Rehabilitation Center of South Georgia

Based on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition Policy and Procedures, the facility failed to implement their abuse policy related to employee screening. The facility failed to ensure references were checked prior to employment for three of ten employees whose employee files were reviewed. Findings include: Review of the facility's policy titled, Abuse Prohibition Policy and Procedures, dated January 2017, revealed The facility will conduct a thorough investigation of the histories of individuals being considered for hire, in addition to the inquiry of the State Nurse Aide Registry or licensing authorities. All reasonable efforts will be made to check references and information from previous and/or current employers to uncover information about any criminal prosecutions. Review of documents provided by the facility, referred to as the employee file, for the Administrator indicated the date of hire was 10/19/2023 and the file failed to include reference checks for employment. Review of documents provided by the facility, referred…

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, Abuse Investigation the facility failed to ensure thorough investigations were conducted of resident-to-resident incidents for four of 25 residents (Residents (R) 60, R55 R90, and R68) reviewed for abuse. This lack of investigation had the potential to place other dependent residents at risk for abuse/neglect. Findings include: Review of the facility's policy titled, Abuse Investigation dated 2008, indicated .All reports of resident abuse, neglect, misappropriation of resident property, and injuries of an unknown source shall be promptly and thoroughly investigated .An interview with the person(s) reporting the incident .Interviews with any witnesses to the incident .Witness reports shall be reduced to writing. Witnesses will be required to sign and date such reports. These reports will be sent in with other investigation information . 1. Review of R60's electronic medical records (EMR) admission Record indicated the resident was…

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's policy titled, Discharging the Resident, the facility failed to provide the receiving facility with documentation regarding the transfer for one of five resident (R) (R86) reviewed for hospitalization. This failure had the potential to affect the care provided by the receiving facility by not informing them of the resident's medical needs or the residents wishes for ongoing care. Findings include: Review of the facility's policy titled, Discharging the Resident, dated 1/18/2023, under the Policy Statement revealed, The purpose of this procedure is to provide guidelines for the discharge process. Under the section titled, Policy Interpretation and Implementation revealed, . 6. If the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed, and telephone report is called to the receiving facility . Review of R86's undated admission Record located in the Electronic Medical Record (EMR) under…

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's policy titled, Notice of Transfer/Discharge, the facility failed to notify the resident and/or resident's responsible party and the Ombudsman of a transfer or discharge in writing for one of five resident (R) (R86) reviewed for hospitalization. This created a potential for the resident or their representative to have incomplete information, misunderstand the reason, and process for transfer or discharge, and the discharge appeal process. Findings include: Review of the facility's policy titled, Notice of Transfer/Discharge, dated March 2017, under the Policy Statement revealed, It is the intent of this facility to ensure an orderly transfer and/or discharge to another living environment in the event it is the choice or best interest of the resident. Under the section titled, Policy Interpretation and Implementation revealed, Immediate Transfer/discharge: 1. Notice of Transfer and Discharge will be made as soon as practicable when .f. An…

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 policy titled, Bed Hold Policy, the facility failed to ensure one of five residents (R) R86 reviewed for hospital transfers was given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for the resident and/or responsible parties to not have the information needed to safeguard their return to the facility. Findings include: Review of the facility's policy titled, Bed Hold Policy, dated 1/19/2022 revealed, Policy Statement: Our facility informs residents of our bed-hold policy upon admission and prior to a transfer for hospitalization or therapeutic leave. Policy Interpretation and Implementation: 1. Information concerning our bed-hold policy is found in the body of the admission agreement and is provided to the resident and/or resident representative upon admission to the facility. 2. At the time a resident is transferred to the hospital or going on therapeutic…

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, interview, record review, and review of the facility's policy titled, Fall Management, the facility failed to ensure an accident prevention measure (bed in lowest position and/or fall mat in place) was implemented for two of five residents (R) R43 and R84. This failure had the potential to cause harm if the residents fell from their bed and the proper fall interventions were not in place. Findings include: Review of the facility's policy titled, Fall Management, dated 5/17/2017, revealed .staff will provide a safe environment for all residents .The facility will assess residents for fall risk, will evaluate each resident individually and provide, to the best of the facility's ability, interventions to decrease the likelihood of falls . 1. Review of R43's electronic medical record (EMR) admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of other paralytic syndrome following a cerebral infarction (stroke). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and review of the facility policy titled, Medication Ordering and Receiving from Pharmacy, the facility failed to have a physician ordered medication available for administration for one of seven residents (Resident (R) 9) during the medication administration observation. This failure had the potential to decrease the effectiveness of the medication rivastigmine (Exelon) patch which was used for dementia. Findings include: Review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, dated 5/1/2020, revealed .Reorder medication four to five days in advance of need .to assure an adequate supply is on hand .The refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy . Review of R9's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed R9 was originally admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with the diagnoses…

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, and review of the facility policy titled, Consultant Pharmacist Reports, the facility failed to ensure pharmacy medication regimen reviews (MRR's) included appropriately monitored medication regimens to include antibiotic usage and ensure that medications received were clinically indicated for one of six residents (Resident (R) 63) reviewed for medication regimens. The failure had the potential to affect resident safety related to antibiotic use. Findings include: Review of the facility's policy titled, Consultant Pharmacist Reports, dated 5/1/2007, revealed The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing 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.

