Harborview Satilla

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans, Facility A failed to implement the comprehensive care plan for one of 63 sampled Residents (R) (R112). Actual harm occurred on 12/5/2025 when Certified Nurse Assistant (CNA) LL failed to transfer R112 using two people to assist, which resulted in a left humerus fracture.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Safe Resident Handling/Transfer, Facility A failed to ensure safe transfer to a shower chair for one of 68 sampled residents (R) (R112). Actual harm occurred on 12/5/2025 when Certified Nurse Assistant (CNA) LL failed to transfer R112 using two people to assist, which resulted in a left humerus fracture. Review of the facility's policy titled, Safe Resident Handling/Transfer, dated 1/1/2026, under the Policy section stated, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk of injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. [...]

Inspectors wroteBased on observations, staff interviews, record review, and review of facility's policy titled, Date Marketing for Food Safety Policy, Facility A failed to ensure food was stored, sealed, and labeled correctly. This deficient practice affected the facility kitchen and had the potential to cause food contamination and foodborne illness among all residents consuming facility-prepared food. Facility A had 75 sampled residents that received an oral diet from the kitchen.

Inspectors wroteBased on observation, record review, and review of the facility's policy titled, Disposal of Garbage and Refuse, Facility A failed to ensure trash and garbage refuse for one of two dumpsters was maintained in a sanitary manner, creating a potential of harboring pest and insects. The facility's census was 75 residents.

Inspectors wroteBased on observation, staff interviews, record review and review of the facility's policy titled Promoting/Maintaining Residents Dignity, Facility A failed to provide one of 59 sampled Residents (R) (R22) privacy during wound care. This deficient practice had the potential to place R22 at risk of diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings Include:Review of the facility's policy titled, Promoting/Maintaining Residents Dignity, dated 1/1/2026 under the Policy section revealed that it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Abuse Neglect and Exploitation, Facility A failed to protect the residents' right to be free from resident-to-resident abuse for one of two residents (R) ( R151) reviewed for abuse. Specifically, R119 touched R151 on the breast. This deficient practice had the potential to affect other residents at the facility.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled, MDS 3.0 Completion, Facility B failed to complete and transmit a Minimum Data Set (MDS) discharge assessment to the Center for Medicaid Services (CMS) for one of two residents (R) (R137) reviewed for discharge.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility's policy titled Medication Administration via Enteral Tube, Facility A failed to ensure services provided met the professional standards of quality care for one of five Residents (R) (R 124) with gastrostomy tubes. This deficient practice had the potential to result in an adverse drug reaction, ineffective treatment, and medical complications.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled, Medication Storage and Controlled Substance Administration & Accountability, Facility A failed to ensure that three of three medication carts ([NAME] Hall, Sunflower Hall, and Dogwood Trail) did not have expired, unlabeled, and discontinued medications stored on the medication carts. The deficient practice had the potential to place residents at risk of receiving expired medications.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Enhanced Barrier Precautions, Facility A failed to ensure infection control practices were followed for one of two sampled Residents (R) (R22) reviewed for pressure ulcers. This deficient practice had the potential to place R22 at risk of infection due to cross-contamination and exposure.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Comprehensive Care Plan the facility failed to ensure the care plan was followed for two person assistance toileting for one Resident ((R) R1) of three residents which resulted in R1 having a fall. On 4/12/2025, actual harm was identified when Certified Nursing Assistant (CNA) BB was providing care alone resulting in R1 falling out of bed and sustaining a left femoral neck fracture and left frontal scalp hematoma.

Inspectors wroteBased on medical record review, staff interviews and review of the facility policy Accidents and supervision, the facility failed to ensure that one resident (R1) of three residents was provided with enough staff to complete perineal care of residents while in bed. On 4/12/2025, actual harm was identified when Certified Nursing Assistant (CNA) BB was providing care alone resulting in R1 falling out of bed and sustaining a left femoral neck fracture and left frontal scalp hematoma.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policy titled, Medication Administration, Facility B failed to ensure over-the-counter medication were not stored at the bedside for one of 55 residents (R) (R151). This deficient practice had the potential to allow unauthorized access of unsecured medications to residents and visitors.

Inspectors wroteBased on interviews, record review, and review of the facility's policy titled, Transfer and Discharge, Facility A failed to provide notice of transfer/discharge to residents or their representatives for one of four sampled residents (R) (R2) reviewed for hospitalization.

Inspectors wroteBased on record reviews, interviews, and review of the facility's policy titled, Bed Hold Prior to Transfer, Facility A failed to provide a notice of bed hold for one of four residents (R) (R2) reviewed for hospitalization.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled, Comprehensive Care Plan and Nail Care Policy, Facility A failed to implement the care plan for two of 55 residents (R) (R22 and R12). Specifically, the facility failed to provide a scoop mattress for resident (R22) and failed to provide proper nail care for (R12). The sample size was 55.

Inspectors wroteBased on observations, record reviews, staff interview, and review of the facility's policy titled, Nail Care, Facility A failed to perform nail care for one totally dependent resident (R) (R12), who had a left-hand contracture. The sample size was 55 residents.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policy titled, Oxygen Administration, Facility B failed to ensure oxygen administered by nasal cannula was set at the prescribed rate for one of 42 residents (R) (R30) receiving oxygen therapy. The deficient practice has the potential to cause adverse consequences for the R30.

Inspectors wroteBased on record review and staff interview, and review of the facility's policy titled, Use of Psychotropic Medication, Facility B failed to indicate the need to extend orders for as needed (PRN) antianxiety medication for one of four residents (R) (R18) beyond 14 days and failed to document the reason for the extension to be in effect.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Date marking for food safety, facility A failed to discard food in the walk-in cooler by the use by date and failed to label and date opened food items in the walk-in refrigerator and dry storage area, this deficient practice had the potential to effect 86 of the 89 residents receiving an oral diet.

Inspectors wroteBased on observation, policy review, staff interview, and review of facility policy titled Food Receiving and Storage, Facility A failed to ensure food items in the dry storage areas were labeled, dated, and failed to discard food items by expiration date. This deficient practice had the potential to affect 84 of 89 residents at Facility A.

Inspectors wroteBased on observation, interview and review of the facility's policy titled Bilevel (CPAP) Therapy, Facility B failed to ensure Continuous Positive Airway Pressure (CPAP) respiratory supplies were properly stored and reservoir emptied when not in use for one resident (R) (R#29) of 19 residents receiving respiratory treatments.

Inspectors wroteBased on record review, staff interview, and review of policy titled Stop orders for Acute Conditions, Facility B failed to ensure that PRN [as needed] orders for psychotropic drugs documented the rationale for the extended duration for the PRN order for one resident (R) (R#132) of five residents reviewed for medication management.