Inspection Reports for
Rehabilitation Center of South Georgia

The facility was found not in substantial compliance with fire safety requirements, including failure to properly test and maintain the fire alarm and smoke detection systems, improper storage height within sprinkler head coverage, unsealed penetrations in firewalls, and blocked electrical panels. All deficiencies were confirmed during the survey and corrected by staff during the visit.

Complaint intake GA00241524 was substantiated with no deficiencies cited. Complaint intake GA00241783, GA00245246, and GA00245890 were unsubstantiated. Complaint intake GA00243142 was substantiated with a deficiency cited.

The survey substantiated one complaint with a deficiency cited related to the Social Service Director's qualifications for a facility licensed for over 120 beds. Other complaints were either unsubstantiated or substantiated with no deficiencies.

The survey investigated multiple complaints (GA00232589, GA00232851, GA00232945, GA00235738, GA00236245, GA00236662, GA00236802, GA00237742, GA00239322, GA00239444). Complaints GA00232589 and GA00239322 were substantiated with deficiencies related to abuse and improper medication disposal. The other complaints were unsubstantiated with no deficiencies.

The facility was found to have substantiated deficiencies related to involuntary seclusion of residents on the Memory Care Unit by a CNA who placed bath linens on top of resident room doors to keep them from opening their doors, and failure to properly destroy fentanyl patches in the presence of two licensed nurses with appropriate documentation.

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#9).

The facility failed to implement the plan of care for one resident related to activities of daily living, specifically not receiving scheduled showers and baths. Additionally, the facility failed to maintain cleanliness and sanitation of feeding pumps for three residents and failed to maintain the facility environment, including scuffed walls, stained ceiling tiles, and dusty air vents.

Complaint Intake Number GA00230277 was investigated in conjunction with the standard survey.

The facility was found not in substantial compliance with regulations, with deficiencies including unclean feeding pumps for residents with gastrostomy tubes, poor maintenance of facility environment such as scuffed walls and dusty air vents, failure to apply for Level II PASRR for a resident with mental illness, failure to implement care plans related to activities of daily living for a resident, failure to provide scheduled showers/baths, and improper storage of respiratory equipment increasing infection risk.

The facility was found not in substantial compliance with life safety requirements, including obstructions in means of egress, failure to maintain emergency lighting and exit signage, deficiencies in kitchen hood fire suppression system, ceiling continuity issues, fire alarm system installation problems, sprinkler system maintenance failures, improper electrical installations, inadequate fire drills, combustible decorations on doors, and generator maintenance deficiencies.

The survey was initiated based on multiple complaints alleging abuse, neglect, and failure to report incidents. Complaints GA00221625, GA00221707, and GA00223645 were unsubstantiated. Complaints GA00225713, GA00225845, and GA00226772 were substantiated with deficiencies and actual harm identified.

The investigation substantiated deficiencies related to failure to report an allegation of illegal drug use and abuse in a timely manner, and failure to implement timely interventions to prevent injury from bed side rails for two residents. Actual harm was identified for Resident B who sustained bruising and swelling to the head from hitting the upper assist rails on the bed.

Complaints GA00215334 and GA00215460 were substantiated, while complaints GA00215472 and GA00216957 were unsubstantiated. The substantiated complaints involved failures in abuse reporting and wound care.

The facility was found to have multiple deficiencies including failure to timely report resident-to-resident altercations and abuse allegations, failure to provide privacy and dignity during care, medication carts not properly secured, and inadequate wound care with failure to follow care plans especially on weekends. Some complaints were substantiated while others were unsubstantiated.

The survey investigated complaints GA00215334, GA00215460, GA00215472, and GA00216957. Complaints GA00215472 and GA00216957 were unsubstantiated. Complaints GA00215334 and GA00215460 were substantiated with cited deficiencies.

The facility was found deficient in multiple areas including failure to provide privacy and dignity during perineal care, failure to timely report abuse allegations, failure to develop and follow comprehensive care plans especially for wound care, failure to provide thorough perineal care, failure to provide wound care on weekends, and failure to properly secure medication carts.

The facility was found not in compliance with infection control regulations, failing to ensure staff wore proper PPE and performed hand hygiene. Eight of 16 sampled residents who refused COVID-19 testing were not placed on droplet precautions or isolated, increasing risk of infection spread.

The facility failed to transport clothing from the laundry room in a sanitary manner potentially affecting 99 of 133 residents, and failed to store personal items in a sanitary manner in three of 74 resident bathrooms. Observations included uncovered plastic containers used to transport clean clothing and unlabeled, unbagged urinals and buckets in shared bathrooms.

Complaint Intake Numbers GA00199499 and GA00194813 were investigated. Complaint GA00199499 was substantiated with deficiencies related to unsanitary conditions, failure to follow physician orders, and inadequate infection control.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsanitary conditions in hallways and resident rooms, failure to maintain wheelchairs in good repair, failure to follow physician orders for blood sugar checks and oxygen administration, inadequate protection of resident medical information, and infection control issues related to laundry transport and storage of personal items.

The facility was found not in substantial compliance with life safety code requirements, including failures in emergency lighting, sprinkler system maintenance, and fire wall integrity, placing residents at risk in the event of an emergency.

The facility was found not in substantial compliance with regulations, with deficiencies including failure to fully develop comprehensive care plans for mood and behaviors, failure to revise care plans after resident falls, failure to conduct root cause analysis for falls, and failure to provide appropriate mental health treatment and services for a resident with major depressive disorder who expressed suicidal ideations.

The investigation was complaint-driven based on concerns about the facility's handling of a resident (R#134) who expressed suicidal ideations and refused psychiatric care. The resident repeatedly voiced statements about wanting to die, refused medications, and exhibited behaviors indicating depression and agitation. The facility failed to adequately respond to these behaviors, notify appropriate medical staff, or provide necessary psychiatric evaluation and treatment.

The facility failed to properly monitor and document the resident's depressive symptoms and suicidal statements, did not notify the attending physician or medical director of the resident's repeated statements about wanting to die, and failed to provide psychiatric or psychological services despite documented needs. The care plan was incomplete and did not fully address the resident's mood and behavioral issues.

The facility was found not in substantial compliance with life safety requirements, including emergency lighting, hazardous area enclosures, kitchen hood exhaust maintenance, fire alarm system testing, sprinkler system maintenance, corridor door latching, smoke/fire barrier integrity, electrical system maintenance, and oxygen cylinder storage.

The facility was found not in substantial compliance with multiple Life Safety Code requirements including means of egress obstructions, improper locking arrangements, lack of approved guards on ramps, inadequate emergency lighting and exit signage, failure to separate hazardous areas, inadequate cleaning of kitchen exhaust hood, deficient fire alarm system testing, incomplete sprinkler protection and maintenance, improperly mounted fire extinguishers, corridor doors not closing and latching properly, unsealed smoke barrier penetrations, and electrical system code violations.

The facility was found not in substantial compliance due to improper disposal of garbage and refuse, and failure to maintain an effective pest control program evidenced by observations of trash accumulation, standing water, and live roaches in the kitchen and storage areas.