Inspection Reports for Brown’s Health & Rehab Center

This document is a Statement of Deficiencies and Plan of Correction for Brown's Health & Rehab Center following a survey completed on December 26, 2024.

The report contains initial comments but does not specify any detailed deficiencies or findings.

A revisit survey was conducted to verify correction of deficiencies cited during the November 7, 2024, Recertification Survey.

All deficiencies cited in the prior Recertification Survey were found to be corrected during this revisit survey.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

All previously cited survey tags have been corrected as noted by the surveyor.

A State Licensure survey was conducted at Brown's Health & Rehab Center from November 4, 2024, through November 7, 2024, to assess compliance with state health regulations.

The survey identified deficiencies including failure to provide written transfer notices to residents or their representatives, failure to provide written notice of bed hold policy at transfer, and failure to develop and implement a care plan for a resident who smoked.

A standard survey was conducted from November 5 through November 7, 2024, including investigation of Complaint Intake GA00249784, which was unsubstantiated.

The facility was found not substantially compliant with Medicare/Medicaid regulations, with deficiencies including failure to provide written information about the right to accept or refuse medical or surgical treatment to residents, failure to provide written notice of transfer and bed hold policy to a resident transferred to the hospital, and failure to develop a care plan for a resident who smoked.

Complaint Intake GA00249784 was investigated in conjunction with the standard survey and was unsubstantiated.

The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition requirements.

The facility was found not in substantial compliance with life safety requirements, with multiple deficiencies noted including blocked exit doors, smoke doors failing to latch, corroded sprinkler heads, unsealed smoke wall penetrations, and power strips placed on the floor. These issues affected various smoke compartments and could impact resident safety.

A revisit survey was conducted to verify correction of deficiencies cited in the prior survey dated 2024-04-11.

All deficiencies cited in the previous survey were found to be corrected during this revisit survey.

An abbreviated/partial extended survey was conducted to investigate complaint number GA00244586 regarding medication administration errors that caused harm to two residents.

The facility failed to follow physician orders for administering pain medication to two residents, resulting in both becoming lethargic and hard to arouse, requiring emergency treatment with Narcan and hospital transfer. One resident was admitted to the hospital and did not return, while the other returned to the facility after evaluation.

Complaint number GA00244586 was substantiated. Actual harm occurred when pain medication with sedative effects was administered improperly to residents R1 and R2 on 3/6/2024, causing lethargy and requiring Narcan treatment and hospital transfer. LPN AA was identified as responsible, suspended, and terminated. The incident was reported to the State Agency and Nursing Board.

A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey to investigate complaints #GA00233903, #GA00230637, and #GA00228678.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS/CDC recommended COVID-19 practices. Complaints #GA00230637 and #GA00233903 were unsubstantiated, while complaint #GA00228678 was substantiated. No regulatory violations were cited.

Complaints #GA00230637 and #GA00233903 were unsubstantiated. Complaint #GA00228678 was substantiated.

A revisit survey was conducted to verify correction of deficiencies cited during the prior survey conducted from 7/15/22 through 7/17/22.

All deficiencies cited as a result of the 7/15/22 through 7/17/22 survey were found to be corrected during the revisit survey on 9/15/22.

A revisit survey was conducted to verify correction of deficiencies cited during the 7/15/22 through 7/17/22 Recertification Survey.

All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.

The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period as required by regulation, which has the potential to cause more than minimal harm to all residents.

A Licensure Survey was conducted from 7/15/22 through 7/17/22 to assess compliance with licensure requirements.

The facility was found deficient in infection control practices related to hand hygiene and glucometer sanitation during resident care, and in maintaining the physical environment with multiple areas of chipped and peeling paint in residents' rooms and hallways.

A standard survey was conducted at Brown's Health and Rehab Center from July 15, 2022 through July 17, 2022 to assess compliance with Medicare/Medicaid regulations for long term care facilities.