Based on observation, staff interviews, record review, and review of the facility policies titled, Crushing Medications, and Administrating Oral Medications, the facility failed to ensure a medication error rate below five percent. During medication administration two medication errors for one resident (Residents (R) 77) were made of 27 opportunities during medication administration resulting in a medication error rate of 7.41 percent. These failures had the potential to increase or decrease the effectiveness of these medications. Findings include: Review of the facility's policy titled, Crushing Medications, dated 3/22/2017, revealed Medications shall be crushed only when it is appropriate to do so . Review of the facility's policy titled, Administrating Oral Medications, dated 3/22/2017, revealed .Check the label on the medication and confirm the medication name and dose with the eMAR [Electronic Medication Administration Record]. Review of R77's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed R77 was admitted to the facility 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 observation, interviews, record review, and review of the facility's policy titled, Medication Administration-General Guidelines, the facility failed to ensure one of six medication carts were locked and a cup of medications was not readily accessible while left unattended with the potential to affect one of two residents (R) R79. This failure had the potential for R79 to have access to medications that were not prescribed for him that could lead to adverse side effects. Findings include: Review of the pharmacy policy titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, dated 5/1/2020 revealed .During administration of medications, the medication cart is kept closed and locked when out of sight if the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward side must be inaccessible to residents or others passing by . Review of R79's undated Face Sheet located in the EMR under the Profile tab,…

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, record review, and review of the facility's policies titled, Handwashing/Hand Hygiene, Dressing Change, Contact Precautions, and Administering Oral Medications, the facility failed to use proper infection control guidelines for a dressing change, during medication pass, and for contact isolation for three of three residents (R) R8, R75, and R77 reviewed for infection control. This failure had the potential for the spread of infections. Findings include: Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 11/5/2018 indicated, This facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall be trained and have regular in-services on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .Use an alcohol-based hand rub or soap and water before and after direct contact with residents .before moving from a contaminated body site to a clean body site during resident care . after…

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, and review of the facility policy titled, Antibiotic Stewardship Program Overview, the facility failed to monitor, evaluate antibiotic use, and track measures of antibiotic usage for one of three residents (Resident (R) 63) reviewed for antibiotic usage. This failure had the potential to affect resident safety related to antibiotic usage. Findings include: Review of an undated, untitled CDC [Centers for Disease Control and Prevention] document located at http://uprevent.[NAME].com/2855wp/wp-content/uploads/2018/01/nh-hac_mcgreercriteriarevcomp_2012-1.pdf; revealed The Core Elements of Antibiotic Stewardship for Nursing Homes indicated .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority .Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use' .CDC also recommends…

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 interview, and record review the facility failed to ensure that the facility's Social Service Director had the proper qualifications for a facility with over one-hundred and twenty (120) beds. Findings include: Review of the facility's licensure revealed that the facility is licensed for one hundred and seventy-eight beds. Review of the personnel file for the Social Service Director (SSD) revealed she was promoted to the position on 11/3/2023. Further review of the record the current SSD had an Associate of Arts degree with concentration in elementary education and a Certificate of Completion for Social Worker 4-Day Virtual Training Course from Georgia Health Care Association. Interview on 4/23/2024 at 3:45 PM with the Administrator, she stated the SSD was hired prior to her coming to the facility and had expressed concern to corporate regarding the SSD not having a Bachelor's degree but was told not worry about it since the SSD was currently in school working towards her Bachelor's Degree in Social Work. Interview on 4/24/2024 at 4:30 PM with the SSD, she stated she…

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 review of video surveillance, record review, staff interviews, and review of the facility policy titled, Abuse Prohibition Policy and Procedure, the facility failed to ensure residents on the Memory Care Unit, which contained 15 resident rooms, were free from involuntary seclusion when Certified Nursing Assistant (CNA) CC placed bath linens on top of resident room doors to keep residents from opening their doors. The total sample was 14 residents. Findings include: Review of the facility policy titled, Abuse Prohibition Policy and Procedures dated January 2017 defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. It also defined involuntary seclusion as separation of a resident from other residents or from his or her room or confinement to his or her (with or without roommates) against the resident's will, or the will of the resident's legal representative. The policy also indicated it will be the responsibility of any department head receiving the complaint of alleged…

