Taylor County Health And Rehabilitation

F-F689

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 115507 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115507 B. Wing 08/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Taylor County Health and Rehabilitation 165 South Broad Street Butler, GA 31006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29015 Residents Affected - Few Based on interview, record review, and review of the facility's policy titled Fall Management, the facility failed to ensure residents were free from accidents and hazards as possible for one of three residents (R) (52) reviewed for accidents out of 21 sampled residents. Specifically, the facility assessed Resident R52 required the assistance of two- staff persons for bathing; however, the resident was only assisted by one staff person when the resident fell from her bed. This failure caused Resident R52 to sustain actual harm of a closed head injury with a laceration.

Findings include:

Review of the facility's policy titled, Fall Management review date of 12/29/2023, revealed each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Each patient's risk for falls is evaluated by the interdisciplinary team (IDT). A plan of care is developed and implemented based on this evaluation with ongoing review.

Review of Resident R52's undated Face Sheet located in electronic medical record (EMR), under the Face Sheet tab, indicated the resident was admitted to the facility on [DATE REDACTED], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, abnormalities of gait and mobility, and muscle weakness.

Review of Resident R52's annual Minimum Data Set (MDS), located in the EMR, under the MDS tab, with an Assessment Reference Date (ARD) of 4/17/2024, revealed the facility assessed the resident to have a Brief

Interview of Mental Status (BIMS) score of nine out of 15, which indicated the resident was moderately cognitively impaired. Additionally, Resident R52 was assessed as being dependent (2-person assist) on staff for toileting hygiene, shower/bathe, upper/lower body dressing, putting on/taking off footwear, and required extensive/substantial assistance for all personal care. There were no falls noted prior to admission or after admission during this assessment.

Review of Resident R52's Comprehensive Nursing assessment dated [DATE REDACTED], provided by the facility as evidence of a Fall Assessment prior to resident's fall revealed Functional Status: . Does the patient need assistance moving from sitting to lying position in bed? Yes. If the patient has difficulty from sit-lying [sic] in bed, answer

the following. Staff completes all of the tasks .If the patient need assistance moving from lying to sitting position on the side of the bed, answer the following. Staff completes all of the tasks. If the patient needs assistance with toileting hygiene, answer the following. Staff completes all of the tasks .Care Plan consideration- all items checked below will trigger to care plan. Activities of Daily Living [ADLs]: Two people assist with transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 115507 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115507 B. Wing 08/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Taylor County Health and Rehabilitation 165 South Broad Street Butler, GA 31006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of the Event Quality Assessment Performance Improvement (QAPI) Tool, dated 4/28/2024 and provided by the facility revealed Description of event: summoned to room per nursing assistant to assist with Level of Harm - Actual harm resident who had fallen off bed during bed bath. Entered room and noted resident lying on right side between bed and heating/cooling unit. Head to toe assessment revealed a one inch cut to right side forehead with Residents Affected - Few moderate amount of bleeding noted. Pressure applied to control bleeding. Resident assisted off floor and onto bed. PERRL [pupils equal, round, reactive to light]. Alert and oriented times three. Resident stated that

she got dizzy when she rolled during bath and resulted in fall.

Review of the Emergency Department Record, dated 4/28/2024, located in the EMR under the Scanned Documents tab, revealed Clinical Impression: closed head injury, forehead laceration.

During an interview on 8/27/2024 at 10:10 am, Certified Nursing Assistant CNA 1 was asked to describe the incident with Resident R52. CNA1 stated she was giving her [Resident R52] a bed bath, turned her towards the window, [Resident R52] was holding onto the bottom of mattress, there were no fall mats, or siderails on the bed. CNA1 added Resident R52 stated she couldn't hold onto the mattress any longer and rolled out of bed. When CNA1 was asked if she should have had additional assistance, CNA1 stated she normally gave Resident R52 her bath herself, but she should have had another person to help. CNA1 further stated she was just trying to get done.

During an interview on 8/27/2024 at 1:41 am, Resident R52 was asked if she recalled falling out of bed? Resident R52 stated Yes. Continued interview revealed the nurse's aide was giving her a bed bath, she became dizzy and fell out of bed and hit her head on the air conditioner. Resident R52 also stated it did not help that there was no sheet on her bed, and the mattress was slippery without it (It should be noted resident is not on a specialized mattress). When asked how many staff members usually completed her bed bath, Resident R52 stated, they always use two nurse aides to give me a bed bath.

During an interview conducted on 8/27/2024 at 2:23 pm, stated she was familiar with Resident R52. When asked how many staff members was needed to provide care for Resident R52, CNA2 stated, we usually use two staff members for turning, and repositioning, and for her bed baths, because she [Resident R52] has no use of her left arm, and her right arm is weak.

During an interview on 8/27/2024 at 2:30 pm, the Director of Nursing (DON) confirmed Resident R52 had been assessed as being an extensive assistance of two persons, per Resident R52's MDS. The DON stated she would have expected two staff members would have given Resident R52's bed bath based on the comprehensive assessments, and care plans. The DON agreed that CNA1 made a bad judgement call while giving Resident R52's bed bath that resulted in the resident falling and sustaining an injury.

During an interview on 8/27/2024 at 2:40 pm, the Administrator stated it was her expectation if Resident R52 was assessed as needing two-person assistance, then she would expect that two staff members would give her

the bath.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 115507 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115507 B. Wing 08/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Taylor County Health and Rehabilitation 165 South Broad Street Butler, GA 31006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 43353 potential for actual harm Based on observation, interview, record review, and review of the facility's policy titled Skilled Nursing Residents Affected - Few Services, Hand Hygiene, the facility failed to ensure an effective infection control and prevention program was implemented during medication pass for four of 11 residents (R) (43, 38, 17, and 57) reviewed for medication administration. Specifically, the nurse failed to ensure proper hand hygiene practices were implemented dur the administration of medication. This failure could promote the spread of multi drug resistant organisms (MDROs) throughout the facility.

