Inspection Reports for
Waycross Health and Rehabilitation
1910 DOROTHY STREET, WAYCROSS, GA, 31501
Back to Facility Profile38 Reports
Inspection Report — Jun 5, 2025
Plan of Correction State
Date: Jun 5, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Waycross Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The document contains an initial comment section but does not provide specific details on deficiencies or findings.
Inspection Report — Jun 5, 2025
Re-Inspection State
Date: Jun 5, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the March 20, 2025, recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report — May 5, 2025
Follow-Up State
Date: May 5, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as of the follow-up survey conducted on May 5, 2025.
Inspection Report — Mar 21, 2025
Life Safety State
Date: Mar 21, 2025
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with fire safety regulations and the Emergency Preparedness Program requirements.
Findings
The facility was found not in substantial compliance with fire safety requirements due to failure to ensure fire sprinkler heads were clear from dust accumulation, specifically in the restroom of Room C2. The Emergency Preparedness Program was found to be in substantial compliance.
Deficiencies (1)
Facility failed to ensure fire sprinkler heads were clear from dust accumulation in the restroom of Room C2.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of dust accumulation on fire sprinkler head during inspection |
Inspection Report — Mar 20, 2025
Routine CMS
Date: Mar 20, 2025
Visit Reason
The inspection was conducted to assess compliance with medication self-administration policies and infection prevention and control practices during wound care at the nursing home.
Findings
The facility failed to assess one resident for the ability to self-administer medications prior to bedside storage, posing a risk of unsafe medication use. Additionally, the facility failed to ensure proper hand hygiene and infection control practices during wound care for another resident, increasing the risk of infection due to cross-contamination.
Deficiencies (2)
F 0554: The facility failed to assess one resident for the ability to self-administer medications prior to leaving medications at the bedside, contrary to facility policy and physician orders.
F 0880: The facility failed to ensure staff followed infection control procedures during wound care, including hand hygiene when changing gloves, increasing risk of infection for one resident.
Report Facts
Residents sampled for medication self-administration assessment: 29
Residents reviewed for wound care: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) AA | Unaware that resident had medication at bedside | |
| Director of Nursing (DON) | Unaware that resident had medication at bedside and confirmed hand hygiene expectations during wound care | |
| Wound Care Nurse (WCN)/Registered Nurse (RN) | Performed wound care without proper hand hygiene |
Inspection Report — Mar 20, 2025
Routine State
Date: Mar 20, 2025
Visit Reason
A standard survey was conducted at Waycross Health and Rehabilitation from March 18, 2025, through March 20, 2025, including investigation of multiple complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00236828, GA00252825, GA00253989, GA00243569, GA00253938, GA00253774, GA00236399, and GA00234099 were investigated. Five complaints were unsubstantiated, and three were substantiated with no deficiencies cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to failure to assess a resident's ability to self-administer medication and failure to follow infection control procedures during wound care, potentially placing residents at risk.
Deficiencies (2)
Failed to assess one resident (R48) for ability to self-administer medications prior to bedside medication storage, risking unsafe medication use.
Failed to ensure staff followed infection control processes during wound care for one resident (R38), risking infection due to cross-contamination.
Report Facts
Residents sampled for medication self-administration assessment: 29
Residents reviewed for wound care: 10
Brief Interview for Mental Status (BIMS) score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Medication Aide (CMA) | Unaware that resident R48 had medication at bedside |
| Director of Nursing | Director of Nursing (DON) | Unaware that resident R48 had medications at bedside; confirmed hand hygiene expectations during wound care |
| Wound Care Nurse (WCN)/Registered Nurse (RN) | Wound Care Nurse/Registered Nurse | Performed wound care without sanitizing hands between glove changes |
Inspection Report — Feb 22, 2023
Plan of Correction State
Date: Feb 22, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Waycross Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies on the provided page.
Inspection Report — Feb 22, 2023
Re-Inspection State
Date: Feb 22, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 12/18/2022 Recertification Survey.
Findings
All deficiencies cited as a result of the 12/18/2022 Recertification Survey were found to be corrected.
