Resorts at Pooler Inc

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled Dietary Services: Food brought in the facility by Family or Visitors and Food Storage Guide: Food Dating and Labeling Guidelines, the facility failed to ensure food items were labeled, dated, and not beyond their expiration date. This deficient practice had the potential to adversely affect 84 of 84 residents receiving an oral diet from the kitchen.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that the outdoor garbage and refuse area was free from debris. This deficient practice had the potential to attract pests and rodents and transfer harmful microorganisms to food, leading to foodborne illness for the 84 residents residing in the facility.

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility policy titled Nursing Home and Resident Rights, the facility failed to ensure resident privacy during incontinent care for one of 37 sampled residents (R) (R90). This deficient practice had the potential to place R90 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled Resident Self-Administration of Medication, the facility failed to ensure that one of 37 sampled residents (R) (R61) did not have unauthorized and unsecured medication and medicated treatment products at the bedside. This deficient practice had the potential to cause adverse effects for R61 and allow unsecured medication and medicated treatment products to be accessible to other residents.

Inspectors wroteBased on observations, staff interviews, record reviews, and the facility policy titled Comprehensive Care Plans, the facility failed to follow the plan of care for one of 37 sampled residents (R) (R44). This deficient practice had the potential to place R44 at increased risk of unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, staff and resident interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure infection control measures were followed for one of 37 sampled residents (R) (R55) by not storing a Continuous Positive Airway Pressure (C-PAP) [a non-invasive mechanical ventilator] mask properly. In addition, the facility failed to ensure that the oxygen flow rate was set correctly for one of 10 R receiving oxygen (R44). These deficient practices had the potential to place R55 and R44 at increased risk of medical complications.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to follow professional standards of practice in regard to following a physician's order to obtain a blood pressure prior to the administration of a blood pressure medication for one of six residents (R) (R16) reviewed for medication administration out of 16 total sample residents. This failure had the potential for R16 to be administered blood pressure medication unnecessarily and to experience adverse effects by receiving the blood pressure medication when not needed.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a physician-ordered antibiotic was available for administration from the pharmacy for one of two residents (R) (R3) out of a total sample of 16 residents. This failure had the potential for R3 to have adverse effects from not receiving the antibiotic as ordered by the physician.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to follow the parameters order for a blood pressure medication in which the medication was given to one of six residents (R) (R3) reviewed for medication administration out of 16 total sample residents. This failure had the potential for R3 to receive unnecessary medications.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to place a resident with an open wound in Enhanced Barrier Precautions (EBP) and failed to follow infection control guidelines for EBP during a dressing change for one of one resident (R) (R9) reviewed and observed for pressure wounds out of a total sample of 16 residents. This failure had the potential to increase the risk and spread of infections throughout the facility to a vulnerable population.

Inspectors wroteBased on staff interviews, record review, and review of facility policy titled Infection Control, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. This deficient practice had the potential to increase all residents' exposure to communicable illnesses. The facility census was 77.

Inspectors wroteBased on observations, resident and staff interviews, and review of the policies titled Maintenance Department Policy and Procedures and Cleaning and Disinfection of Environmental Surfaces, and review of the facility document titled Room Cleaning Step by Step, the facility failed to ensure that resident rooms were clean, homelike, and in good repair on two of three halls (Hall B and Hall C). The deficient practice placed residents at risk of residing in an unsanitary living environment and the potential for a diminished quality of life.

Inspectors wroteBased on staff interviews, family interview, record reviews, and a review of the facility policy titled Bed Hold Acknowledgement Form: Georgia, the facility failed to provide bed hold information, in writing, at the time of transfer or within 24 hours, for four of six residents (R) (R50, R66, R13, and R11) reviewed for transfer to the hospital. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policies titled Medication Orders and Storage of Medications, the facility failed to ensure unauthorized medications at the bedside were safely stored and failed to obtain a physician order for self-administration of medications for one of three residents (R) (R223) observed during medication administration. This deficient practice placed R223 at risk for unsafe medication use.

Inspectors wroteBased on staff interviews, record review, and a review of the facility policy titled Preadmission Screening and Resident Review (PASRR) Level I and II Policy, the facility failed to submit for a PASRR Level II for one resident (R) (R32) after a new mental illness diagnosis was added and failed to implement recommendations of a PASRR Level II for one resident (R16). This deficient practice had the potential to affect the appropriate level of care and services provided for R32 and R16. The sample size was 42.

Inspectors wroteBased on observations, staff interview, record review, and review of the facility policy titled Oxygen Therapy Policy, the facility failed to ensure oxygen equipment was safely stored for two of 19 residents (R) (R50 and R223) who received oxygen therapy. The deficient practice had the potential to increase the probability of respiratory infection for R50 and R223.

Inspectors wroteBased on observations, staff interviews, and review of facility menus, the facility failed to ensure the planned menu was followed related to portion sizes for nine residents that had physician's orders for a pureed diet.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to implement an infection prevention and control program (IPCP) designed to provide a safe and sanitary environment to help prevent the possible development and transmission of Coronavirus (COVID-19) as well as other communicable diseases and infections. Specifically, the facility failed to ensure visitors were screened for COVID-19 before gaining access to the facility and failed to ensure unvaccinated residents were encouraged to wear masks and/or socially distance from other residents throughout the facility. This deficient practice had the potential to affect all residents of the facility and occurred during the COVID-19 pandemic.