Inspection Reports for
George Regional Health & Rehabilitation Center

M500 - Residents' rights. The facility failed to resolve and provide follow-up regarding grievances brought forward by the Resident Council related to food quality and cleanliness of resident rooms for six of twelve months reviewed.

M815 - Safe food handling procedures. The facility failed to ensure opened food items were properly covered, labeled, dated, and discarded, and failed to remove moldy and deteriorated fresh produce from refrigerated storage, risking all residents served by the dietary department.

F0812 - The facility failed to procure, store, and maintain food under sanitary conditions by not properly covering, labeling, dating, and discarding opened food items and by failing to remove moldy and deteriorated fresh produce from refrigerated storage, potentially affecting all residents receiving dietary food.

F0565 - The facility failed to resolve and provide follow-up regarding grievances brought forward by the Resident Council related to food quality and cleanliness of resident rooms for six months of Resident Council meetings reviewed.

F0641 - The facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected Resident #24's nutritional status by coding the resident as receiving tube feeding when the resident had no feeding tube, did not receive enteral nutrition during the assessment period, and had an active physician order for a regular diet.

F0644 - The facility failed to ensure PASRR Level I screenings were completed accurately and residents received appropriate referral for PASRR Level II evaluation for Residents #2 and #8.

F0656 - The facility failed to develop and implement individualized comprehensive care plan interventions addressing assessed needs and physician-prescribed treatment regimens for Residents #6, #7, and #55, including pain management, call light accessibility, and monitoring for medication side effects.

F0689 - The facility failed to ensure Resident #7's call light was maintained within reach consistent with the resident's assessed fall risk and care plan interventions, placing the call light out of reach for multiple days.

F0695 - The facility failed to ensure required oxygen cautionary signage was posted for Resident #12 receiving oxygen therapy.

F0757 - The facility failed to ensure residents receiving psychotropic and high-risk medications, including anticoagulants, were monitored for potential adverse consequences in accordance with professional standards and facility policy for Residents #7 and #55.

M500 - Residents' rights were violated when personal care signage containing confidential information was posted on the walls of Resident #10 and Resident #29's rooms, compromising their privacy and dignity.

M1570 - The facility failed to prevent possible infection spread by not following manufacturer guidelines for cleaning and disinfecting the glucometer used for Resident #95's blood glucose monitoring.

F0583 - Personal Privacy/Confidentiality of Records. The facility failed to maintain residents' privacy and confidentiality by posting personal care signage on walls in Resident #10 and Resident #29's rooms for multiple days.

F0732 - Posted Nurse Staffing Information. The facility failed to post daily nurse staffing information in a visible and accessible location for two of three survey days.

F0759 - Free of Medication Error Rates 5 Percent or More. The facility failed to maintain a medication error rate below 5%, with a 12.9% error rate due to improper administration of medications via PEG tube for Resident #11.

F0760 - Residents are Free of Significant Medication Errors. The facility failed to ensure medications were administered according to professional standards by crushing and combining all medications into a single dose for administration via PEG tube without individualized assessments for Resident #11.

F0880 - Infection Prevention & Control. The facility failed to prevent possible infection spread by not following manufacturer guidelines for cleaning and disinfecting the glucometer for Resident #95.

F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.

M610 - The facility failed to provide adequate activities of daily living care, specifically toenail care, for a resident dependent on staff, as evidenced by long, thick toenails that were not trimmed despite the resident's request.

M715 - The facility failed to ensure multidose insulin pens were dated when opened for six of nineteen diabetic residents, risking administration of ineffective insulin.

M815 - The facility failed to store foods safely, with observations of open, undated, unlabeled foods, and expired items not discarded, posing a potential hazard to residents.

F0623 - Notice Requirements Before Transfer/Discharge. The facility failed to provide written notification of hospital transfers to the resident or their representative for three sampled residents.

F0641 - Accuracy of Assessments. The facility failed to complete the Discharge Minimum Data Set assessment for one resident discharged to home.

F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop a care plan for a resident with an indwelling catheter and failed to implement care plan interventions for medication administration and toenail care for two residents.

