7 CMS Surveys
Inspection Report — Jul 2, 2025
Routine
Date: Jul 2, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, pharmaceutical services, drug regimen management, and infection prevention and control at Resorts at Pooler Inc nursing facility.
Findings
The facility failed to follow physician orders for blood pressure monitoring prior to medication administration, failed to ensure timely availability of physician-ordered antibiotics, administered blood pressure medication despite parameters to hold it, and failed to implement enhanced barrier precautions during wound care, all with potential for minimal harm to a few residents.
Deficiencies (4)
Failed to follow physician's order to obtain blood pressure prior to administration of blood pressure medication for one resident.
Failed to ensure a physician-ordered antibiotic was available for timely administration for one resident.
Failed to follow parameters order for blood pressure medication resulting in unnecessary medication administration for one resident.
Failed to place a resident with an open wound in Enhanced Barrier Precautions and failed to follow infection control guidelines during dressing change.
Report Facts
Residents reviewed for medication administration: 16
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication doses not documented as given: 3
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 3 | Admitted not taking blood pressure prior to medication administration and confirmed order entry error | |
| Regional Director of Nursing (RDON) | Stated nurse should have followed physician's order for blood pressure monitoring | |
| Pharmacist | Explained delay in antibiotic delivery due to unconfirmed order | |
| Licensed Practical Nurse (LPN) 3 | Called pharmacy to obtain antibiotic and confirmed order in electronic record | |
| Director of Nursing (DON) | Described medication order confirmation process and expectations for nurses | |
| Licensed Practical Nurse (LPN) 1 | Observed performing dressing change without gown and acknowledged error | |
| Director of Nursing (DON) | Observed lack of gown use during wound care and stated staff should follow enhanced barrier precautions |
Inspection Report — Jun 16, 2024
Routine
Date: Jun 16, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication administration, resident environment, bed hold policies, PASRR screening, respiratory care, and infection control.
Findings
The facility was found deficient in several areas including unsafe medication storage and lack of physician orders for self-administration, unsanitary and poorly maintained resident rooms, failure to provide written bed hold information at transfer, failure to submit and implement PASRR Level II screenings and recommendations, unsafe storage of oxygen equipment, and inadequate infection prevention and control program implementation.
Deficiencies (6)
Failed to ensure unauthorized medications at the bedside were safely stored and failed to obtain a physician order for self-administration of medications for one resident.
Failed to ensure resident rooms were clean, homelike, and in good repair on two of three halls, placing residents at risk of unsanitary living environment.
Failed to provide bed hold information in writing at the time of transfer or within 24 hours for four residents, risking denial of re-admission and loss of resident's home.
Failed to submit for a PASRR Level II for one resident after new mental illness diagnosis and failed to implement PASRR Level II recommendations for another resident.
Failed to ensure oxygen equipment was safely stored for two residents receiving oxygen therapy, increasing risk of respiratory infection.
Failed to maintain an effective infection prevention and control program with ongoing surveillance, recognition, investigation, and control of infection, increasing exposure risk to communicable illnesses.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 77
Residents affected: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Interviewed regarding medication self-administration and bed hold policy |
| Director of Nursing | Director of Nursing | Interviewed regarding medication self-administration, bed hold policy, oxygen equipment storage, infection control, and PASRR screening |
| LPN/Unit Manager BB | LPN/Unit Manager | Interviewed regarding medication self-administration and bed hold policy |
| Housekeeping Supervisor | Interviewed regarding room cleaning and maintenance staffing | |
| Maintenance Director | Maintenance Director | Interviewed regarding maintenance logbook and repair priorities |
| Administrator | Administrator | Interviewed regarding facility repairs and bed hold policy |
| Social Service Director | Social Service Director | Interviewed regarding PASRR Level II submission and psychiatric services |
| Unit Manager DD | Unit Manager | Interviewed regarding psychiatric services for resident with PASRR Level II |
| Infection Control Preventionist CC | Infection Control Preventionist | Interviewed regarding infection control program and use of McGeer criteria |
Inspection Report — Jun 16, 2024
Routine
Date: Jun 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident environment, bed hold policies, PASRR screenings, respiratory care, and infection control at Resorts at Pooler Inc nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure safe medication self-administration and storage, inadequate cleanliness and maintenance of resident rooms, failure to provide written bed hold information at transfer, failure to submit and implement PASRR Level II screenings and recommendations, unsafe storage of oxygen equipment, and lack of effective infection prevention and control program using McGeer criteria.