Inspection Report — Jan 27, 2023
Follow-Up State
Date: Jan 27, 2023
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report — Dec 19, 2022
Life Safety State
Date: Dec 19, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including non-functioning emergency lighting at the Therapy Den exit, failure to conduct annual fire alarm testing for 2022, sprinkler pipes obstructed by wires throughout the facility, and power strips not properly mounted off the floor in staff areas.
Deficiencies (4)
Emergency lighting of at least 1-1/2-hour duration was not working correctly at the Therapy Den exit.
Annual fire alarm testing was not conducted for the year 2022.
Sprinkler pipes were obstructed by wires throughout the facility.
Power strips were not properly mounted off the floor in staff areas throughout the facility.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report — Dec 18, 2022
Complaint Investigation CMS
Date: Dec 18, 2022
Visit Reason
The inspection was conducted based on complaints regarding failure to obtain physician signature on POLST forms, medication administration errors, unsafe food temperature causing burns, and infection control issues.
Complaint Details
The complaint investigation substantiated failures including lack of physician signature on POLST, medication administration errors, unsafe food temperature causing burns to a resident, and inadequate infection control practices leading to cross contamination risks.
Findings
The facility failed to obtain a physician's signature on a POLST form, administer medication according to physician orders, ensure safe food temperatures resulting in a resident sustaining second degree burns, and maintain sanitary conditions to prevent cross contamination in housekeeping and laundry areas.
Deficiencies (5)
F578: The facility failed to obtain a Physician's signature for a POLST form for one of 26 residents reviewed (R#44).
F656: The facility failed to follow the care plan for one of five residents (R#44) related to administering medications as ordered.
F684: The facility failed to follow Physician's Orders related to blood pressure medication for one of five residents (R#44), administering medication outside order parameters.
F689: The facility failed to ensure soup was served at a safe temperature for one resident (R#45), resulting in second degree burns.
F880: The facility failed to maintain sanitary and clean conditions related to cross contamination in one hallway and the laundry room, with a census of 54 residents.
Report Facts
Residents sampled: 26
Residents reviewed for medication: 5
Food temperature: 160
Burn incident date: Nov 26, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Confirmed medication administration outside order parameters and described reheating procedures |
| CNA CC | Certified Nursing Assistant | Served hot soup to resident who sustained burns; described incident details |
| CNA DD | Certified Nursing Assistant | Heated soup in microwave and returned it without checking temperature |
| Director of Nursing | DON | Reported on medication administration issues and soup incident |
| Housekeeper JJ | Housekeeper | Observed using improper cleaning methods leading to cross contamination |
| Housekeeping Supervisor | Reported on housekeeping practices and lack of laundry policy | |
| Social Services | Social Services Director | Responsible for following up on POLST physician signature and post-incident follow-up |
Inspection Report — Dec 18, 2022
Annual Inspection State
Date: Dec 18, 2022
Visit Reason
A State Licensure survey was conducted from December 16, 2022 through December 18, 2022 to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to follow Physician's Orders for one of five residents reviewed for unnecessary medication administration, specifically for resident #44 regarding carvedilol medication given outside prescribed blood pressure parameters.
Deficiencies (1)
Failure to follow Physician's Orders for resident #44 by administering carvedilol outside of prescribed blood pressure parameters.
Report Facts
Medication administration dates outside parameters: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Confirmed trainings were provided and reviewed EMAR confirming medication was administered outside order parameters. |
| HH | Director of Nursing (DON) | Reported unawareness of medication being administered outside order parameters until informed by pharmacist. |
Inspection Report — Dec 18, 2022
Routine State
Date: Dec 18, 2022
Visit Reason
A standard survey was conducted at Waycross Health and Rehabilitation from December 16, 2022 through December 18, 2022 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to obtain a physician's signature on a POLST form, failure to follow medication orders for one resident, serving soup at an unsafe temperature causing second degree burns to a resident, and failure to maintain sanitary conditions related to cross contamination in the laundry and hallways.
Deficiencies (5)
Failure to obtain a Physician's signature for a POLST for one resident.
Failure to follow care plan and medication orders related to antihypertensive medication administration for one resident.
Failure to follow Physician's Orders related to blood pressure medication resulting in unnecessary medication administration for one resident.
Failure to ensure soup was served at a safe temperature resulting in second degree burns to one resident.
Failure to maintain sanitary and clean conditions related to cross contamination in laundry and hallways.