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 interview, and review of the facility policy titled, Disposal of Medications and Medication-Related Supplies, the facility failed to ensure fentanyl patches were destroyed in the presence of two licensed nurses and documented on the Certificate of Inventory and Destruction for Reverse Distribution form for one resident (R) (R#9). The total sample was 14. Findings include: Review of the facility policy titled, Disposal of Medications and Medication-Related Supplies dated 12/14/2022 indicated the following procedure: If the used medication patch is a controlled substance, e.g., fentanyl patch, the patch should be immediately folded over against itself so that the adhesive sides adhere to each other when it is removed from the resident's skin. The used patch should be destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record/book on the back in the Waste/Disposal table. R#9 had a physician's order since 7/25/2023 for a Fentanyl patch 75 micrograms/Hour apply one patch trans dermally every 72 hours 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, staff interviews, and review of the facility policy titled, Care of Facility Property, the facility failed to ensure that the feeding pumps for three (3) of four (4) residents (R) (R#2, R#5, and R#26) who received nutrition through a gastrostomy tube (tube inserted into the stomach) were clean and sanitary. The facility also failed to ensure that the facility was maintained in a clean and sanitary condition related to scuffed walls in rooms [ROOM NUMBER] and dirty air vents outside of rooms [ROOM NUMBERS]. Specifically, the facility failed to ensure that the feeding pumps for R#2, R#5, and R#26 were clean and sanitized to prevent build-up of dirt and debris and to ensure that the air vents were free of dust and debris in the residents' living area. Findings include: 1.Review of the facility undated policy titled, Care of Facility Property Under Policy Interpretation and Implementation revealed: 9. All equipment used during the course of a shift must be cleaned and disinfected prior to…

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 interviews, the facility failed to apply for a Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of two residents (R) #87 that had a positive level I PASRR for mental illness. Specifically, R#87 had diagnosis of Bipolar and Major Depressive order prior to and on admission to the facility that was not addressed. Findings include: Record review for R#87 revealed an approved DMA-6 (Physician's Recommendation Concerning Nursing Facility Care or Intermediate Care for Mentally Retarded) from admission with a diagnosis of Bipolar. Further record review for R#87 revealed current diagnoses that include, but not limited to, Bipolar and Major Depressive Disorder. Review of physician orders revealed the resident was currently receiving lamotrigine 200 milligrams (mg) one tablet at bedtime once a day, mirtazapine 45mg tablet once a day at bedtime, Quetiapine Fumarate 50mg one tablet once a day at bedtime, Sertraline 100mg…

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 policy titled, Goals and Objectives, Care Plans the facility failed to implement plan of care for one of 35 residents (R) R#267 related to Activities of Daily Living (ADL) not receiving a Shower/Bath. Findings Include: A review of the policy titled, GOALS and Objectives, Care Plans dated 4/18/2017 under Policy Statement: Care Plans shall incorporate goals and objectives that lead to the residents highest obtainable level of independence. Policy Interpretation and Implementation 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. 5. Goals and objectives are reviewed and/or revised b. when the desired outcome has not been achieved. A review of the clinical record for R#267 revealed resident was admitted to the facility with diagnoses of but not limited to Acute Pyelonephritis, Fracture of Sacrum, Diarrhea, and Pressure ulcer sacral region. Review of care plan for R#267 dated 11/30/2022…

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, Shower/Tub Bath the facility failed to ensure that activities of daily living (ADL) were provided for one of 23 residents (R) R#267. Specifically, the facility failed to ensure that R#267 received scheduled showers and baths. Findings include: A review of the facility policy titled, Shower/Tub bath dated 3/23/2017 under Policy statement: The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Under documentation 1. Date and time of bath, 2. Name of staff who assisted, 5. If the resident refused the shower/tub bath, the reason (s) why and the intervention taken. A review of the clinical record for R#267 revealed resident was admitted to the facility with diagnoses of but not limited to Acute Pyelonephritis, Fracture of Sacrum, Diarrhea, and Pressure ulcer sacral region. A review of the Minimum Data Set (MDS) admission assessment dated [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observations, Interviews, and record review, the facility failed to ensure that respiratory equipment was properly stored when not in use to minimize the potential for respiratory infections for one of 26 Residents (R)#62 related to Continuous positive airway pressure (CPAP) masks and oxygen nasal canula (NC) were not properly stored. Findings Include: Review of the medical record for R #62 revealed resident was admitted to the facility with diagnoses that include but is not limited to Acute and chronic respiratory failure, Chronic Atrial Fibrillation, Heart Failure, and Hypertension. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed in section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Section O (Special Treatments and Programs) O0100 - Respiratory indicated resident was receiving oxygen therapy. Review of Physicians orders dated 1/18/2023 revealed ensure resident wears her CPAP every night order dated…

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.