Lee County Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Leesburg, Georgia.
- Location
- 214 Main Street, Leesburg, Georgia 31763
- CMS Provider Number
- 115614
- Inspections on file
- 15
- Latest survey
- May 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lee County Health And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to administer critical medication as care planned, resulting in a resident's critical lab values not remaining within a therapeutic range. The resident, with a history of liver transplant and gangrene of the gallbladder, missed several doses of cyclosporine due to the facility's failure to follow up with the pharmacy. This noncompliance posed a risk of serious harm.
A resident with a liver transplant experienced acute cellular rejection due to the facility's failure to administer cyclosporine timely and accurately. The resident's cyclosporine trough levels were consistently outside the therapeutic range, and there were discrepancies in the administration of other medications. Staff interviews confirmed issues with medication management and communication.
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.4%. Errors included missed doses, incorrect medication forms, and incorrect dosages for three residents, confirmed through staff interviews and record reviews.
Failure to Administer Critical Medication as Care Planned
Penalty
Summary
The facility failed to ensure that medications were administered as care planned, which resulted in critical laboratory results not remaining within a therapeutic range for a resident. The resident had a care plan problem dated 1/9/2024, which included an intervention for nursing staff to administer medications and labs as ordered. The goal was to prevent hospitalization related to critical lab values. However, the facility did not follow through with this care plan, leading to a significant deficiency in care. The resident's clinical record revealed diagnoses including liver transplant status and gangrene of the gallbladder in cholecystitis. The resident was prescribed cyclosporine, an anti-rejection medication, to be administered twice daily. Despite the medication running out on 12/29/2023, there was no evidence that the facility's nursing staff followed up with the pharmacy or refilled the medication until 1/2/2024. This lapse in medication administration was documented in the resident's electronic Medication Administration Record (eMAR), showing missed doses on 12/30/2023, 12/31/2023, 1/1/2024, and 1/2/2024. Interviews with staff confirmed that cyclosporine is a critical immunosuppressant medication, and the resident's cyclosporine levels were undetectable due to the medication not being administered. The facility's failure to ensure the availability and administration of the medication as ordered led to a situation where the resident's critical lab values were not maintained within the therapeutic range, posing a risk of serious harm. The facility's noncompliance with the care plan and medication administration requirements was identified as having the likelihood to cause serious injury, harm, impairment, or death to residents.
Removal Plan
- R1 was discharged from the facility and no other residents in the facility are receiving antirejection medication.
- The policy for comprehensive care plans titled Patient's Plan of Care was reviewed by the Administrator, DON, and Divisional Nurse with no revisions made.
- The DON, Assistant Director of Nursing (ADON) and nurse managers reviewed all 58 of 58 resident's medication records and medication carts audited to ensure that medication was available for administration as indicated in the plan of care.
- The Divisional Nurse in-serviced 5 of 5 nurse managers including the DON, ADON, Registered Nurse (RN) Nurse Manager, Resident Assessment Instrument (RAI) Director, and Wound Care Coordinator regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/or discontinue medication as outlined in the facility's policy titled Medication Unavailable for Administration to ensure the plan of care is being followed.
- The DON initiated education for licensed nurses and Certified Medication Aides (CMAs) regarding following the plan of care regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/or discontinue medication as outlined in the facility's policy titled Medication Unavailable for Administration.
- The Divisional Nurse implemented a monitoring tool, F656 Development/Implementation of Comprehensive POC Audit Tool regarding administration of medication to include medication not administered due to unavailability and completed by the DON or nurse managers five times per week, Monday through Friday, to include review of medication administered on weekends.
- 11 of 12 nurses (6 RNs, 6 LPNs for a total of 92%) and 6 of 6 CMAs (for a total of 100%) were educated on documentation and following the plan of care for medication administration.
- The remaining 1 LPN nurse will be in-serviced on the next scheduled workday prior to beginning their shift by the Director of Nursing. Any RNs, LPNs and CMAs that are PRN or on LOA will be provided education upon return to work. Newly hired RNs, LPNs, and CMAs will be provided education during the orientation process.
