Colquitt Regional Senior Care & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy, the facility failed to ensure residents were informed of the benefits, risks, and alternatives of treatment prior to initiating or increasing psychotropic medication for two of five residents (R) (R2 and R9) of five residents reviewed for unnecessary medications. This deficient practice had the potential for residents to receive medications without knowing the benefits, risks and treatment options. Findings include:1. Review of R2's admission Record located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses that included but not limited to major depressive disorder and insomnia. Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/2025, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated little to no cognitive impairment. The MDS Section N: Medications revealed R2 received antidepressant and hypnotic…

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 facility policy, the facility failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint background check was completed for the Food Service Supervisor (FSS). The deficient practice could result in a staff with an unknown criminal background having access to residents. Findings include:Review of employee records for the Food Service Supervisor (FSS) revealed he was hired on 09/07/2022. The required GCHEXS fingerprint background check clearance letter was not located in the file. During an interview on 01/07/2026 at 11:04 AM, the Assistant Administrator stated FSS did not have a GCHEXS background check completed upon hire.During an interview on 01/07/2026 at 11:59 AM, the Administrator stated Human Recourses did not complete fingerprint background checks for staff that did not have direct care with residents.During an interview on 01/07/2026 at 12:14 PM, the Human Resources Assistant (HRA) stated environmental services and food services staff would not have direct contact with residents and did not have fingerprint background…

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, interview, and facility policy review, the facility failed to ensure professional standards were followed for one resident (R) (R50) of 17 sampled residents. Specifically, R50 received nonsteroidal anti-inflammatory drugs (NSAIDs) with a physician's order to avoid NSAID use. This deficient practice placed R50 at risk of adverse clinical outcomes. Findings include:Review of R50's admission Record, located in the electronic medical record (EMR) under the Profile'' tab revealed an admission date of 08/05/2024. Further review revealed that R50's diagnoses included, but were not limited to chronic obstructive pulmonary disease, type 2 diabetes mellitus and chronic kidney disease.Review of R50's EMR under the ''Orders'' tab revealed a physician order dated 03/19/2025 that documented, Avoid all NSAIDs at all times.'' R50 had a subsequent physician order dated 05/29/2025 for Ibuprofen (an NSAID) 800 milligram (mg) tablet, give one tablet by mouth every six hours as needed (PRN) for pain.Review of the Medication Administration Record (MAR) for 2025, located in the EMR…

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, interview, and review of facility policies, the facility failed to ensure staff followed standard infection control practices during wound care and Enhanced Barrier Precautions (EBP) for two of seventeen residents (R) (R9 and R12) reviewed for infection control practices. These deficient practices have the potential to place residents and staff at risk for cross-contamination and the spread of infections.Findings include:1. Review of R12's admission Record, located in the electronic medical record (EMR) under the Profile'' tab, revealed R12 was initially admitted to the facility on [DATE] with diagnoses that included, but were not limited to, colostomy status, type 2 diabetes mellitus, and overactive bladder.Review of R12's Physician Orders dated 02/05/2024, documented an order for Colostomy care.''Review of R12's Care Plan revised 8/5/2025 revealed R12 was placed on Enhanced Barrier Precautions (EBP).Observation on 01/07/2026 at 9:15 AM revealed a yellow magnet posted on R12's door frame,…

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 interview, review of facility documentation, and review of the facility's policy titled, Antibiotic Stewardship, the facility failed to develop an effective Antibiotic Stewardship Program (ASP) to monitor antibiotic use. Specifically, the facility failed to ensure that residents were not prescribed an antibiotic, or were not administered an antibiotic(s), without diagnostic testing that identified an organism and documented symptomology to support the continued use of an antibiotic. This deficient practice has the potential to affect all residents in the facility. Facility census was 54 residents. Findings include: Review of the facility's policy titled Antibiotic Stewardship dated 9/2022 indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program/QAPI (Quality Assurance and Performance Improvement) Committee .Antibiotic usage and outcome data will be collected, documented, and any trends will be reported to the QAPI committee. Review of the facility's ASP, since the last recertification survey…

