Bryan County Hlth & Rehab Ctr

Inspectors wroteBased on observation, staff interviews, and review of the facility's policy titled Preparation of Pureed Foods for Residents with Dysphagia, the facility failed to ensure that pureed foods were prepared according to standardized recipes and professional food service standards for residents (R) requiring texture modified diets. This deficient practice had the potential to affect nine residents receiving pureed diets. Findings Include:Review of the undated policy titled Preparation of Pureed' foods for the Residents with Dysphagia, revealed under the Moist and Consistency section, to add appropriate liquids to achieve proper consistency: broth, milk, gravy or approved thickened liquids. It was revealed under the Nutritional Adequacy section to ensure meals meet residents' nutritional needs. Fortify foods when needed (e.g., adding protein powder, butter, or supplements). [...]

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled Food Storage, the facility failed to ensure that all foods were properly labeled, dated, and discarded, and failed to ensure the cleanliness of kitchen equipment used in the preparation of food for residents. Failure to follow this policy resulted in improper food storage and unsanitary food preparation practices. This deficient practice had the potential to place 83 residents (R) who received an oral diet at risk of contracting a foodborne illness.

Inspectors wroteBased on observations, staff interviews, and the facility policy, Outside Dumpster Policy the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, creating the potential for harboring pests and insects.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the policy titled Resident Dignity & Safe Feeding Policy, the facility failed to maintain dignity for four of 45 sampled residents (R7, R27, R67, and R83). This failure placed the residents at risk for a reduced quality of life in an environment meant to support their well being. Findings Include:Review of the facility's policy titled, Resident Dignity & Safe Feeding Policy, revised 7/23/2025 revealed that Prohibited Practices included Do not feed while standing, rush feeding, feed multiple residents at once, or ignore swallowing difficulty.1. Review of the Quarterly Minimum Data Set (MDS) for R7, dated 02/01/2026, revealed that Section C (Cognitive Patterns) documented that R7 had a Brief Interview for Mental Status (BIMS) score of 00 (indicating severe cognitive impairment). [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the policy titled, Self Administration of Medications at Bedside Policy, [NAME] County Health and Rehabilitation Center, the facility failed to ensure that one of 46 sampled residents, Resident R23, did not have access to self administered medications. This failure had the potential to place Resident R23 at risk for adverse consequences.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration - General Guidelines, the facility failed to administer a medication at the correct time for one of eight sampled resident(R) (R6), whose medication was ordered to be given on an empty stomach, and failed to crush and administer medications separately for one of eight sampled R (R60). These failures occurred among eight residents with gastrostomy tubes observed during medication administration. This deficient practice had the potential to place R6 and R60 at risk for medical complications and abnormal laboratory results. Findings Include:Review of the facility's policy titled, Medication Administration-General Guidelines, effective date 4/1/2016 under Procedures revealed, A. Preparation. 7. Tablet crushing/Capsule opening: [...]

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Medication Storage in the Facility, the facility failed to ensure that one of two medication rooms was free of expired medications. This deficient practice had the potential to place residents at risk of receiving expired medications. Findings Include: A review of the facility's policy titled Medication Storage in the Facility, effective 4/1/2026, documented under section Expiration Dating (Beyond-Use dating).a. Blister-pack cards and medication vials-12 months from the date of dispensing (where the manufacture's expiration date is longer than 12 months). C.Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: 1. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a complete and accurate medical record was maintained for one of three sampled Residents (R1) reviewed for skin conditions. Specifically, R1's medical record did not contain documentation of all care planned skin assessments or consistent documentation of the completion of ordered skin treatments.

