Dekalb County Rehab & Nursing

Inspectors wroteBased on interview and record review, the facility failed to have fall prevention interventions in place for one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in R1 experiencing a fall and injury which required eight staples to the top of his head.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete the cooling process for a turkey roast. This applies to all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene during lunch service and failed to follow its hand hygiene policy and procedure. This deficiency affected all 37 residents reviewed for infection control currently residing in the memory care unit and has the potential to affect all 109 residents currently residing in the facility.

Inspectors wroteBased on the interview and record review, the facility failed to ensure the Safety of a resident while pushing their wheelchair for one of 6 residents (R40) reviewed for Safety in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that an indwelling catheter tube remained off the floor for one of two residents (R18) reviewed for catheters in the sample of 24.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure accurate monthly weights were obtained for 1 of 3 residents (R51); and failed to document accurate meal intakes and/or offer alternative meal options for 1 (R83) reviewed for nutrition in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen was administered at the physician prescribed rate for 1 of 1 resident (R32) reviewed for oxygen in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure occupational services were provided for 1 of 1 resident (R39) reviewed for therapy services in the sample of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident (R2) was transferred safely and in a manner to prevent a resident fall. The facility failed to ensure care-planned, fall interventions were in place for a resident (R2) with a recent fall. The facility failed to ensure a resident (R3) was supervised while being toileted which contributed to a resident fall. These failures apply to 2 of 3 residents (R2, R3) reviewed for safety and supervision in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to handle and store three bulk bin scoops in a sanitary manner. This has the potential to effect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide feeding assistance in a dignified manner for four of 21 residents (R42, R55, R58, R84) reviewed for dignity in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents eating from the Oak and Birch dining rooms with the correct serving sizes for the parmesan herb potatoes, regular carrots, mechanical soft ham, pureed ham, au gratin potatoes, and mashed potatoes. This applies to 4 of 21 residents (R9, R32, R50, R75) reviewed for diets in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's urinary indwelling catheter bag was not touching the floor to prevent contamination for 1 of 4 residents (R86) reviewed for catheters in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide behavioral interventions for a resident with a diagnosis of dementia that was displaying behaviors for one of 15 residents (R62) reviewed for dementia care in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two residents with a smooth consistency pureed pork chop that was free of chunks. This applies to 2 of 2 residents (R13, R55) reviewed for pureed diets in the sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to ambulate residents with the assistance of a gait belt to ensure residents were ambulated in a safe manner. This failure applies to 2 of 4 residents (R1, R2) in the sample of 4 reviewed for safety and supervision. This failure resulted in R1 falling while ambulating with staff, resulting in R1 fracturing her left femur (upper leg) and requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review facility, failed to ensure sure staff doffed PPE (personal protective equipment) in a manner to prevent cross-contamination after caring for COVID-19 positive residents; failed to ensure residents were not exposed to staff exhibiting symptoms of COVID-19; failed to implement transmission-based precautions for residents exhibiting symptoms of COVID-19; failed to have a system in place to accurately track/trend resident and staff exposures to COVID-19 during a facility outbreak; failed to have an effective system in place to test staff and residents for COVID-19 during a facility outbreak; and failed to ensure COVID negative residents were not exposed to COVID positive residents. These failures resulted in a facility outbreak of COVID-19 which, as of 9/11/23, included twenty-eight positive residents and fourteen positive staff. [...]

Inspectors wroteBased on observation, interview, and record revie,w the facility failed to ensure meals were delivered to residents at an appetizing temperature for 1 of 3 residents (R6) reviewed for food temperatures in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to serve liquids at a safe temperature to prevent burns, and failed to supervise residents at risk for burns and with poor safety awareness for 3 of 9 residents (R9, R32, R33) reviewed for safety and supervision in the sample of 23. These failures resulted in R32 sustaining a partial thickness burn to his right foot.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the walk-in refrigerator and freezer free of ice build up, failed to wash hands between touching dirty and clean dishes, failed to use tongs or clean gloves while serving food to the residents, and failed to cover food and drinks being delivered to a residents room. This applies to all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a pressure injury prior to a Stage 3 for 1 of 8 residents (R8) reviewed for pressure in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was monitored during medication administration for 1 of 1 resident (R20) reviewed for medication administration in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure wound care and medication administration were performed in a manner to prevent cross-contamination for 2 of 8 residents (R32, R64) reviewed for infection control in the sample of 23.