George Regional Health & Rehab Center

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to procure, store, and maintain food under sanitary conditions by failing to ensure opened food items were properly covered, labeled, dated, and discarded in accordance with facility policy and by failing to remove moldy and deteriorated fresh produce from refrigerated storage, with the potential to affect all residents who received food prepared by the dietary department.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to resolve and provide follow-up regarding grievances brought forward by the Resident Council related to food quality and cleanliness of resident rooms for six (6) of (12) months of Resident Council meetings reviewed.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the Resident's nutritional status by coding the resident as receiving tube feeding when the resident had no feeding tube, did not receive enteral nutrition during the assessment reference period, and had an active physician order for a regular diet, affecting one (1) of (16) residents reviewed for MDS accuracy. (Resident #24).

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) Level I screenings were completed accurately and residents received appropriate referral for PASRR Level II evaluation in accordance with PASRR requirements, affecting two (2) of (2) residents reviewed for PASRR requirements. (Residents #2 and #8). Findings Include:A review of the facility's policy, Resident Assessment- Coordination with PASARR program with revision date 10/30/25, revealed Policy: the facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder (MD), intellectual disability (ID), or related condition receives care and services in the most integrated setting appropriate to their needs. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and implement individualized comprehensive care plan interventions that addressed residents' assessed needs and physician-prescribed treatment regiments, for three (3) of (16) residents reviewed for comprehensive care planning. (Residents #6, #7, and #55).

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to ensure the resident environment remained as free of accident hazards as possible by maintaining Resident #7's call light within reach, consistent with the resident's assessed fall risk, left-sided hemiplegia, need for assistance with mobility and toileting, and comprehensive care plan interventions, affecting one (1) of (16) residents reviewed for accident prevention. (Resident #7).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure required oxygen cautionary signage was posted for a resident receiving oxygen therapy, affecting one (1) of two (2) residents reviewed for respiratory care. (Resident #12).

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure residents receiving psychotropic and high-risk medications, including anticoagulants, were monitored for potential adverse consequences in accordance with professional standards of practice and facility policy, affecting two (2) of five (5) residents reviewed for unnecessary medications. (Residents #7 and #55).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents' rights to privacy and confidentiality were maintained when personal care signage was posted on the wall for two (2) of three (3) survey days. Resident #10 and Resident #29. Findings Included: A review of the facility's policy, Promoting/Maintaining Resident Dignity, dated 10/10/24, revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .Compliance Guidelines: . 12. Maintain resident privacy . A review of the facility's policy, Resident Rights, dated 2/10/25, revealed, . The facility will inform the resident .of his or her rights and all the regulations governing resident conduct and responsibilities during the stay in the facility . Resident rights. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than five percent (5%) for four (4) of thirty-one (31) observed medication opportunities, resulting in a medication error rate of 12.9%.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure medications were administered according to professional standards of practice by crushing and combining all medications into a single dose for administration via Percutaneous Endoscopic Gastrostomy (PEG) tube, without providing a rational for combining the medication or individualized resident needs, for one (1) of three (3) residents reviewed with feeding tubes. (Residents #11).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to prevent the possible spread of infection by not following manufacturer guidelines for cleaning and disinfecting the glucometer for one (1) of two (2) residents observed for blood glucose monitoring, Resident #95.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure daily nurse staffing information was posted in a visible and accessible location for two (2) of three (3) survey days.

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to store foods safely as evidenced by food left open and exposed on shelves, undated/unlabeled foods without a use-by -date, food stored without an identifying label, and not discarding food items after their use-by or sell-by date for one (1) of two (2) kitchen observations. Findings Include: A review of the facility's policy titled, Food and Supply Storage, review date 08/2021, revealed, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Most products contain an expiration date. The words sell-by or use-by should precede the date . The sell-by, best-by or use-by date is the last date that a food can be consumed . [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to correct a quality deficiency from a previous survey for one (1) re-cited deficiency of five (5) cited deficiencies from a previous annual recertification survey in October 2021. The deficiency was related to initiating and implementing care plans. The facility's continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee. Findings Include: [...]

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to complete the Discharge Minimum Data Set (MDS) assessments for one (1) of 16 residents sampled. Resident # 6 Findings Include: A review of the facility's policy titled, MDS 3.0 Completion, reviewed/revised 10/02/23, revealed, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan . Policy Explanation and Compliance Guidelines: 2f. Discharge Assessment - completed using the discharge date as the ARD (Assessment Reference Date). Must be completed within 14 days of the discharge date /ARD . A record review of the facility's Face Sheet, revealed the facility admitted Resident #6 on 07/20/23, with diagnoses that included Essential Hypertension. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed develop a comprehensive care plan for a resident (Resident #21) who had an indwelling catheter and failed to implement comprehensive care plan interventions for medication administration (Resident #21) and toenail care (Resident #34) for two (2) of 16 resident care plans reviewed. Findings Include: Review of the facility's policy Care Plans, Comprehensive Person-Centered, revised December 2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timelines to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Policy Interpretation and Implementation .8. The comprehensive, person-centered care plan will .b. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to follow a physician's order to obtain a resident's pulse before administering an antihypertensive medication for one (1) of four (4) medication administration observations. Resident #21 Findings Include: Review of the facility's policy, Medication Administration, with a revision date of 2/2023, revealed Policy: Medications are administered by licensed nurses .in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .Example guidelines for Medication Administration .Medication requiring vital signs prior to administration .Anti-Hypertensives . [...]

Inspectors wroteBased on observation, interviews, record review, and the facility policy review, the facility failed to provide Activities of Daily Living (ADL) care for a resident who was dependent upon staff for toenail care for one (1) of two (2) residents reviewed for ADL care.

Inspectors wroteBased on observations, staff interview, record review, and facility policy review the failed to ensure multidose insulin pens were dated when opened for six (6) of 19 diabetic residents who are prescribed multidose insulin pens. Findings Include: Review of the facility's policy, Labeling of Medication Containers, revised 4/2007, revealed, Policy Statement .All medications maintained in the facility shall be properly labeled in accordance with the current state and federal regulations .Policy Interpretation and Implementation .3. Labels for individual drug containers shall include all necessary information, such as .h. The expiration date when applicable; . On 12/18/23 at 3:30 PM, an observation of the 600 Hall medication cart, with Licensed Practical Nurse #2 (LPN), revealed an opened NovoLog FlexPen pre-filled multi-dose insulin pen with no date indicating when the pen was opened. [...]

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to provide the resident, or the Resident Representative (RR), written notification of a hospital transfer at the time of transfer for three (3) of three (3) sampled residents reviewed for hospitalization. Resident #8, Resident #22, and Resident #24. Findings Include: Review of the facility's, Transfer or Discharge Notice revised December 2016 revealed Policy Statement: Our facility shall provide a resident and or the residents representative (sponsor) with a thirty (30)-day written notice of impending transfer or discharge. Policy Interpretation and Implementation: 1. A resident and or his or her representative (sponsor) will be given 30-day advance notice of an impending transfer or discharge from our facility. 2. [...]