- The Administrator reviewed the results of the audit during an ADHOC QAPI meeting.
- All Corrective Actions were completed.
- The facility alleges that the IJ is removed.
Failure to Administer Medications Timely and Accurately
Penalty
Summary
The facility failed to ensure that a resident obtained medications timely, administered as ordered, and maintained medication trough levels within a therapeutic range. The resident, who had a liver transplant and was diagnosed with gangrene of the gallbladder in cholecystitis, was prescribed cyclosporine, an anti-rejection medication. However, there were multiple instances where the medication was not administered as scheduled, and the facility staff did not follow up with the pharmacy to ensure timely refills. This led to significant lapses in the administration of the medication, which was critical for preventing organ rejection. The resident's cyclosporine trough levels were consistently outside the therapeutic range, with some levels being undetectable, indicating that the medication was not administered properly. Despite the physician's orders and the facility's policy, the nursing staff failed to reorder the medication in a timely manner and did not notify the provider when the medication was unavailable. This resulted in the resident experiencing acute cellular rejection and elevated liver function tests, leading to hospitalization shortly after discharge from the facility. Additionally, there were discrepancies in the administration of other medications, such as mycophenolate mofetil and valganciclovir, with more doses documented as administered than what was provided by the pharmacy. This further highlights the facility's failure to manage and administer medications accurately, putting the resident's health at serious risk. Interviews with staff and family members confirmed the issues with medication administration and the lack of proper communication and follow-up with the pharmacy and healthcare providers.
Removal Plan
- R1 was discharged from the facility, there are no other residents in the facility receiving antirejection medication.
- The policy for Medication Unavailable for Administration was reviewed by the Division Nurse, DON, and Administrator with no changes in policy noted.
- A root cause analysis was identified for medication being unavailable and a Performance Improvement Plan (PIP) was developed regarding CMAs lack of awareness of the reordering process and reporting missing medication to the nurse. The PIP was updated as an allegation of compliance and incorporated into the facility's Quality Assurance Performance Improvement (QAPI) process. An ADHOC QAPI meeting was conducted with the medical director.
- Education was provided by the DON to Licensed Nurses (Registered Nurse (RN) and Licensed Practical Nurse (LPN)) and Certified Medication Aides (CMAs) regarding reordering of medication as outlined in the Medication Unavailable for Administration policy, including best practices for reordering medication when 5-7 days of medication are remaining as well as regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/ or discontinue medication.
- The Divisional Nurse implemented a monitoring tool, F760 Significant Medication Error regarding administration of medication to include medication not administered due to unavailability and completed by the DON or nurse managers five times per week, Monday through Friday, to include review of medication administered on weekends.
- 11 of 12 nurses (6 RNs and 6 LPNs for a total of 93%) and 6 of 6 CMAs (for a total of 100%) were educated on documentation and follow up with pharmacy and MD regarding medications not available and best practices for ordering of medication process.
- The remaining 1 LPN nurse will be in-serviced on the next scheduled workday prior to beginning their shift by the Director of Nursing regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/ or discontinue medication. Any RNs, LPNs and CMAs that are PRN or on LOA will be provided education upon return to work. Newly hired RNs, LPNs, and CMAs will be provided education during the orientation process.
- The Administrator reviewed the results of the audit during an ADHOC QAPI meeting.
- All Corrective Actions were completed.
- The facility alleges that the IJ is removed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in an observed error rate of 11.4%. This was based on 35 medication administration opportunities with four errors involving three residents. For Resident 2, a Certified Medication Assistant (CMA) failed to administer diclofenac topical gel as scheduled because the medication was not on the cart. The Director of Nursing (DON) confirmed that the medication order did not go through electronically, and the pharmacy was contacted to send the medication later. For Resident 7, the CMA administered Artificial Tears eye drops instead of the prescribed eye ointment and failed to administer lactulose as ordered because it was not available on the medication cart. The DON stated that only the eye drops were available as a stock medication. For Resident 8, a Licensed Practical Nurse (LPN) administered only one 1000 mg cyanocobalamin tablet instead of the prescribed two tablets for age-related osteoporosis. These deficiencies indicate that the facility did not adhere to its policy titled, Medication Administration-General, which requires medications to be administered in accordance with valid prescriber orders. The errors observed included missed doses, incorrect medication forms, and incorrect dosages, all of which were confirmed through staff interviews and record reviews. These failures had the potential to adversely affect the clinical conditions of the residents involved.
