Eatonton Health and Rehabilitation

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Medication Storage in the Care Center, the facility failed to ensure that medications were properly stored in one of one medication storage rooms. This deficient practice had the potential to increase the risk of residents receiving medications with altered effectiveness.

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility's policy titled Self-Administration of Drugs, the facility failed to ensure two of 17 sampled residents (R) (R29 and R48) were assessed for medication self-administration before allowing unsecured medications to be kept at the bedside. This deficient practice had the potential to place R29 and R48 at risk of unauthorized use of medication, inaccurate medication dosing, and a diminished quality of life.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled Grievance/Concern Guidelines for Patients, the facility failed to document resident grievances and failed to provide a resolution for the grievance for one of 17 sample residents (R) (R6). This deficient practice had the potential to place R6 at risk of unresolved grievances.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Bed Hold During Hospital Stays and Therapeutic Leaves, the facility failed to ensure one of four residents (R) (R8) reviewed for hospitalizations, or their Resident Representative (RR), received written notice that specified the duration of the bed hold policy. Specifically, the facility failed to include the current rate for the reserve bed payment in the event the resident did not return within seven days. This failure had the potential to place R8 at risk of denial of re-admission and loss of their room following hospitalization.

Inspectors wroteBased on resident, resident Power of Attorney (POA), and staff interviews and record review, the facility failed to ensure three of three dependent residents (R) (R29, R8, and R64) from a sample of 17 residents received showers according to the schedule. This failure had the potential to place the residents at risk for diminished self-worth, self-esteem, feelings of embarrassment, and/or medical issues.

Inspectors wroteBased on observations, resident, resident Power of Attorney ([NAME]), and staff interviews, record review, and review of the facility policy titled Restorative, the facility failed to ensure splint application was provided for one of one resident (R) (R64) sampled for Restorative Nursing from a sample of 17. This failure had the potential to place R64 at risk for increased contractures and decreased range of motion.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Medication Destruction: Collection Receptacle All Medications (Non-Controlled and Controlled), the facility failed to ensure discontinued medications were stored in a manner to maintain control and accountability for five of 17 sampled residents (R) (R2, R8, R54, R59, and R273). This failure had the potential to increase the risk for drug diversion or misappropriation of medications.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Documentation in the Medical Record, the facility failed to maintain an accurate medical record for one of 17 sampled residents (R) (R29). Specifically, the facility failed to ensure the staff member delivering care was also the staff member who documented the care related to Activities of Daily Living (ADLs) and showers.

Inspectors wroteBased on observations and staff interviews the facility failed to remove ice build-up from cases of food items in the stand-up freezer to prevent contamination. This deficient practice had the potential to affect 51 of 53 residents receiving an oral diet.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Antibiotic Stewardship, the facility failed to identify trends in antibiotic use, maintain documentation for clinical indication of use for antibiotics, implement systematic protocols to monitor, decrease use, and measure the effectiveness of antibiotics, and failed to create an action plan to lower the use of antibiotics that did not meet criteria for one of 28 sampled residents (R) (R28).

Inspectors wroteBased on observations, staff interviews, a review of the facility document titled Personal Items, and a review of the facility policy titled Laundry Services, the facility failed to ensure resident personal care items and 12 clean mop heads were stored in a manner to prevent cross-contamination. These failures had the potential to expose residents to infections due to cross-contamination.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility document titled Call Light Guidelines, the facility failed to ensure the call light was within reach for one resident (R) (R24). The facility census was 53 residents.

Inspectors wroteBased on staff interviews, record review, and review of facility policy titled Baseline Care Plans, the facility failed to develop a baseline care plan for two residents (R) (R20 and R55) of six newly admitted residents in the past 30 days. Specifically, the facility failed to develop a baseline care plan related to dementia care and antipsychotic medication use for R20 and failed to develop a baseline care plan for R55.

Inspectors wrote2. A review of R13's Quarterly MDS assessment dated [DATE] revealed: Section K - Swallowing and Nutritional Status: Received a mechanically altered and therapeutic diet while in the facility. A review of the physician orders for R13 revealed an order dated 5/18/2023 for a renal diet and an order dated 5/30/2023 for a puree diet. A review of the comprehensive care plan revealed a care area/problem for altered nutrition as evidenced by a therapeutic diet and mechanically altered diet. Interventions included providing a diet as prescribed. Observation on 1/28/2024 at 12:30 pm revealed R13 was served pureed lasagna instead of a pureed beef patty that the facility document titled Diet Spreadsheet indicated to be provided for a renal diet, in place of the lasagna. [...]

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to serve a proper renal diet for one resident (R) (R13) of one resident ordered to receive a renal diet. The deficient practice had the potential to adversely affect R13's nutritional intake.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that the daily nurse staffing information was posted daily and was readily accessible to residents and visitors on three of three survey dates, 1/26/2024, 1/27/2024, and 1/28/2024. The facility census was 53 residents.