F0658 - Services Provided Meet Professional Standards. The facility failed to follow a physician's order to obtain a resident's pulse before administering an antihypertensive medication.

F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide toenail care for a resident dependent on staff for ADL care, resulting in long, thick toenails.

F0761 - Label/Store Drugs and Biologicals. The facility failed to ensure multidose insulin pens were dated when opened for six diabetic residents.

F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to store foods safely as evidenced by open and exposed foods, undated/unlabeled foods without use-by dates, and food stored past expiration dates.

F0867 - QAPI/QAA Improvement Activities. The facility failed to sustain an effective QAPI program, as evidenced by repeated deficiencies related to comprehensive care plans from a previous survey.

F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.

M640 - Accidents. The facility failed to ensure a vulnerable resident was protected from accidents and hazards when a Temporary Nursing Assistant provided incontinent care without assistance, causing Resident #31 to fall and sustain bilateral femur fractures. The facility also failed to remove the responsible staff promptly and did not protect residents from rodents, with mice observed in resident rooms and droppings found under beds and in drawers.

M970 - Control of insects, rodents, etc. The facility failed to maintain effective pest control measures to prevent mice infestation, as evidenced by mouse droppings and sightings in seven of sixteen resident rooms on the 300 hall, including Resident #31 who had a possible mouse bite resulting in lesions on her left great toe.

M500 - Resident Rights. The facility failed to protect Resident #31's rights by neglecting to provide adequate supervision and assistance during care, resulting in a fall with major injury.

F0600 - Freedom from abuse and neglect. The facility failed to ensure a resident was protected from neglect when a Temporary Nursing Assistant (TNA) provided incontinent care without required assistance, resulting in a fall with bilateral femur fractures. The facility also failed to remove the TNA from the facility immediately following the incident, placing residents at risk of further harm.

F0610 - Investigation of alleged violations. The facility failed to thoroughly investigate and prevent further potential abuse and neglect by not immediately suspending the Temporary Nursing Assistant (TNA) following the incident that caused a resident fall with major injury. The TNA was allowed to work for two days after the incident.

F0656 - Comprehensive care plan. The facility failed to follow the comprehensive care plan for one resident who required two-person assistance for Activities of Daily Living (ADLs). The Temporary Nursing Assistant (TNA) provided incontinent care without the required assistance, resulting in a fall with major injury.

F0689 - Free of accident hazards and adequate supervision. The facility failed to protect residents from accident hazards by allowing a Temporary Nursing Assistant (TNA) to provide care without required assistance, resulting in a resident fall with bilateral femur fractures. The facility also failed to maintain a safe environment free from rodents, as evidenced by mouse sightings in resident rooms, mouse droppings under beds and in furniture, and a resident sustaining a possible mouse bite.

K0353 - The facility failed to meet the standard for inspection, testing, and maintenance of the fire sprinkler system as required by NFPA 25, section 5.2.1, by not providing documentation of the annual and quarterly sprinkler system tests for 2021.

M500 - Residents' rights policies and procedures were not followed as evidenced by failure to provide privacy during medication administration for one resident.

M610 - The facility failed to provide nail care to prevent potential skin breakdown and/or infection for one resident.

F0583 - Personal privacy/confidentiality of records. The facility failed to provide privacy during medication administration for one of six residents observed.

F0623 - Notice requirements before transfer/discharge. The facility failed to notify the resident and/or Resident Representative in writing of transfers to the hospital for two residents reviewed.

F0625 - Notice of bed hold policy before/upon transfer. The facility failed to provide written notice of the bed hold policy upon transfer for two residents reviewed for hospitalization.

F0656 - Develop/implement comprehensive care plan. The facility failed to implement the care plan for nail care for one resident.

F0677 - ADL care provided for dependent residents. The facility failed to provide nail care to prevent potential skin breakdown and/or infection for one resident.

F0732 - Posted nurse staffing information. The facility failed to post required nurse staffing information correctly for three days of survey.

F0812 - Food procurement, store/prepare/serve-sanitary. The facility failed to ensure kitchen equipment was cleaned properly to prevent food borne illness.