Sadie G. Mays Health & Rehabilitation Center

Inspectors wroteBased on observation, interview, record review, and a review of the policy titled Food Preparation Guidelines, the facility failed to prevent avoidable accidents for two of three sampled residents (R) (R41 and R56) related to (1) hot chocolate burn and (2) fall risk. Harm was identified to have occurred on 3/18/2025 when R41 spilled hot chocolate on her left arm, causing a burn, blisters, and requiring transport to an acute care setting and wound treatment.

Inspectors wroteBased on record review, staff interviews, and a review of the policy titled Management of Beneficiary Funds, the facility failed to ensure that the surety bond was sufficient to cover the resident trust fund deposits. This deficient practice had the potential to adversely affect 129 of 129 residents in the facility.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to have an adequate water management program for 129 of 129 residents in the facility. The facility's water management program was incomplete and was not consistent with current ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers) Guidelines, which specifically called for design and maintenance procedures for the potential exposure of Legionnaires' disease (a serious pneumonia infection) within a healthcare facility.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Call Lights: Accessibility and Timely Response, the facility failed to ensure the call button was accessible for one of 27 sampled residents (R) (R56). This failure had the potential to place R56 at risk for accidents, injuries, or unmet needs related to an inability to call for staff assistance.

Inspectors wroteBased on record review, resident family member and staff interviews, and a review of the policies titled Medication Administration and Notification of Changes, the facility failed to ensure the physician was notified of a change of condition for one of 27 residents (R) (R93) related to a refusal of bedtime medications for four days in a row. This failure had the potential to result in clinical complications and potentially hospitalization.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled, Administering Medications, the facility failed to ensure the provider and the resident representative were notified when seven out of 21 sampled Residents (R1, R2, R3, R4, R5, R6, and R7) were not administered their medications, as ordered by the provider. This failure placed the provider and the resident's representatives of potential complications from not receiving their medications.

Inspectors wroteBased on resident and staff interviews, record review, and review of facility policy, the facility failed to ensure medications were administered per the provider's order for seven of 21 sampled (Residents (R)1, R2, R3, R4, R5, R6, R7 reviewed. This failure placed the residents at risk of health complications and a diminished quality of life.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain the dignity of one out of 21 Resident (R) (R14) reviewed in the sample. Specifically, the facility did not have any urinary drainage bags available and R14 was placed in an adult incontinence brief. This had the potential for the resident to have a diminished quality of life.

Inspectors wroteBased on record review, resident and staff interviews, and review of the facility’s policy titled, “Policy and Procedure, the facility failed to timely report allegations of abuse to the required agencies and physician within the state reporting time frame for two of 21 sampled Residents (R) (R12 and R9). This failure has the potential to increase the risk of abuse.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to conduct a thorough investigation of alleged abuse of two (Residents (R)12 and R9) out of 21 sampled residents. This failure had the potential to provide a safe environment for all residents against abuse.

Inspectors wroteBased on observation, record review, staff interview, and review of facility policy, the facility failed to revise the care plans related to falls for four (Residents (R)9, R10, and R15) from a sample of 21 residents. This failure had the potential for residents to continue to fall and possibly result in injuries.

Inspectors wroteThe facility failed to ensure activities of daily living (ADLs) were provided for one of three residents (Residents (R)9) who was dependent on staff for assistance with ADLS out of a total sample of 21. This failure placed R9 at risk of a diminished quality of life.

Inspectors wroteBased on observation, staff interviews, record review, and review of facility policy, the facility failed to ensure adequate supervision to potentially prevent accidents for two of four residents (Residents (R)9 and R11) reviewed for accidents in a total sample of 21. These failures placed the residents at risk of injury and unmet care needs.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to properly position urinary drainage bags to promote adequate drainage and to potentially prevent recurring urinary tract infections (UTIs) for two residents (R)16 and R14 from four residents with urinary drainage bags out of a total sample of 21 residents. This failure has the potential for residents to develop recurring UTIs.

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and review of the facility policy titled, Standard Precautions, Administering Oral Medications, and Glucometer Cleaning, the facility failed to ensure nebulizers were bagged, dated, and labeled for two of three residents (R) (R20, R68); ensure the oxygen concentrator tubing was dated and the filter in the concentrator was clean for one resident (R20); and ensure bed pans were properly bagged, labeled, and stored for one resident (R607); and (5) to properly clean and disinfect the medication cart and provide a clean barrier for accu-checks for one resident (R74).

Inspectors wroteBased on record review, staff interviews, and review of the facility policies titled, Antibiotic Stewardship, Antibiotic Stewardship - Orders for Antibiotics, and Antibiotic Stewardship - Review and Surveillance of Antibiotic Use the facility failed to maintain review of antibiotic prescribing practices and the documentation of the programs efforts to follow up on antibiotic usage data for all nine months (January 2024 to September 2024) that were reviewed. The deficient practice had the potential to affect any resident who was prescribed an antibiotic.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating the facility failed to report an alligation of sexual abuse for two of four residents (R10 and R108) reviewed for abuse.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating the facility failed to complete a thorough investigation of abuse for three of four residents (R) (R98, R96, and R3) investigated for abuse.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed quarterly for two residents (R) (R33) and (R405) of 58 sampled residents.

Inspectors wroteBased on staff interviews, record review, and a review of the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to ensure that the baseline care plan was completed for one of 11 residents (R) (R355) admitted with a catheter.

