George Regional Health & Rehab Center

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents' rights to privacy and confidentiality were maintained when personal care signage was posted on the wall for two (2) of three (3) survey days. Resident #10 and Resident #29. Findings Included: A review of the facility's policy, Promoting/Maintaining Resident Dignity, dated 10/10/24, revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .Compliance Guidelines: . 12. Maintain resident privacy . A review of the facility's policy, Resident Rights, dated 2/10/25, revealed, . The facility will inform the resident .of his or her rights and all the regulations governing resident conduct and responsibilities during the stay in the facility . Resident rights. The resident has the right to a dignified existence, self-determination . 7. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes…

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 facility policy review, the facility failed to ensure a medication error rate of less than five percent (5%) for four (4) of thirty-one (31) observed medication opportunities, resulting in a medication error rate of 12.9%. Findings included: A review of the facility's policy titled, Medication Administration, revised 2/1/25, revealed, .Medications are administered .in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .17. Administer medications as ordered in accordance with manufacturer specifications .c .Do no crush medications with 'do not crush' instruction .Example guidelines for Medication Administration (unless otherwise ordered by physician) .Do Not Crush Medications: Crushed meds are not to be combined and given all at once, if via feeding tube . A review of the facility's policy titled, Medication Administration via Enteral Tube, revised 1/20/25, revealed, It is the policy of this facility to ensure 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, interview, record review, and policy review, the facility failed to ensure medications were administered according to professional standards of practice by crushing and combining all medications into a single dose for administration via Percutaneous Endoscopic Gastrostomy (PEG) tube, without providing a rational for combining the medication or individualized resident needs, for one (1) of three (3) residents reviewed with feeding tubes. (Residents #11). Cross Reference F759 Findings included: A review of the facility's policy titled, Medication Administration, revised 2/1/25, revealed, .Medications are administered .in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .17. Administer medications as ordered in accordance with manufacturer specifications .c .Do no crush medications with 'do not crush' instruction .Example guidelines for Medication Administration (unless otherwise ordered by physician) .Do Not Crush Medications: Crushed meds are…

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, record review, and facility policy review, the facility failed to prevent the possible spread of infection by not following manufacturer guidelines for cleaning and disinfecting the glucometer for one (1) of two (2) residents observed for blood glucose monitoring, Resident #95. Findings include: A review of the facility's policy, Blood Glucose Monitoring, dated 2/15/25, revealed, It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders . Policy Explanation and Guidelines . 2. The nurse will perform the blood glucose test utilizing the facility's glucometer as per manufacturer's instruction. 3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. 4. If possible, glucometers should not be shared between residents, but if this is not possible, the nurse is responsible for cleaning and disinfection of the machine between residents…

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, and facility policy review, the facility failed to store foods safely as evidenced by food left open and exposed on shelves, undated/unlabeled foods without a use-by -date, food stored without an identifying label, and not discarding food items after their use-by or sell-by date for one (1) of two (2) kitchen observations. Findings Include: A review of the facility's policy titled, Food and Supply Storage, review date 08/2021, revealed, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Most products contain an expiration date. The words sell-by or use-by should precede the date . The sell-by, best-by or use-by date is the last date that a food can be consumed . Foods past the use-by, sell-by, best-by, or enjoy-by date should be discarded .Cover, label and date unused portions and open packages . On 12/18/23 at 10:44 AM, an initial tour of the kitchen with the Dietary Manager 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 staff interview, record review, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to correct a quality deficiency from a previous survey for one (1) re-cited deficiency of five (5) cited deficiencies from a previous annual recertification survey in October 2021. The deficiency was related to initiating and implementing care plans. The facility's continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee. Findings Include: Record Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Program revised August 2017, revealed, .The facility shall .maintain an ongoing, facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems .Policy Interpretation and Implementation The objectives of the QAPI Plan are to .5. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans 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 facility policy review, the facility failed to complete the Discharge Minimum Data Set (MDS) assessments for one (1) of 16 residents sampled. Resident # 6 Findings Include: A review of the facility's policy titled, MDS 3.0 Completion, reviewed/revised 10/02/23, revealed, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan . Policy Explanation and Compliance Guidelines: 2f. Discharge Assessment - completed using the discharge date as the ARD (Assessment Reference Date). Must be completed within 14 days of the discharge date /ARD . A record review of the facility's Face Sheet, revealed the facility admitted Resident #6 on 07/20/23, with diagnoses that included Essential Hypertension. A record review of the facility's Discharge Summary, for Resident #6, revealed the facility discharged the resident to home on [DATE]. A record review of the MDS, for Resident #6, revealed there 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.

Based on observation, interviews, record review, and facility policy review, the facility failed develop a comprehensive care plan for a resident (Resident #21) who had an indwelling catheter and failed to implement comprehensive care plan interventions for medication administration (Resident #21) and toenail care (Resident #34) for two (2) of 16 resident care plans reviewed. Findings Include: Review of the facility's policy Care Plans, Comprehensive Person-Centered, revised December 2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timelines to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Policy Interpretation and Implementation .8. The comprehensive, person-centered care plan will .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .13 .care plans are revised as information about the residents and the residents' conditions change . Resident #21 Record review of 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 interview, record review, and facility policy review, the facility failed to follow a physician's order to obtain a resident's pulse before administering an antihypertensive medication for one (1) of four (4) medication administration observations. Resident #21 Findings Include: Review of the facility's policy, Medication Administration, with a revision date of 2/2023, revealed Policy: Medications are administered by licensed nurses .in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .Example guidelines for Medication Administration .Medication requiring vital signs prior to administration .Anti-Hypertensives . On 12/18/23 at 4:24 PM, in an observation of medication administration, Licensed Practical Nurse (LPN) #2 administered Metoprolol Tartrate and did not obtain the resident's pulse prior to administering the medication. Record…

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, interviews, record review, and the facility policy review, the facility failed to provide Activities of Daily Living (ADL) care for a resident who was dependent upon staff for toenail care for one (1) of two (2) residents reviewed for ADL care. Resident #34 Findings include: Review of the facility's policy Activities of Daily Living (ADLs), Supporting, revised 1/12/2021, revealed Policy Statement . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .Policy Interpretation and Implementation .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including appropriate support with: a. Hygiene (bathing, dressing, grooming) . Review of the facility's policy Fingernails/Toenails, Care of, revised 02/2018, revealed .Purpose: The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . General Guidelines 1. Nail care includes daily…

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 interview, record review, and facility policy review the failed to ensure multidose insulin pens were dated when opened for six (6) of 19 diabetic residents who are prescribed multidose insulin pens. Findings Include: Review of the facility's policy, Labeling of Medication Containers, revised 4/2007, revealed, Policy Statement .All medications maintained in the facility shall be properly labeled in accordance with the current state and federal regulations .Policy Interpretation and Implementation .3. Labels for individual drug containers shall include all necessary information, such as .h. The expiration date when applicable; . On 12/18/23 at 3:30 PM, an observation of the 600 Hall medication cart, with Licensed Practical Nurse #2 (LPN), revealed an opened NovoLog FlexPen pre-filled multi-dose insulin pen with no date indicating when the pen was opened. LPN #2 confirmed there was no date on the multi-dose pen or the box the pen was stored in. LPN #2 stated that all insulin pens should have a date written on the pen or box indicating the date it 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.