Latest citations in Georgia
The facility failed to follow its abuse investigation policy when responding to an allegation that a male resident wandered into a female shared room, allegedly sat on a resident’s bed, inappropriately touched her leg, stared at another resident, and opened the bathroom door to watch a third resident brushing her teeth. The allegation was reported by a cognitively intact resident and involved residents with varying levels of cognitive impairment. The investigation, conducted by the Administrator and former DON, relied only on interviews with a RN and a CNA, did not obtain required written, signed, and dated witness statements, and did not include interviews with other residents to assess their sense of safety. Despite these omissions and incomplete documentation, the facility’s final report concluded the allegation was unsubstantiated.
A resident with protein calorie malnutrition and a terminal prognosis was admitted on hospice with corresponding physician orders and a care plan, but hospice services were not coded on either the admission or quarterly MDS assessments. The MDS Coordinator and two MDS LPNs confirmed that, despite the resident receiving hospice care, Section O of both MDS assessments incorrectly indicated the resident was not on hospice, which the Administrator and DON acknowledged resulted in inaccurate MDS data.
Surveyors found that PTAC unit filters in two resident rooms on one hallway were not maintained free of visible grey, fuzzy debris, despite facility policy requiring regular inspection and cleaning or replacement at least every three months. Across multiple observations on different days, the condition of the dirty filters remained unchanged. The Maintenance Director reported he is responsible for monthly cleaning and checks, including spot checks and inspections in construction areas, and did not dispute the observed dust accumulation when shown. The Administrator confirmed that maintenance staff are responsible for monthly PTAC filter cleaning as part of preventative maintenance and acknowledged that this issue could negatively affect residents’ health and well-being.
A resident with intact cognition and known skin integrity risks reported being left on a bedpan for an extended period and not being adequately cleaned by a CNA. The following shift, another CNA found the resident on soiled linens with a blister on the left upper thigh but did not report this new skin issue to the charge nurse or DON. Subsequent documentation showed development of an open area on the thigh associated with pain, and later NP evaluation identified a larger wound requiring sharp excisional debridement. These events show failure to provide adequate incontinent care and to promptly assess and report a new wound, contrary to the facility’s abuse/neglect prevention policy and CNA responsibilities.
A cognitively intact resident with skin-related diagnoses reported delayed and inadequate incontinent care after using a bedpan, describing prolonged waits for staff response and feeling not properly cleaned by a CNA. The next morning, another CNA found feces-soiled linen and a blister on the resident’s left upper thigh, later documented as a new open area. The resident texted the Administrator stating that a CNA had left feces on her and that she had developed a painful blister, but the Administrator did not report this allegation of neglect to the State Survey Agency as required by facility policy.
A resident with lymphedema and identified risk for pressure ulcers developed a new open wound on the upper thigh, documented by a NP with specific wound measurements. Although the existing care plan included interventions to observe and document skin changes, the care plan was not updated to include this new wound. The Wound Care Nurse and the resident confirmed the wound location, while the MDS Coordinator reported not receiving recent weekly wound reports and only recently learning of the wound. The MDS Coordinator confirmed that the care plan had not been revised in real time as required by facility procedures, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
The facility did not complete a required Georgia Criminal History Check System (GCHEXS) fingerprint background check for a CNA, as identified during review of ten employee files with a census of eighty residents. The facility’s abuse-prevention policy required criminal background checks for all employment candidates, but there was no documentation of a fingerprint records check for this CNA. The HR manager, who is responsible for background and fingerprint checks and maintaining employee files, confirmed that the GCHEXS fingerprint check had not been conducted, resulting in a deficiency under F-Tag 600.
