Muscogee Manor & Rehabilitation Ctr

Inspectors wroteBased on observations, interviews, record review, and review of the facility's policy titled Self-administered Medication, Treatments, the facility failed to ensure that one resident (R) (R57) of 42 sampled residents swallowed medication before leaving the resident's room. This deficient practice had the potential to increase the risk of clinical complications.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility's policies titled Privacy Policy, Medication Administration General Guidelines, and Electronic Medical Records, the facility failed to ensure that private, clinical information was not visible to unauthorized staff, other residents, and visitors for three of 42 sampled residents (R) (R51, R62, and R43) and one of three medication carts. This deficient practice had the potential to place R51, R62, R43, and other residents at risk for protected health information to be viewed by unauthorized individuals.

Inspectors wroteBased on observation, interview, record review, the facility's policy titled Care Plan Policy, the facility failed to develop and/or implement a comprehensive care plan related to oxygen and medication parameters for two residents (R) (R62 and R70) from a sample of 42 residents. The deficient practice had the potential to increase the risk of clinical complications for R62 and R70.

Inspectors wroteBased on record reviews, staff interviews, and the facility policy titled Medication Administration Subcutaneous Insulin, the facility failed to follow physician ordered protocol for finger stick blood sugar results and failed to accurately administer insulin from a pen device for two residents (R) (R83 and R51) from a sample of 25 residents receiving insulin. The deficient practice increased the risk of poor clinical outcomes.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Therapy Guidelines, the facility failed to ensure that one of 11 residents (R) (R70) receiving oxygen was administered oxygen therapy in accordance with the physician orders. This deficient practice had the potential to place R70 at risk for respiratory complications and a diminished quality life.

Inspectors wroteBased on observations, staff interviews, record review and review of the facility's policy titled Medication Administration General Guidelines, the facility failed to follow acceptable standards of practice when administering medications for one resident (R) (R62) from a sample of 42 residents. The deficient practice had the potential to increase the risk of poor clinical outcomes.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to place open dates on two bottles of glucose test strips in two of four medication carts. This deficient practice had the potential to cause abnormal blood sugar readings and worsening of the residents' medical conditions.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policies titled, Food Storage, Floor Stock, and Accepting Food Deliveries, the facility failed to ensure proper labeling and storage of food with open and expiration dates, failed to discard food items by the expiration dates, and failed to properly cover opened food items. This deficient practice had the potential to affect 85 residents who received food orally.

Inspectors wroteBased on resident and staff interviews, record reviews, review of the facility's policy titled, Advance Directive Policy, and review of the facility's admission Agreement-Statement of Acknowledgement, the facility failed to provide residents or resident representatives written information regarding choices and the right to accept or refuse medical or surgical treatment for one of seven sampled residents (R) (R56). This deficient practice had the potential to affect the resident or representative's ability to make informed decisions about their care.

Inspectors wroteBased on staff interviews and record review, the facility failed to submit for a Preadmission Screening and Resident Review (PASRR) Level II for a mental health diagnosis for one of 33 residents (R) (R82). This deficient practice had the potential for R82 not receive services and/or care according to his needs.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Care Plan Policy, the facility failed to ensure that a care plan was developed and/or implemented for three of 23 residents (R) (R19, R24, and R6). Specifically, the facility failed to implement the care plan for (R19 and R24) for monitoring and recording meal intake and the facility failed to develop and implement a care plan for (R6) for oxygen use.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policy titled Accident/Hazard Prevention, the facility failed to ensure a working door alarm to prevent the elopement of one of 31 residents (R) (R73) housed on a COVID unit. This failure had the potential to place R73 at risk for avoidable accidents and adverse consequences.

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and review of the facility's policy titled, Oxygen, Therapy, the facility failed to ensure oxygen was administered as ordered by the physician for one of twelve residents (R) (R6) receiving oxygen. The deficient practice had the potential to place R6 at risk for medical complications, and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of facility's policy titled, Food Service Policy and Procedures, the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance of food. Specifically, the facility failed to use a recipe when preparing pureed food. This deficient practice has the potential to affect 13 residents who were ordered a pureed diet.

Inspectors wroteBased on observations, interviews, staff interviews, and review of the policy titled, Medication Storage in The Care Center the facility failed to ensure that three of eight medication carts and one of three treatment carts were locked when the carts were out of view of the nurse. Additionally, one bottle of eye drops requiring refrigeration was unrefrigerated and an inhaler was not stored properly.

Inspectors wroteBased on observation, record review, staff and resident interviews, the facility failed to accommodate the needs for one of 30 sampled residents (R) (#48) related to providing a wheelchair for mobility out of the room.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Protection of Resident Funds, the facility failed to maintain a surety bond sufficient to cover the resident trust fund account balance for 107 of 108 residents with a trust fund account at the facility. The facility also failed to ensure the surety bond obligee was the Georgia Department of Community Health.