Inspectors wroteBased on observations, staff interviews and review of the facility policy titled, Food Storage, the facility failed to ensure that all opened food was labeled and dated. The deficient practice had the potential to affect all residents who were on an oral diet.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Standard Precautions the facility failed to ensure infection control practices were followed for two of eight residents (R) (R37 and R84) during wound care, the facility failed to ensure infection control practices were followed when disposing of used Personal Protective Equipment (PPE), and the facility also failed to ensure infection surveillance was conducted monthly. The deficient practices had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observations, staff interviews, record review, and the review of the facility policies titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol and Residents Federal and State Rights, the facility failed to ensure four of eight residents (R) (R37, R84, R11, and R45) were provided privacy during wound care treatment. Specifically, the facility failed to ensure R37, R84, R11, and R45 full privacy was provided by ensuring window blinds were closed and the privacy curtains were fully engaged when conducting wound care treatments.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled, Environment Rounds/Repairs, the facility failed to ensure that the environment was safe, clean, comfortable, and homelike in two rooms on A hall (room [ROOM NUMBER] and room [ROOM NUMBER]) located on two of four halls. Specifically, plaster on the wall was missing and cracked in two areas on Hall C, and chipped floor tile, black marks on privacy curtains, and a dirty feeding pump pole were noted on hall A.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, Care Planning- Interdisciplinary Team and Care Plans, Comprehensive Person-Centered, the facility failed to ensure a care plan for oxygen use was developed for one of nine residents (R) (R52) using oxygen. The facility also failed to ensure a care plan was developed for one of three residents, R35 that had an indwelling catheter. The deficient practice had the potential to increase the probability of R52 and R35's needs not being met according to their care needs.

Inspectors wroteBased on observations, record review. and staff interviews, the facility failed to follow the Physician Orders related to wound care for one of four residents observed during wound care (R11). The deficient practice had the potential for R11's wound to worsen.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure an environment free from potential accident hazards by failing to properly secure an oxygen (O2) tank for one of 10 residents (R) (R28) receiving oxygen therapy. The deficient practice had the potential to harm R28 or other residents that could come in contact with the unsecured O2 tank.

Inspectors wroteBased on observation, staff interview, and review of the facility policy titled, Oxygen Administration, the facility failed to ensure one of nine residents (R) (R52) oxygen (O2) was administered as ordered by the physician. Specifically, the facility to failed to ensure R52's O2 rate was set on 2 liters per minute (LPM) instead of 4 LPM via nasal cannula (NC).

Inspectors wroteBased on staff interview and record review the facility failed to ensure that six residents ((R) R#66, R#67, R#74, R#126, R#176, R#276) of 8 residents reviewed had completed pneumococcal consent forms and received pneumococcal vaccines in a timely manner.

Inspectors wroteBased on staff interviews, record review, and review of policy titled Facility COVID-19 Vaccination Plan, the facility failed to ensure that five residents ((R) R#66, R#74, R#126, R#176, R#276) of eight residents reviewed received COVID-19 vaccines in a timely manner.

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to accommodate one resident (providing equipment to encourage self toileting at night), (R) R#57) of 20 sampled residents.

Inspectors wroteBased on record review, resident and staff interviews, and policy titled, Admission, Transfer, and Discharge Policy & Procedure, the facility failed to notify the Physician or the responsible party of change in condition for one resident (R) R#18) of 4 residents transferred to the hospital.

Inspectors wroteBased on observation, record review, staff interview, and review of the facility policy titled Using the Care Plan the facility failed to follow the care plan related to providing oxygen as ordered for one resident (R) (R#67) one of 15 sampled residents receiving oxygen. Findings Include: Review of the facility policy titled Using the Care Plan (revision date August 2006) revealed the following; Policy Statement: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Review of medical record for R#67 revealed diagnoses that consisted of but not limited to chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypercapnia, and chronic respiratory failure with hypoxia. [...]

Inspectors wroteBased on observation, record review, staff interviews, and review of the facility policy titled, Oxygen, Use of Policy and Procedure, the facility failed to have clear oxygen orders for one resident (R) R#67) of 15 residents receiving oxygen. Findings Include: Review of facility policy titled Oxygen, Use of Policy and Procedure, (not dated) revealed the following: Policy: Designated staff member will administer oxygen therapy only per physician's orders or as an emergency measure until and or as an emergency measure until and order can be obtained. The physician's orders will specify the rate of flow of oxygen. Review of records for R#67 revealed diagnoses of chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypercapnia, and chronic respiratory failure with hypoxia. [...]

Inspectors wroteBased on record review, staff interviews, and facility's policy titled Medication Orders IB3: Stop Orders, the facility failed to document the intended rationale and duration of therapy for one resident ((R) R#57), that had an as needed order (PRN) for a PRN antianxiety medication beyond 14 days of five residents reviewed for medication usage.