Surveyors found that four of six resident shower rooms were not kept free of hazards or adequately cleaned. On one floor, razors were on the floor, dirty gloves and a comb were on a shower bed, floors were stained, an opened gallon of bath soap and a bottle of chemical-resistant spray were present, and a razor and hair clippers were in a bag on the floor along with a shower cap and toothbrush. On other floors, surveyors observed multiple opened containers of skin and hair cleaner, conditioner, and skin ointment, along with a strong urine odor. Unit managers and the Environmental Senior Director stated that CNAs were responsible for cleaning after each resident and that environmental services cleaned shower rooms daily, and acknowledged that items should not be left on the floor and that product containers should be closed.
Surveyors found that staff did not follow standard and transmission-based precautions when handling ice on two floors. On one floor, the ice scoop cover on top of the ice machine had visible black specks near the end of the scoop used to dispense ice. On another floor, the ice scoop was observed submerged in ice and water inside the cooler used to serve residents, despite the unit manager acknowledging that the scoop should not be left in the cooler. The Maintenance Director reported that maintenance cleaned and checked ice machines regularly, while nursing staff were responsible for cleaning scoops and covers. The SDC/Infection Control nurse stated that all staff had been in-serviced on hand hygiene and ice scoop protocol, including that scoops should be stored in a holder after use and never left in the ice.
A resident with multiple serious conditions, moderate cognitive impairment, and total dependence for ADLs was placed in bed with side rails intended to assist with positioning, despite the MDS indicating no bed rail use. Facility records showed no evidence of safe rail spacing or regular inspection of the bed and rails. The assigned CNA, who came on duty late in the evening, last saw the resident around the start of the shift and did not check on him again for several hours, relying on the resident to use a call light. In the early morning, the CNA and an RN found the resident partially out of bed, entrapped in the half side rail, requiring multiple staff to free and reposition him. The resident was unresponsive except for moaning, with altered mental status and respiratory failure documented by EMS and the ER, and later expired at the hospital. The facility’s failure to provide required monitoring and to ensure safe side rail use resulted in neglect and Immediate Jeopardy.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of sexual abuse in accordance with its policy titled “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating.” The policy required that all allegations be thoroughly investigated, including reviewing documentation and evidence, interviewing any witnesses, interviewing staff on all shifts who had contact with the resident, and completely documenting the investigation, with written, signed, and dated witness statements. A facility-reported incident documented that a male resident was wandering into a female three-bed room, allegedly inappropriately touching one resident, staring at another for a length of time, and then opening the bathroom door and staring at a third female resident while she was brushing her teeth. The allegation was initially reported by a cognitively intact resident (BIMS score 15) and involved another resident with moderate cognitive impairment (BIMS score 8) and a resident with severe cognitive impairment (BIMS score 99). The Administrator reported that the investigation of this incident was conducted by the former DON and herself after the allegation was reported by a RN. She stated that this was not the first time the alleged male resident had wandered into other residents’ rooms and described the allegation as the male resident entering a resident’s room, sitting on the resident’s bed, and allegedly touching the resident’s leg. Staff interviews for the investigation were limited to the RN and a CNA, and the Administrator acknowledged that no written witness statements were obtained, contrary to facility policy. She also confirmed that no additional residents were interviewed to assess their sense of safety following the incident. The facility’s final investigation report concluded that the allegation was unsubstantiated, despite the lack of comprehensive interviews, written statements, and full documentation required by the facility’s abuse investigation policy.
Failure to Accurately Code Hospice Services on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for a resident receiving hospice services. The facility’s policy on Certification of Accuracy of the MDS requires that appropriate health professionals correctly document residents’ medical, functional, and psychosocial problems using the Resident Assessment Instrument. The resident in question was admitted with diagnoses including protein calorie malnutrition and had a care plan dated 01/09/2026 indicating a terminal prognosis and admission to hospice, with a goal to honor advance directives and provide comfort with dignity. Physician’s orders dated 12/09/2025 also included an order to admit the resident to hospice. Despite this, review of the admission MDS and a subsequent quarterly MDS showed that hospice services were not coded in Section O (Special Treatments, Procedures and Programs), even though both assessments documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. Interviews with the MDS Coordinator and two MDS LPNs confirmed that the resident had been on hospice since admission and that both the admission and quarterly MDS assessments were incorrectly coded as not on hospice. The MDS Coordinator acknowledged that the MDS should present an accurate clinical picture for a given period and stated that this was a clerical error, resulting in CMS not receiving correct hospice coding for the resident. The Administrator and DON stated their expectation that MDS assessments accurately reflect residents’ services and confirmed that failure to code hospice in the MDS results in an inaccurate reflection of the data.