Deficiencies (6)
Failed to ensure unauthorized medications at bedside were safely stored and failed to obtain physician order for self-administration of medications for one resident.
Failed to ensure resident rooms were clean, homelike, and in good repair on two of three halls.
Failed to provide bed hold information in writing at time of transfer or within 24 hours for four residents.
Failed to submit PASRR Level II for one resident after new mental illness diagnosis and failed to implement PASRR Level II recommendations for another resident.
Failed to ensure oxygen equipment was safely stored for two residents receiving oxygen therapy.
Failed to maintain an effective infection prevention and control program demonstrating ongoing surveillance, recognition, investigation, and control of infection using McGeer criteria.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Interviewed regarding medication self-administration and bed hold policy |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication self-administration, bed hold policy, oxygen equipment storage, infection control program, and PASRR screenings |
| LPN/Unit Manager BB | LPN/Unit Manager | Interviewed regarding medication self-administration and bed hold policy |
| Housekeeping Supervisor | Interviewed regarding room cleaning and staffing | |
| Maintenance Director | Interviewed regarding maintenance log and repairs | |
| Administrator | Interviewed regarding maintenance and bed hold policy | |
| Social Service Director | Social Service Director (SSD) | Interviewed regarding PASRR screening submissions and psychiatric services |
| Unit Manager DD | Unit Manager | Interviewed regarding psychiatric services for resident with PASRR Level II |
| Infection Control Preventionist CC | Infection Control Preventionist | Interviewed regarding infection control program and use of McGeer criteria |
Inspection Report — Apr 30, 2024
Annual Inspection
Date: Apr 30, 2024
Visit Reason
Annual survey inspection of Resorts at Pooler Inc to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Apr 19, 2022
Routine
Date: Apr 19, 2022
Visit Reason
The inspection was conducted to assess compliance with nutritional needs and infection prevention and control protocols, including COVID-19 related measures, at the facility.
Findings
The facility failed to ensure that the planned menu was followed for nine residents on pureed diets, with discrepancies in portion sizes served versus menu specifications. Additionally, the facility failed to implement an effective infection prevention and control program, including failure to screen visitors for COVID-19 and failure to encourage mask use and social distancing among unvaccinated residents during the COVID-19 pandemic.
Deficiencies (2)
Failure to ensure the planned menu was followed related to portion sizes for nine residents on pureed diets.
Failure to implement an infection prevention and control program, including failure to screen visitors for COVID-19 and failure to encourage mask use and social distancing among unvaccinated residents.
Report Facts
Residents affected: 9
Residents not vaccinated: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RR | Dietary Manager | Provided menu extensions and information about portion sizes |
| TT | Consultant Registered Dietitian | Provided expectations regarding menu and portion size adherence |
| AA | Infection Control Preventionist | Reported non-compliance with mask use and screening procedures |
| DON | Director of Nursing | Acknowledged failure to screen visitors and discussed facility routines and vaccination status |
Inspection Report — Feb 7, 2019
Routine
Date: Feb 7, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to PASARR screening, pain management, infection control, and care planning at Resorts at Pooler Inc nursing home.
Findings
The facility failed to ensure proper PASARR Level II screening for one resident, did not follow the pain management plan for one resident including failure to assess pain every shift, and failed to prevent cross contamination of laundry affecting all residents.
Deficiencies (4)
Failed to ensure a PASARR Level II screening for one resident with major depressive disorder and psychotic features.
Failed to follow the plan of care related to pain management for one resident, including failure to assess pain every shift and missing orders on the Medication Administration Record.
Failed to complete a pain assessment every shift for one resident requiring such services.
Failed to assure cross contamination prevention in laundry handling, including soiled laundry touching staff uniforms and clean linens being contaminated by falling on the floor.
Report Facts
Sample size: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Named in pain management deficiency related to pain assessments and medication administration |
| Director of Nursing | Director of Nursing (DON) | Discussed issues with pharmacy orders and pain management deficiencies |
| Social Service Director | Social Service Director (SSD) | Interviewed regarding PASARR screening procedures |
| Administrator | Administrator | Interviewed regarding staff expectations for PASRR form reviews |
| EE | Laundry Aide | Observed and interviewed regarding laundry handling deficiencies |
| Environmental Coordinator | Environmental Coordinator | Interviewed regarding laundry handling policies and PPE use |
CMS Survey — Dec 7, 2025
Dec 7, 2025
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