Emory Health and Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 6 (Resident #19) residents reviewed. The facility failed to update Resident #19's care plans for her fall mat on 04/30/25. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free of accidents and hazards for 1 of 6 (Resident #19) residents reviewed for accidents. The facility failed to ensure Resident #19's fall mat was beside her bed on 08/03/25. This failure could place residents at risk for fall related injuries.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 1 medication room reviewed for pharmacy services. The facility failed to ensure the Medication Storage Room did not contain Resident #18's expired ondansetron (nausea medication) with an expiration date of 06/11/25 or an expired Tums bottle with an expiration date of 09/2024. This failure could place the residents at risk of not receiving the intended therapeutic benefits of prescribed medications and medications being used passed their effective or expiration date.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Nurse Cart) observed for medication storage. The facility failed to ensure the Nurse's cart did not contain Resident #2's undated NovoLog insulin bottle. This failure could place residents at risk for not receiving drugs and biologicals as needed and medications being used passed their effective or expiration date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 15 residents reviewed for infection control practices (Resident #20). The facility failed to ensure CNA C changed his gloves and performed hand hygiene while providing incontinent care to Resident #20. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were labeled and dated. 2. Hair restraints worn. 3. The microwave was clean and free of food debris. 4. The toaster was clean and free of food debris. 5. Expired food item was discarded. 6. Refrigerator/Freezer log was kept up to date. 7. Personal drinks were kept out of facility refrigerator. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 4 of 4 resident's (Resident #'s 4, 17, 25, and 34) reviewed for a homelike environment. The facility failed to ensure Resident #25's wall behind her bed was free from deep gouges into the sheetrock measuring 4 inch wide and 2 feet long. The facility failed to ensure Resident #17's and Resident #34's bed linens were changed. The facility failed to ensure Resident #34 had hot water available in the bathroom. The facility failed to ensure Resident #34 had a toilet seat that was free from peeling paint. The facility failed to ensure Resident #34's toilet was flushing properly. The facility failed to ensure Resident #4's hot water in the bathroom sink was not running continuously, and Resident #4 had cold water available. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 2 of 4 residents (Resident #'s 140 and 17) reviewed for ADLs. The facility failed to ensure Resident #140's face was free from facial hair. The facility failed to ensure Resident #17 received routine scheduled showers. These failures could place residents at risk for not receiving services/care and a decreased quality of life. 1) Record review of a face sheet dated 6/10/2024 indicated Resident #140 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of profound intellectual disabilities (the inability to live alone, and care for themselves). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 staff (Laundry Aides G, H, and K) reviewed for infection control practices on 2 of 4 halls ( halls 1 and 2). The facility failed to ensure that Laundry Aides G , H, and K covered the laundry cart while delivering the resident's clothing. This failure could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative and consult the physician immediately when there was a significant change in the resident's physical, mental, or psychosocial status that is, a deterioration of health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 4 residents (Resident #30) reviewed for notification of changes. The facility failed to consult Resident #30's physician and notify the resident representative when Resident #30 refused to have a CMP (complete metabolic panel lab draw to provide information about the body's chemical balance) and a HBA1C (glycated hemoglobin test that measure the average amount of blood sugar) lab drawn on 05/09/24, 05/10/24, and 05/13/24. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 3 of 31 residents (Resident #17, and Resident #14 and Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #17's care plan indicated he smoked. The facility failed to ensure Resident #14's care plan indicated he wandered. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 3 residents (Resident #7) reviewed for respiratory care and services. The facility failed to properly store Resident #7's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress.

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to ensure correct installation, use and maintenance of bedrails for 1 of 1 resident (Resident #21) reviewed for bedrails. 1. The facility failed to assess Resident #s 21 for the risk of entrapment from bed rails prior to installation. 2. The facility failed to document the attempt of alternatives to meet Resident #21's needs. These failures could place residents at risk for entrapment with serious injury and even death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received therapeutic diets that were prescibed by the attending physician for 1 of 13 residents (Resident #28) reviewed for therapeutic diets. The facility did not ensure Resident #28 was given double protein portion as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident # 21) reviewed for hospice services. The facility failed to obtain Resident #21's most recent updated hospice plan of care. The facility failed to ensure Resident #21's hospice plan of care accurately reflect his medication regimen. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 1 of 4 residents (Resident #1) reviewed for antibiotic use. The facility failed to ensure Resident #1 had documented appropriate lab work and diagnoses to support the use of prescribed antibiotics. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 2 of 14 residents (Resident #17 and Resident #184) reviewed for accidents hazards from hot coffee. The facility failed to ensure safety measures were in place after Resident #184 received a second-degree burn (burns that involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful) from hot coffee that required treatment. The facility failed to ensure safety measures were in place to prevent Resident #17 from obtaining an injury from hot coffee. An Immediate Jeopardy (IJ) situation was identified on 05/09/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and served in a manner that prevented foodborne illness for 1 of 1 kitchen reviewed for food preparation and serving. The facility did not ensure hair restraints were worn appropriately by Dietary [NAME] C and [NAME] D while they prepared and served residents' food. This failure could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 of 1 nurse's cart and 1 of 2 medication carts (#2 medication cart) reviewed for pharmacy services. The facility failed to ensure the nurse's cart was locked when left unattended in the hallway. The facility failed to ensure all medications on the nurses' cart and the #2 medication cart were labeled when opened. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: 1. During an observation and interview on 05/09/23 at 09:28 AM, the nurse's cart was on the 100 hall and was unlocked. There was no staff present. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately consult with the resident's physician when there was significant change in the resident's physical, mental, or psychosocial status for 1 of 2 residents (Resident # 17) reviewed for notification of changes. The facility failed to notify the physician for Resident #17 after LVN E assessed redness on his left inner thigh from spilled hot coffee. This failure could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the residents' conditions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 14 residents reviewed for care plans. (Resident #30) The facility failed to develop a care plan for Resident #30's right wrist and hand contractures. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 3 residents reviewed for pressure ulcers. (Resident #20) LVN A failed to change his gloves while providing wound care for Resident #20. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 4 residents reviewed for respiratory care (Residents #24). The facility failed to ensure Resident #24 had an oxygen concentrator filter in place. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed for unnecessary medications. (Resident #26) The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #26's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 14 residents reviewed for laboratory services (Residents #25). The facility failed to obtain ordered CBC and BMP levels for Resident #25. This failure could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to notify residents and/or the residents' Responsible Party (RP) or families by 5:00 p.m. the following day, after 2 of 2 residents (Resident #'s 14 and 84) test positive for Covid-19. The facility failed to inform residents and/or the residents' RPs/family of Resident #'s 14 and 84's confirmed infections of Covid-19 by the 5:00 p.m. on 12/08/2022 and 03/02/2023. This failure could place residents, families, and responsible parties at risk of not being kept informed on the Covid-19 status in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 2 resident (Resident #3) reviewed for discharge MDS assessments. The facility did not ensure Resident #3's discharge MDS assessment was completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 1 facility reviewed for administration (Fiscal year 2023 for the first quarter October 1, 2022, to December 31, 2022). The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for the 1st quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met.