The facility was found not in substantial compliance with multiple regulatory requirements including maintenance of a safe and homelike environment, care plan timing and revision, accident hazard prevention, respiratory care, and infection control practices. Deficiencies included chipped/peeling paint in resident areas, failure to revise care plans after falls, inadequate fall prevention interventions, improper oxygen equipment maintenance, and lapses in infection control during wound care and glucometer use.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found to be in compliance with the Life Safety Code requirements and the Emergency Preparedness Program met regulatory standards.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00220138 and #GA00221267.

The complaints #GA00220138 and #GA00221267 were unsubstantiated and no regulatory violations were cited.

Complaints #GA00220138 and #GA00221267 were investigated and found to be unsubstantiated.

The document is a statement of deficiencies and plan of correction for Brown's Health & Rehab Center, indicating a regulatory inspection was conducted.

The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed on the page provided.

A revisit survey was conducted to verify correction of deficiencies cited during the 6/29/2021 Complaint Survey.

All deficiencies cited as a result of the 6/29/2021 Complaint Survey were found to be corrected.

The visit was a follow-up to a complaint survey conducted on 6/29/2021; all cited deficiencies were corrected.

The inspection was conducted as a Licensure Survey to assess compliance for renewal of the facility's license.

No deficiencies were identified during the Licensure Survey conducted from 6/28/2021 through 6/29/2021.

An abbreviated/partial extended survey was conducted to investigate complaints GA00215054, GA00215494, and GA00215310. Two complaints were unsubstantiated, and one complaint was substantiated.

The facility failed to ensure that residents were allowed to receive visitors on weekends for two of three residents reviewed, contrary to CMS visitation guidance. The facility restricted visitation on weekends due to limited staff availability despite low county COVID-19 positivity rates and a high resident vaccination rate.

Complaint GA00215310 was substantiated; complaints GA00215054 and GA00215494 were unsubstantiated.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00211539.

The complaint #GA00211539 was substantiated with no regulatory violations found.

Complaint #GA00211539 was substantiated with no regulatory violations.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00208884.

The complaint #GA00208884 was unsubstantiated with no regulatory violations found during the survey.

Complaint #GA00208884 was investigated and found to be unsubstantiated with no regulatory violations.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and recommended practices related to COVID-19 preparedness and infection control.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00207838.

The complaint #GA00207838 was substantiated, but no deficiencies were identified during the investigation.

Complaint #GA00207838 was substantiated with no deficiencies found.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.

The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented recommended practices to prepare for COVID-19.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected during this follow-up visit.

A follow-up to the Recertification survey of May 8, 2019 was conducted to verify correction of previously identified deficiencies.

The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of June 22, 2019.

A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and related NFPA standards at Brown's Health & Rehab Center.

The facility was found not in substantial compliance with NFPA 101 Life Safety Code and related standards due to deficiencies including lack of sprinkler coverage beneath exterior porches, obstructed corridor doors, smoke compartment doors not closing fully, failure to conduct annual fire door inspections, and improper oxygen cylinder storage.

A complaint survey was conducted on 10/22/2018 and 10/23/2018 to investigate complaints #GA 00191947 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

Complaint investigation for complaints #GA 00191947; no deficiencies were found.

A follow-up to the Recertification survey of May 2, 2018 was conducted to verify correction of previously identified deficiencies.

The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of June 16, 2018.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.

The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found not in substantial compliance with emergency preparedness and life safety requirements, including failure to update the Emergency Preparedness Plan since 2014, lack of a required risk assessment, smoke barriers not constructed to required fire resistance standards, and failure to conduct and document required fire drills.

An abbreviated/partial extended survey was conducted to investigate complaint GA00180804.

The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.

Complaint GA00180804 was investigated and found to be unsubstantiated.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00176670 and GA00177086.

The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was substantiated but no deficiencies were cited.

The complaint was substantiated but no deficiencies were cited.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.

A follow-up visit was conducted to verify correction of deficiencies identified in the prior recertification survey.

The deficiencies identified in the prior recertification survey had been corrected at the time of this follow-up visit.

The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.

The facility was found not in substantial compliance due to failure to ensure the fire alarm system was inspected, tested, and properly maintained according to NFPA 72 standards. Specifically, the sensitivity test for the smoke detectors had not been completed.