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 titled, Transfer or Discharge documentation, the facility failed to ensure a written transfer/discharge notice with required content was provided prior to being transferred for three residents (R), R32, R1, R8, and the resident representatives (RR). In addition, the facility failed to provide the State LTC (Long Term Care) Ombudsman office with notification of residents who transferred or discharged . The deficient practice had the potential for residents to be inappropriately transferred or discharged by not being informed of their rights and appeal options. The sample size was 22 residents. Findings include: Review of the facility's policy titled, Transfer or Discharge documentation dated 10/2022 revealed, .4 .when a resident is transferred .from the facility, the following information will be documented in the medical record .b. That an appropriate notice was provided to the resident and /or legal representative . 1. Review of R32'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 interview, record review, and review of the facility's policy titled, Antipsychotic Medication Use, the facility failed to implement a care plan for monitoring the use of psychotropic medications for two of two residents (R) R154 and R31 reviewed for psychotropic medications. This failure could result in unwarranted use of psychotropic medications and unmanaged medication side effects. The sample size was 22 residents. Findings include: Review of the facility's policy titled, Antipsychotic Medication Use, dated 8/2022, revealed, .The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others .based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication . 1. Review of R154's undated Face Sheet located under the Profile tab in the electronic [NAME] record (EMR)…

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 interview and record review, the facility failed to document discharge needs and assessment of a resident being discharged home for one of three residents (R) R44 out of 22 sampled residents. The result of this failure was incomplete documentation and communication among staff in the discharge process of R44. Findings include: Review of R44's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R44 was admitted to the facility on [DATE] with the diagnosis of fracture of unspecified part of the right femur with subsequent encounter for closed fracture with routine healing. Review of R44's admission Minimum Data Set (MDS), revealed R44 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This represented R44 was cognitively intact. Review of R44's Progress Notes revealed no documentation of the discharge needs or assessment of R44 when discharged home. There was also no date in the progress notes as to the date R44 was discharged home.…

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 interview, record review, review of the dialysis contract, and review of the facility's policy titled, End-Stage Renal Disease, Care of the Resident with, the facility failed to completely document care of a dialysis resident and failed to collaborate with the dialysis center for one of one resident (R) R9 out of 22 sampled residents. This failure resulted in a lack of documentation in the medical record and communication of all staff involved in the care of R9. Findings include: Review of the facility's policy End-Stage Renal Disease, Care of the Resident with dated 9/2010 revealed, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . Review of the dialysis contract dated 5/15/2024 stated, . Provider shall document all Dialysis Services, Related Services, (as defined below) and all other information that should be documented in accordance with standard Clinical documentation practices. At a minimum such documentation must include…

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, interview, and review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, the facility failed to ensure that the daily nurse staffing was posted to accurately reflect the actual staff hours to care for the 54 residents. This failure had the potential to inaccurately inform any resident, family member, or visitor of the available nursing staff caring for residents. The sample size was 22 residents. Findings include: Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers dated 10/2022 indicated, Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents .1. Within two hours of the beginning of each shift, the number of licensed nurses .and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location .3. Shift staff information shall be recorded .g. The actual time worked during that shift for each category and type of nursing staff . Observation on 8/11/2024 at 7:54…

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, Change in a Resident's Condition or Status the facility failed to notify the responsible party and the physician of a change in condition for two residents (R) R#4 and R#9) of 16 residents reviewed. Findings include: 1.Review of the facility policy titled Change in a Resident's Condition or Status revised 2/2021, revealed: Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a: d. Significant change in the resident's physical/emotional/mental condition. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. There is a significant change in the resident's physical/emotional/mental condition. Review of R#4's diagnoses revealed but not limited to monoplegia of upper limb following cerebral infarction affecting the left side, cyst on pancreas, anxiety, cognitive impairment, major depression…

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 document the duration of therapy for one resident (R) R#57) that had an order for PRN [as needed] antianxiety medication beyond 14 days of five residents reviewed for unnecessary medications. Findings include: Review of medical record for R#57 revealed an admission date of 7/27/22 with diagnoses that included but not limited to generalized anxiety, dementia with behavioral disturbances, and major depressive disorder. Review of R#57's admission Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: brief interview of mental status (BIMS) score of 12 indicating minimum cognitive deficit; Section D-Mood: mood score of five (5), Section E-Behavior: no behaviors; and Section N-Medications: antianxiety and antidepressant use. Review of R#57's Physician's orders revealed (partial list): lorazepam tablet one (1) milligram (MG) give 1 tablet by mouth (PO) every 12 hours PRN for anxiety with an order start date of 7/27/22. An interview held 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 observations, interviews, and review of policy titled, Hand Hygiene, the facility failed to implement consistent infection control practices during medication administration for four residents (R) R#58, R#10, R#24, and R#26). This omission had the potential to affect any resident receiving medications at the facility. The census was 53. Findings Include: Review of policy titled Hand Hygiene (dated [DATE]) revealed Policy interpretation and Implementation 1. All personnel shall follow our established handwashing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. 2. Associates must perform appropriate handwashing procedures under the following conditions: a. When coming on duty; d. Before preparing or handling medications; g. After contact with blood, body fluids, excretions, secretions, mucous membranes or non-intact skin; and j. After removing gloves. Observation during medication administration with Licensed Practical Nurse (LPN) HH on 8/17/22…

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.