Report Facts
Medication administration dates: 25
Temperature of reheated soup: 160
Time to staff response: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA CC | Certified Nursing Assistant | Named in soup burn incident for serving soup and responding to call light |
| CNA DD | Certified Nursing Assistant | Named in soup burn incident for reheating soup |
| LPN FF | Licensed Practical Nurse | Reported resident's code status and lack of physician signature on POLST |
| Director of Nursing | Director of Nursing | Reported unawareness of medication administration outside order parameters and soup incident details |
| Resident Care Coordinator HH | Resident Care Coordinator | Reported on medication administration issue |
| Social Services | Social Services | Responsible for obtaining physician signature on POLST |
| Administrator | Administrator | Reported on POLST signature and expectations for food temperature checks |
| LPN AA | Licensed Practical Nurse | Confirmed medication administration outside order parameters and reheating food procedures |
| Laundry Aide II | Laundry Aide | Observed folding linens without hand sanitization |
| Housekeeper JJ | Housekeeper | Observed cross contamination in cleaning practices |
Inspection Report — Aug 10, 2022
Abbreviated Survey State
Date: Aug 10, 2022
Visit Reason
An abbreviated survey was conducted to investigate two complaints, #GA00222000 and #GA00225082.
Complaint Details
Complaint #GA00222000 was unsubstantiated. Complaint #GA00225082 was substantiated.
Findings
Complaint #GA00222000 was found to be unsubstantiated, while complaint #GA00225082 was substantiated. No regulatory violations were cited during the survey.
Inspection Report — Oct 5, 2021
State
Date: Oct 5, 2021
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Waycross Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or findings are detailed in the provided page.
Inspection Report — Oct 5, 2021
Re-Inspection State
Date: Oct 5, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey on 2021-08-05.
Findings
All deficiencies cited in the prior Recertification survey were found to be corrected, and the facility was in substantial compliance as of 2021-09-03.
Report Facts
Previous survey date: Aug 5, 2021
Substantial compliance date: Sep 3, 2021
Inspection Report — Aug 5, 2021
CMS
Date: Aug 5, 2021
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to the development and implementation of baseline care plans for newly admitted residents.
Findings
The facility failed to develop baseline care plans within 48 hours of admission for two residents, R#45 and R#295. The care plans did not address key diagnoses and allergies, and staff responsible for completing the plans were unfamiliar with the process.
Deficiencies (1)
F0655: The facility failed to create and implement a baseline care plan within 48 hours of admission for residents R#45 and R#295. Care plans did not address critical diagnoses and allergies for these residents.
Report Facts
Residents present: 44
Residents affected: 2
Inspection Report — Aug 5, 2021
Renewal State
Date: Aug 5, 2021
Visit Reason
A licensure survey was conducted at Waycross Health and Rehabilitation from 8/3/2021 through 8/5/2021 to assess compliance with licensure requirements.
Findings
The survey revealed that the facility was in substantial compliance with regulatory requirements.
Inspection Report — Aug 5, 2021
Routine State
Date: Aug 5, 2021
Visit Reason
A standard survey was conducted at Waycross Health and Rehabilitation from 8/3/2021 through 8/5/2021 to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance due to failure to develop baseline care plans within 48 hours of admission for two residents (R#45 and R#295). The care plans did not address key diagnoses and allergies as required.
Deficiencies (1)
Failure to develop a baseline care plan within 48 hours of admission for two residents, with care plans missing key diagnoses and allergy information.
Report Facts
Number of residents with deficient baseline care plans: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set (MDS) Coordinator | Stated that baseline care plans were not completed for R#45 and R#295 on admission and that she was responsible for their completion. | |
| Director of Health Services | Interviewed and revealed unfamiliarity with the baseline care plan process and policy. |
Inspection Report — Jul 8, 2021
Abbreviated Survey State
Date: Jul 8, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00215543.
Complaint Details
Complaint #GA00215543 was substantiated with no regulatory violations cited.
Findings
The complaint #GA00215543 was substantiated but no regulatory violations were cited.
Inspection Report — Jul 6, 2021
Life Safety State
Date: Jul 6, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program met regulatory standards.
Inspection Report — Feb 25, 2021
Abbreviated Survey State
Date: Feb 25, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00212299, #GA00212255, and #GA00212275.
