacting the health and well-being of residents. The facility census was 84. Findings Include: A review of the facility's policy titled Housekeeping, dated 12/29/2023, under the section titled Intent revealed, 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. Under the section titled Guidelines revealed, This center should be cleaned in a manner that is consistent with protocols and recommendations from the manufacturer of the chemicals 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of the EMR for R32 revealed she was admitted to the facility on [DATE]. R40 had diagnoses that included but not limited to, unspecified dementia (moderate) with other behavioral disturbance, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, unspecified sequelae of cerebral infarction, other lack of coordination, pain (unspecified). Review of R32's quarterly Minimum Data Set (MDS) dated [DATE] documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident was cognitively intact. Review of the care plan revised on 8/12/2024, revealed R32 was care planned for cognitive impairment related to dementia and history of cerebrovascular accident (CVA), as evidence by memory problem, poor decision making/needs cues, on dementia medications, memory problem short term, and impaired decision making in new situation. Review of the care plan revised on 8/12/2024, revealed R32 was care planned for risk 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 observations, resident and staff interviews, record reviews, and review of the facility's policy titled, Skilled Nursing Services Use of Oxygen Therapy, the facility failed to ensure one of 11 residents (R) (R33) receiving oxygen therapy, was administered oxygen in accordance with the physician order. Specifically, R33 did not receive oxygen at the accurate flow rate prescribed by the physician. The deficient practice had the potential to cause respiratory complications for R33. Findings include: Review of the facility's policy titled Skilled Nursing Services Use of Oxygen Therapy, dated 7/1/2024 revealed, Intent: To ensure that patients maintain optimal oxygenation via the proper device and concentration when appropriate and medically indicated. Guideline: . oxygen with liter flow as ordered . Review of the Electronic Health Records (EHR) revealed R33 was admitted on [DATE] with diagnoses that included but not limited to paroxysmal atrial fibrillation, hypertensive heart disease with heart failure 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interview, and review of the facility's policy titled Oral Inhalation and Nebulizer Administration, the facility failed to properly administer an oral steroid inhaler for one of nine residents (R) R6 observed during medication administration. This failure had the potential to reduce the efficacy of the medication. Findings include: Review facility's policy titled Oral Inhalation and Nebulizer Administration, dated 2022 revealed, that if a steroid inhaler is used, have patient thoroughly rinse mouth with water and spit out after use to minimize risk of oral pharyngeal candidiasis (thrush). Review of clinical records revealed R6 was admitted on [DATE] with chronic obstruction pulmonary disease (COPD), atrial fibrillation (AF), and peripheral vascular disease (PVD). Review of the quarterly Minimum Data Set (MDS) assessment dated revealed, R6 had a Brief Interview for Mental Status (BIMS) of eight; thus, the resident had mildly impaired cognition. She has no behaviors 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 observation, record review, resident and staff interviews, and review of facilities policies titled, Fall Management and Documentation in the Medical Record revealed, the facility failed to maintain accurately documented resident record in accordance with accepted professional standards and practices regarding falls for one Resident (R) R32 out of 29 sampled residents. The facility census was 84. Findings Include: A review of the policy titled, Fall Management dated 12/29/2023 under the section titled Overview revealed, Each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. Each patient's risk for falls is evaluated by the interdisciplinary team (IDT). A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure…

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 and review of the facility's policy titled, Guidelines for Eyewash Stations and Emergency Showers, the facility failed to maintain one of one eyewash station observed in a safe, functional manner by ensuring proper drainage. Specifically, water flowed from an open pipe below the eyewash station onto the floor and onto the feet of staff using the sink. This deficiency had the potential to cause falls and injury to staff utilizing the eye wash station. Findings include: Review of facility's policy titled Guidelines for Eyewash Stations and Emergency Showers (undated) documented Location: Adequate drainage; Provide a drain for the large amounts of water used in flushing or ensure a plan exists to manage and remove the water if a drain does not exist. Inspection: Ensure proper drainage or collect run-off water under the device. Observation on 10/23/2024 at 12:03 pm during tour of the laundry department revealed water flowing from an open pipe below the eye wash station when the eye wash station was in use. Water was observed flowing from under 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.