Inspectors wroteBased on observations, staff interviews, record review, and the facility's policy titled Activities of Daily Living (ADL), Supporting, the facility failed to provide preventative care consistent with professional standards of practice for one of 58 sampled residents (R) (R455) at risk for skin breakdown related to repositioning.

Inspectors wroteBased on observations, record reviews, staff and resident interviews, and review of the facility policy titled, Call System, the facility failed to ensure that one of 58 sampled residents (R) (R23) had a functioning call light.

Inspectors wroteBased on observation, record review, interviews, and facility policies, the facility failed to ensure two of 19 residents (R) (R6 and R15) weren't provided with nursing care and services to ensure their medical needs were met related to pain management for R6 and R15; administering medication without a physicians order for R15; and a pest infestation of gnats that were on the R6 left leg wound. Further, harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate.

Inspectors wroteBased on observation, record review, staff interviews, and the facility policy Administering Medications the facility failed to ensure one of forty-three sampled residents (R) (R15) was receiving medications as prescribed by the psychiatrist. The pharmacy continued to dispense Fluoxetine (Prozac) to R15 after it was discontinued on 6/29/2023 by the psychiatrist. Harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate.

Inspectors wroteBased on interviews, record review, and review of facility policy titled Administering Medications, the facility failed to ensure one of two residents (R) (R15) was free from unnecessary psychotropic medications. Resident (R15) was administered Fluoxetine (Prozac) during a medication observation. Harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate.

Inspectors wroteBased on record review, staff interviews, and the State of Georgia Nurse Aide Registry Nurse Aide Certification Renewal the facility failed to ensure that two Certified Nursing Assistance (CNA) certifications were renewed out of ten employee files selected for review. One CNA TT worked six months with an expired certification and CNA UU worked thirty days with an expired certification. The facility's census was one hundred and fifty-five residents.

Inspectors wroteBased on observation, staff interviews, and review of the facility policies titled Cleaning and Disinfection of Resident-Care Items and Equipment, and Administering Medications, the facility failed to maintain infection control standards by not cleaning and disinfecting reusable items between residents, and not performing hand hygiene after assisting a resident and picking paper up off the floor during a medication observation. The facility census was 150 residents.

Inspectors wroteBased on observation, resident and staff interviews, and review of the facility policies titled, 7 Step Cleaning Process, and Maintenance Service, the facility failed to maintain a safe, clean, and comfortable, homelike environment in five of 30 sampled resident rooms related to a buildup of dirt and grime inside the air discharge grille of the Packaged Terminal Air Conditioner (PTAC) units; a large hole under the sink in one bathroom; missing sheetrock in one resident's room; and by not ensuring an adequate supply of linen for nine days.

Inspectors wroteBased on observations, interviews, and a review of the facility's policies titled Pest Control and Maintenance Service, the facility failed to maintain an effective pest control program on one of four units (Unit B) related to an infestation of black gnats.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure reasonable accommodation of needs was provided for two of 16 sampled residents (R) (R6 and R8) related to providing wheelchair accessibility to accommodate R6 in getting out of bed and related to honor accommodations for bathing for R8.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policies titled Abuse, Neglect, and Exploitation, the policy titled Background Screening Investigations, and the Director of Human Resource job description, the facility failed to ensure that a criminal background check was conducted for two Registered Nurse's (RN) of ten employee files selected for review (RN GG and RN HH). The facility census was one hundred and fifty residents.

Inspectors wroteBased on record review, interviews, and review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, the facility failed to report a situation involving misappropriation of a controlled drug (Oxycodone) to the State Survey Agency (SSA) for two of 18 sampled residents (R) (R17 and R18).

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled Care Plans, Comprehensive Person-Centered and Activities of Daily Living (ADL), Supporting, the facility failed to develop a comprehensive, person-centered care plan for five residents (R) (R3, R7, R8, R9, and R16) of sixteen reviewed for care plan. This failure had the potential for these residents not to receive treatment and/or care according to their needs.

Inspectors wroteBased on observations, staff interviews, record reviews, and a review of the facility policy titled Activities of Daily Living (ADL), Supporting, the facility failed to provide ADL assistance to one of eight residents (R) (R9) reviewed. This failure had the potential to cause R9 to be unclean and feel self-conscious of his appearance.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policies titled Background Screening Investigations and Hiring Process, the facility failed to ensure that one of three staff members (Registered Nurse (RN) HH) had the required licensure to provide nursing care to the residents. The facility census was 150 residents.

Inspectors wroteBased on record review, staff interviews, and the facility policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents, the facility failed to obtain vaccination consent before administering COVID-19 vaccines on two of five Residents (R) (R1 and R10) reviewed for vaccination status.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to provide a privacy curtain to ensure personal privacy for two of 45 sampled residents (R) (R#16 and R#47).

Inspectors wroteBased on record review, interviews, observations, and review of the facility's policy titled, Oxygen Administration, it was determined the facility failed to follow physician orders related to oxygen administration for two of two residents (R) (R#44 and R#134) reviewed with oxygen.

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility's policy titled, Administering Medications, it was determined that the facility failed to maintain a medication error rate of 5% or less. There were two errors out of 27 opportunities, which resulted in a 7.4% medication error rate for two of three residents (R) (R#105 and R#106) observed during medication pass.

Inspectors wroteBased on interviews, observations, and review of the facility's policy titled, Storage of Medications and Administering Medications, it was determined the facility failed to maintain a secure, locked medication cart for one out of six medication carts.