Complaint Details
Complaints #GA00212299, #GA00212255, and #GA00212275 were investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were found during the survey.
Inspection Report — Jan 27, 2021
Abbreviated Survey State
Date: Jan 27, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00211514.
Complaint Details
Complaint GA00211514 was investigated and found to be unsubstantiated.
Findings
The complaint investigation was concluded as unsubstantiated with no deficiencies noted in the report.
Inspection Report — Nov 13, 2020
Abbreviated Survey State
Date: Nov 13, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00201696, #GA00208267, and #GA00208679.
Complaint Details
Complaints #GA00201696, #GA00208267, and #GA00208679 were investigated and found to be unsubstantiated.
Findings
The investigation resumed on November 12, 2020 and concluded on November 13, 2020. The complaints were unsubstantiated and no regulatory violations were cited.
Inspection Report — Oct 15, 2020
Routine State
Date: Oct 15, 2020
Visit Reason
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 preparedness and infection control.
Findings
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 for COVID-19.
Inspection Report — Sep 23, 2020
Abbreviated Survey State
Date: Sep 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
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 for COVID-19.
Inspection Report — Jul 29, 2020
Abbreviated Survey State
Date: Jul 29, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00206258.
Complaint Details
Complaint GA00206258 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report — Jul 23, 2020
Routine State
Date: Jul 23, 2020
Visit Reason
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.
Findings
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.
Inspection Report — Feb 7, 2020
Abbreviated Survey State
Date: Feb 7, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00201696.
Complaint Details
The complaint was investigated and found to be unsubstantiated.
Findings
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.
Inspection Report — Dec 19, 2019
Abbreviated Survey State
Date: Dec 19, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA#00200815 related to dietary services, environmental services, and quality of care.
Complaint Details
The complaint related to dietary services, environmental services, and quality of care was investigated and found unsubstantiated.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.
Inspection Report — Oct 29, 2019
Abbreviated Survey State
Date: Oct 29, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaint allegations identified by codes GA00196124, GA00196768, GA00196994, GA00199268, and GA00199325.
Complaint Details
The complaints investigated during the survey were unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaints were unsubstantiated and no deficiencies were cited.
Inspection Report — Feb 6, 2019
Abbreviated Survey State
Date: Feb 6, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00194488 regarding misappropriation of property.
Complaint Details
Complaint for misappropriation of property was investigated and found to be unsubstantiated.
Findings
The complaint for misappropriation of property was unsubstantiated.
Inspection Report — Nov 6, 2018
Re-Inspection State
Date: Nov 6, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies found during the annual survey conducted from September 4, 2018 through September 6, 2018.
Findings
All deficiencies resulting from the annual survey were found to be corrected during this revisit survey.
Inspection Report — Sep 5, 2018
Life Safety State
Date: Sep 5, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness plan was also in substantial compliance with Appendix Z requirements.
Report Facts
Certified beds: 92
Inspection Report — Mar 6, 2018
Abbreviated Survey State
Date: Mar 6, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00185978.
Complaint Details
Complaint GA00185978 was investigated and found to be unsubstantiated.
Findings
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.
Inspection Report — Dec 27, 2017
Re-Inspection State
Date: Dec 27, 2017
Visit Reason
A revisit survey visit was conducted to verify correction of deficiencies cited in the October 19, 2017 Standard Survey.
Findings
All deficiencies cited in the prior October 19, 2017 Standard Survey were found to be corrected during this revisit survey.
Inspection Report — Dec 12, 2017
Follow-Up State
Date: Dec 12, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey deficiencies had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report — Oct 16, 2017
Life Safety State
Date: Oct 16, 2017
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically related to improper protection of cooking facilities and failure to conduct and document required fire drills. These deficiencies could place 68 residents at risk in the event of a fire.
Deficiencies (3)
The hood extinguishing system spray nozzles were not properly aimed at the deep-fat fryer.
The deep-fat fryer did not maintain a minimum distance of 16 inches from fryer and surface flames from adjacent cooking equipment, nor was a steel or tempered glass baffle plate installed at a minimum of 8 inches in height between the fryer and surface flames of the adjacent appliance.
Failure to conduct and properly document a fire drill during the 2nd shift of the 4th quarter of 2016.
Report Facts
Certified beds: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observation |
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