Failure to Maintain Clean PTAC Unit Filters in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain Packaged Terminal Air Conditioner (PTAC) unit filters in a safe, clean condition in two resident rooms on the Sapphire Hallway. The facility’s written policy titled "Instructions" requires that air filters be removed and inspected for cleanliness, washed or replaced if dirty, and at a minimum replaced or thoroughly cleaned every three months. During multiple observations in one room on 3/22/2026, 3/24/2026, and 3/25/2026, the PTAC unit filter was noted to have visible grey, fuzzy debris accumulation, with no change in condition across all three observations. Similar repeated observations on those same dates in another room showed the PTAC unit filter also contained visible grey, fuzzy debris accumulation that remained unchanged. In an interview, the Maintenance Director stated he is responsible for cleaning and checking the PTAC filters monthly, including conducting monthly checks and random inspections in areas where construction is occurring, and confirmed that the maintenance department is responsible for ensuring filters are clean and functioning properly. He also stated that expectations include spot checks of PTAC units. However, during an observation of one of the affected rooms in his presence, dust accumulation was again observed on the PTAC unit filter, and he did not dispute the finding. In a separate interview, the Administrator stated that the maintenance department is responsible for cleaning PTAC filters, which are supposed to be cleaned monthly, and that her expectation is for preventative maintenance to be completed monthly and as needed, noting that a potential negative outcome is the impact on residents’ health and well-being.
Neglect of Incontinent Care and Delayed Wound Reporting Leading to Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to prevent neglect and to assess and provide timely wound and incontinent care to a cognitively intact resident with known skin integrity risks. The resident, who had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema, was care planned as being at risk for pressure ulcer development and skin integrity issues, with interventions directing staff to observe, document, and report any changes in skin status. On a night shift, the resident reported being left on a bedpan for approximately an hour and a half. When the CNA on that shift (CNA BB) assisted with post-toileting care, the resident told her she did not feel adequately cleaned; CNA BB did not recheck or further clean the resident and left the room. The next morning, the resident reported burning in the left upper thigh and informed another CNA (CNA EE) that she had not been cleaned well. During morning care, CNA EE found the pad under the resident soiled with feces and wet with urine and observed a blister on the resident’s left upper thigh, but did not report the new blister to the charge nurse or DON. A subsequent Skin Wound Note documented a new open area on the left posterior thigh with the resident reporting pain while sitting on the bedpan. Later, an NP wound care consult documented that the thigh wound had been present for approximately two weeks per nursing report and measured 3.5 cm x 4.0 cm x 0.2 cm, requiring sharp excisional debridement to remove necrotic tissue and decrease bacterial burden. On observation by the surveyor with the Wound Care Nurse, the left upper thigh area was open to air, shiny pink and granular, about the size of a half dollar. These findings demonstrate that the facility did not follow its abuse/neglect prevention policy and CNA job responsibilities to provide necessary care and to report changes in condition, resulting in neglect of incontinent care and delayed wound assessment and treatment for this resident.
