Macon Rehabilitation and Healthcare

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled Abuse Prevention Policy, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA), specifically an alleged head injury, within the required time frame for one of three sampled residents (R) (R1).

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled Abuse Prevention Policy, the facility failed to thoroughly investigate an allegation of injury of unknown origin for one of three sampled residents (R) (R1).

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Food Storage: Cold Foods, the facility failed to ensure food items were covered/wrapped, labeled, and dated when opened. In addition, the facility failed to ensure sanitary conditions for two of two ice machines used by the kitchen. Additionally, the facility failed to ensure sanitary conditions in the kitchen. These deficient practices had the potential to place the 89 residents receiving food and hydration from the kitchen at risk of foodborne illness.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Behavioral Management Program, the facility failed to refer one of two residents (R) (R5) reviewed for Preadmission Screening and Resident Review (PASRR), from a total sample of 46, for evaluation by the appropriate State-designated authority. This deficient practice has the potential to place R5 at risk of not receiving necessary care and services. [...]

Inspectors wroteBased on staff and resident interviews, record review, and review of the facility policy titled Activities of Daily Living, the facility failed to ensure two of 46 sampled residents (R) (R53 and R72) received assistance with Activities of Daily Living (ADL) care. This deficient practice had the potential to place R53 and R72 at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, record review, and review of facility policy titled Infection Prevention and Control Program, the facility failed to follow infection control procedures for one resident (R) R68 on Enhanced Barrier Precautions (EBP). This deficient practice had the potential to increase the risk of the spread of infection in the facility. The census was 94.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled Care Plan Policy, the facility failed to ensure a care plan was developed or implemented for six of 37 residents (R) (R46, R51, R61, R4, R54, R67). Specifically, the facility failed to ensure the care plan was implemented for R46 and R51 for Activities of Daily Living (ADL), R61 for providing a privacy bag for a urinary catheter, R4 for oxygen use, and R54 for tube feeding. In addition, the facility failed to develop a care plan for R67 for the use of antipsychotic and anticoagulant medications. The deficient practices had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policies titled Activity of Daily Living, Quality of Life, Special Rehabilitative Services, and Nail Care (Finger and Toe), the facility failed to ensure five residents (R) (R51, R29, R21, R56, and R46) were provided care and services in accordance with their personal needs. Specifically, the facility failed to ensure R51 and R29's nails were clean and trimmed, R46's beard was trimmed and clean without food particles present, and R21 and R56 received baths and removal of facial hair. These failures placed R51, R29, R21, R56, and R46 at risk for unmet needs and a diminished quality of life. The sample size was 37 residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Urinary Catheter Care, Anchoring and Changing, the facility failed to ensure a urinary catheter privacy bag was provided for one of four residents (R) (R61) with a urinary catheter. This failure had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on observation, resident and staff interviews, and a review of the facility's policy titled Care Plan Policy, the facility failed to update the care plan for one resident (R) (R56) related to an indwelling urinary catheter that had been removed and discontinued. The sample size was 37 residents. This failure placed R56 at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility's policy titled Nail Care (Finger and Toe), the facility failed to obtain a podiatry appointment for one resident (R) (R39) of 37 sampled residents. This deficient practice had the potential to cause R39 unnecessary discomfort and decreased quality of life.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility's policy titled Enteral Nutrition Policy, the facility failed to provide enteral (a method of supplying nutrients directly into the gastrointestinal tract) nutrition according to physician orders for one resident (R) (R54) of 10 residents receiving enteral feeding in the facility. This deficient practice placed R54 at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Tracheostomy Policy, Emergency Management, Tracheostomy Care and Services, and Oxygen Therapy Policy, the facility failed to ensure two residents (R) (R71 and R14) had a written physicians order for the tracheostomy tube sizes in use. In addition, the failed to ensure respiratory supplies for R71 were available at the bedside. Additionally, the facility failed to ensure two residents (R24 and R4) receiving oxygen (O2) therapy had written physician orders for oxygen use, ensure oxygen was administered as ordered by the physician, and failed to ensure oxygen concentrator filters were free of dust and debris. The deficient practices had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life. The sample size was 37 residents.

Inspectors wroteBased on staff and resident representative interviews, record review, and review of facility policies titled Resident Grievance Policy, and Resident Rights, the facility failed to appropriately resolve a resident's grievance related to lost personal items and keep the resident informed of the progress towards resolution for one resident (R) (R2) of 15 sampled residents.

Inspectors wroteBased on staff and resident representative interviews, record review, and review of the facility policy titled Incident Report-Documentation, Investigating, and Reporting, the facility failed to ensure a reportable incident for one of 15 sampled residents (R) (R8) to the State Agency (SA) in a timely manner. Specifically, the facility failed to report an incident of a mechanical device failing to operate and hitting R8 in the face.

Inspectors wroteBased on observations, record review, interviews, review of the facility policies, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to implement effective infection control program to prevent the spread of infections. Specifically, the facility failed to follow isolation procedures; facility failed to ensure signage was posted for use of personal protective equipment (PPE) and failed to ensure that PPE was worn appropriately on two of two Halls (North Hall and South Hall) to prevent the spread of SARS-CoV-2 infection.

Inspectors wroteBased on record review and staff interview, the facility failed to attempt to obtain background checks for eight of 11 files reviewed and reference checks for nine of 11 employee files reviewed.

Inspectors wroteBased on observations, interviews, and record review the facility failed to (1) ensure the care plan was followed for one of 28 sampled residents (R#35) related receiving oxygen as ordered; (2) failed to develop an Activities of Daily Living (ADL) care plan for one of 28 sampled residents (R#1) related to grooming and dressing; (3) failed to implement an Activities of Daily Living (ADL) care plan for two of 28 sampled residents (R#2 and R#39) related to grooming and dressing; (4) failed to implement the activities care plan for three of three residents (R#1, R#16, R#39) reviewed for activities.

Inspectors wroteThe facility failed to provide an individualized activities program to meet the needs of three of three residents (R#1, R#16, and R#39) reviewed for activities.

Inspectors wroteBased on observation, interview and review of the facility's policy, the facility failed to ensure an expired medication was not available for use and that controlled substances (narcotics) were stored under double lock in one (1) of one (2) medication refrigerators.

Inspectors wroteBased on observations, resident interview, and staff interviews the facility failed to ensure that it was maintained in a safe clean and comfortable environment. Specifically, the facility failed to ensure residents toilets were in good repair in one (N18) of 64 resident toilets.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) care for four of 28 samples residents (R) (R#2, R#39, R#1, and R#129).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that one resident (R) (R#49) received treatment and care in accordance with professional standards of practice related to timely care and treatment of a newly identified impairment of skin integrity. The sample size was 28 residents.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide treatment and assessments to monitor and prevent a reduction in Range of Motion for one of 28 sampled residents (R) (R#2).

Inspectors wroteBased on observations, interviews, and review of policy titled Oxygen Therapy Policy the facility failed to ensure one of four residents (R#35) receiving oxygen received oxygen as ordered.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the medication error rate was less than five per cent (5%). A total number of 28 medication opportunities were observed, and there were two errors for one of three residents (R) (R#39), by one of two nurses and one certified medication aide (CMA) observed giving medications, for an error rate of 7.14%.