Failure to Report Allegation of Neglect to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the State Survey Agency (SSA) as required by its own abuse and neglect reporting policy. The facility’s policy, dated 1/2025, states that any complaint, allegation, observation, or suspicion of resident neglect must be immediately communicated to the Abuse Coordinator and promptly investigated and documented, and that all alleged violations involving mistreatment, abuse, or neglect will be thoroughly investigated under the direction of the Administrator in accordance with state and federal law. Despite this, the Administrator acknowledged that an allegation of neglect reported by a resident was not reported to the SSA. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. The resident reported that during a night shift she requested assistance for incontinent care after using a bedpan and experienced multiple delays before a CNA assisted her. She stated that when the CNA finally provided care, she did not feel adequately cleaned, and the CNA did not verify cleanliness before leaving. The next morning, another CNA found soiled linen with feces and a blister on the resident’s left upper thigh, which the resident reported as burning. A subsequent skin/wound note documented a new open area on the left posterior thigh. The resident texted the Administrator describing that a CNA had left feces on her and that she had developed a painful blister. The Administrator confirmed receiving this text but did not report the allegation of neglect to the SSA, despite being aware it should have been reported.
Failure to Update and Implement Care Plan for Newly Developed Pressure Ulcer
Penalty
Summary
Surveyors identified a failure to implement and update the care plan for a newly developed pressure ulcer for one resident. The facility’s policy "RAI Care Planning Management" requires a comprehensive, accurate assessment and real-time modification of the care plan when changes occur. The resident was admitted with diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. A recent MDS quarterly assessment showed the resident was cognitively intact (BIMS 15), at risk for pressure ulcer development, and had no unhealed pressure ulcers at that time. The existing care plan, dated 6/6/2024, identified potential for pressure ulcer development and skin integrity issues related to immobility and lymphedema, with interventions to observe, document, and report changes in skin status, including wound size, stage, and signs of infection. Subsequently, a NP wound report documented a new open wound on the resident’s thigh that had been present for approximately two weeks, with specific measurements recorded. During observation and interview, the Wound Care Nurse and the resident confirmed the wound was on the left upper thigh, which differed from the NP report that referenced the right thigh. The MDS Coordinator reported she previously received weekly wound sheets from the Wound Care Nurse but had not received one in about a month, and that the DON was now responsible for emailing the weekly wound report. She verified that the last wound report she received did not include this resident and stated that new wounds should be discussed in the morning management meeting and the care plan updated in real time. The MDS Coordinator confirmed she only recently became aware of the upper left thigh wound and that the resident’s care plan had not been updated to reflect this new wound, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
Failure to Complete Required GCHEXS Fingerprint Check for CNA
Penalty
Summary
The facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for one CNA among ten employee files reviewed, despite a census of eighty residents and a written policy requiring criminal background checks for all employment candidates. The policy titled "Freedom of Abuse Abuse Prevention Fast Alert" dated 1/2025 states that, as part of pre-employment screening, all candidates must authorize a criminal background check for conviction of crimes. During record review with the Human Resources Manager (HRM), there was no documentation of a fingerprint records check for CNA BB, and the HRM confirmed that this CNA did not have a GCHEXS fingerprint check conducted. The HRM also stated that she is responsible for background checks, fingerprint checks, reference checks, and maintaining employee files. This failure to complete the required fingerprint background check for CNA BB resulted in noncompliance cited under F-Tag 600. No resident-specific medical histories, conditions, or direct resident care events were described in the report related to this deficiency.
Failure to Maintain Safe and Clean Conditions in Multiple Resident Shower Rooms
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate environmental controls in multiple resident shower rooms. On the 4th floor, observation with the Unit Manager showed four razors on the floor, dirty gloves and a dirty comb on a shower bed, stained/dirty floors, an opened gallon bottle of complete bath soap, and a bottle of chemical resistant spray in the shower room. A razor and hair clippers were found in a black bag on the floor, and a shower cap and toothbrush were lying on the floor. The 4th floor Unit Manager stated that CNAs were supposed to clean up before showering residents and acknowledged that the items found should not be on the floor. The Environmental Senior Director reported that shower rooms were cleaned daily, with responsibilities including cleaning high-touch areas, sweeping and mopping floors, removing linen, and cleaning the area, and stated there had been no complaints about showers not being cleaned. On the 3rd floor, observation with the Unit Manager revealed an open bottle of skin and hair cleaner, an open bottle of conditioner, and an open bottle of skin ointment in the resident shower room. The 3rd floor Unit Manager stated that items in the shower room should be closed and that CNAs were to clean after each resident. On the 2nd floor, observation with the Unit Manager revealed two opened gallon containers of skin and hair cleaner and a strong urine odor in the shower room. The 2nd floor Unit Manager stated that the soap should have a top on it and that CNAs were responsible for cleaning after each resident. These observations and interviews showed that four of six resident shower rooms were not maintained free of hazards and were not cleaned as expected by facility staff, creating the potential for injury and spread of infection as stated in the report.
Improper Ice Scoop Handling and Storage Breaches Infection Control Protocol
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper handling and storage of ice scoops on two of four floors. On the 4th floor, observation of the ice scoop and scoop cover showed black specks near the end of the scoop used to put ice in cups, and the scoop cover was located on top of the ice machine. The 4th floor Unit Manager stated that kitchen staff cleaned the scoops once a week and acknowledged that the scoop should be clean. On the 3rd floor, observation of the ice chest/cooler used to serve residents revealed the ice scoop submerged in ice and water. The 3rd floor Unit Manager later confirmed that the ice scoop was not supposed to be left in the cooler. The Maintenance Director reported that maintenance staff were responsible for cleaning the ice machines, which were checked weekly and monthly, while nursing staff were responsible for cleaning the ice scoops and covers. The Staff Development Coordinator/Infection Control staff stated that all staff had been trained in infection control procedures, including hand hygiene and handling of the ice scoop and holder, and that staff had been educated that the ice scoop should be placed in the scoop holder after use and never left in the ice. Documentation in the maintenance logbook showed monthly checks and cleaning of all four ice machines, and the ice machine cleaning log showed that the ice machines on the 2nd, 3rd, and 4th floors and in the kitchen had been cleaned on specific dates. Staff training records indicated that an in-service on handwashing and ice scoop protocol had been provided for all staff.
Neglect Related to Inadequate Supervision and Unsafe Side Rail Use Leading to Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to inadequate supervision and oversight of side rail use, resulting in entrapment. Facility policies on Abuse, Neglect and Exploitation required protections to prevent neglect, defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy on Proper Use of Bed Rails required a person-centered approach, attempts at alternatives before bed rail use, and ensuring correct installation, use, and maintenance of bed rails, including attention to entrapment risk. For this resident, the Medicare 5-day MDS indicated moderate cognitive impairment (BIMS score of 8), total dependence on staff for all ADLs, and documented that bed rails were not used, while an admission assessment documented side rails were placed to assist with movement in bed. Facility records showed no evidence that safe rail spacing and regular inspection of side rails and beds had been completed. The resident had multiple serious medical diagnoses, including acute and subacute infective endocarditis, end stage renal disease, hemiplegia and hemiparesis following cerebral infarction, bacteremia, and cervical disc degeneration, and was dependent on staff for all ADLs. Nursing staff last observed the resident at 12:46 am when a sponge bath was provided; there was no documented monitoring or ADL assistance between 12:46 am and 4:30 am. The assigned CNA reported coming on duty at 11:00 pm, seeing the resident up with the bed in a low position, placing the call light in the resident’s hands, and not seeing or checking the resident again until approximately 4:30–5:00 am, stating that the resident did not press the call light during that time. Around 5:00 am, the CNA requested help from the RN, reporting that the resident needed assistance. The RN found the resident with the lower part of his body hanging off the bed and the upper body still on the bed, with his elbow wedged into the half side rail, requiring three staff to reposition him back into bed. The RN stated the resident, who was quadriplegic, was no longer as alert as when put to bed, did not respond to sternal rubs, had open but unfocused eyes, and was not verbally interactive. The CNA described finding the resident on his knees, all the way out of bed, with one hand tangled in the side rail, and noted that he was moaning but not talking after being returned to bed. Progress notes documented that EMS was called for evaluation and treatment due to the resident’s condition, and hospital ER records indicated he arrived with altered mental status and respiratory failure, agonal respirations, and a GCS of 3. The facility’s Maintenance Director stated bedrails had been checked the prior year but could not provide proof, and requested documentation of safe rail spacing and regular inspection was not provided.
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