Findings include:

Review of the facility's policy titled, Skilled Nursing Services, Hand Hygiene, revised on 12/29/2023, indicated, under the section Intent: It is the intent of this facility to promote and facilitate appropriate hand washing .GUIDELINE .Associates should use alcohol based hand rub or wash hands with soap and water for

the following indications: Immediately before touching a patient. Before performing an aseptic task (e.g., placing an indwelling device or handling indwelling devices). Before moving from a soiled body site to a clean body site on the same patient. After touching a patient or the patient's immediate environment. After contact with blood, body fluids or contaminated surfaces. Immediately after glove removal, unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in absence of a sink, are an effective method of cleaning hands. Wash hands with soap and water when visibly soiled. After caring for someone with known or suspected diarrhea. After known or suspected exposure to spores (e.g. B. anthracis, C difficile). Gloves should not be used as a substitute for hand hygiene. lf your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves

Review of the facility training document titled, Hand Hygiene Competency Validation, used revealed staff was evaluated monthly on the three areas of hand hygiene opportunities, performing hand hygiene with soap and water, and performing hand hygiene with alcohol-based hand rub (ABHR).

Review of the facility training document titled, Hand Hygiene Observation Tool, revealed it was used to

record the staff's skill check off performing hand hygiene using ABHR and washing hands with soap and water

1.Review of Resident R43's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/2024, located in the EMR under the MDS tab, revealed the facility assessed the resident to have a Brief

Interview for Mental Status (BIMS) score of zero out of 15 which indicated Resident R43 was severely cognitively impaired.

During an observation on 8/26/2024 at 1:20 pm in Resident R43's room, Licensed Practical Nurse LPN1 performed hand hygiene, donned gloves, administered Eye Drops, one drop to each of Resident R43's eyes. LPN1 doffed the gloves, disposed of the gloves into Resident R43's bathroom trash can, and left Resident R43's room without performing hand hygiene prior to leaving room. Continued observation revealed LPN1 unlocked the medication cart, put Resident R43's eye drops back into the cart, and logged into the laptop EMR to move onto the next resident preparing her medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 115507 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115507 B. Wing 08/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Taylor County Health and Rehabilitation 165 South Broad Street Butler, GA 31006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. During an observation on 8/26/2024 at 1:26 pm, LPN1 obtained one tramadol [medication used to treat pain] 50 milligram (mg) tablet from the narcotic box in med cart and poured a cup of water without performing Level of Harm - Minimal harm or hand hygiene first. LPN1 then knocked on Resident R38's door, entered her room, and administered Resident R38 her tramadol potential for actual harm medication with the cup of water. Resident R38 poured the medicine cup containing tablet into her mouth and took a drink of water. Resident R38 gave an empty medicine cup and the cup with remaining water back to LPN1. LPN1 set Residents Affected - Few the water cup down on Resident R38's bedside table next to her, tossed the medicine cup in trash, and left Resident R38's room without performing hand hygiene prior to leaving room. LPN1 was observed unlocking the medication cart and logging into laptop to move onto next resident preparing his medication.

3. During an observation on 8/26/2024 at 1:32 pm, LPN1 obtained a Sodium Bicarbonate (antacid that neutralizes stomach acid and relieves heartburn and indigestion) 650 mg tablet from the medication cart, crushed and mixed the medication with vanilla pudding in a medicine cup, and poured a cup of water without performing hand hygiene first. Continued observation revealed LPN1 knocked on Resident R17's door, entered his room, administered Resident R17 his mixture of medicine and pudding from a wooden depressor/spoon, and gave Resident R17 a drink of water. LPN1 collected an empty cup from Resident R17's bedside table, went to the bathroom, tossed

the empty medicine cup and two water cups in the trash. LPN1 left Resident R17's room without performing hand hygiene prior to leaving room. LPN1 was observed unlocking the medication cart and logging into laptop to move onto next resident preparing his medication.

4. During an observation on 8/26/2024 at 1:41 pm, Resident R57 was lying in her bed. Continued observation revealed LPN1 obtained one hydrocodone (narcotic pain medication) 10 mg/acetaminophen 325 mg tablet from the narcotic box in medication cart and poured a cup of water without performing hand hygiene first. LPN1 then knocked on Resident R57's door, entered her room and administered Resident R57 her medicine in a medicine cup with the cup of water. Resident R57 poured the medicine cup containing the tablet into her mouth and took drink of water. Resident R57 gave an empty medicine cup and the cup with the remaining water back to LPN1. LPN1 removed a partially full water cup from her bedside table and tossed them all into the bathroom trash. LPN1 left Resident R57's room without performing hand hygiene prior to leaving room. LPN1 was observed unlocking the medication cart and logging onto the laptop to move onto the next resident preparing his medication.

During an interview on 8/26/2024 at 1:45 pm, when asked what step he forgot to do in between each resident, LPN1 stated, Oh I forgot to wash my hands. LPN1 also stated, And I always remember to do hand hygiene any other time.

During an interview on 8/26/2024 at 2:35 pm, the Director of Nursing (DON) stated, Staff are expected to use hand sanitizer or wash their hands anytime they touch something dirty, before and after providing care of a resident, and when they don and doff gloves. I expect them to use soap and water after every third time unless they're visibly soiled or wet.

During an interview on 8/26/2024 2:40 pm, the Infection Control Preventionist (ICP) stated, My expectation is that staff perform hand hygiene prior to care and every time they leave a resident's room from doing care. I expect them to use soap and water when their hands are visibly dirty, before and after eating and after using

the restroom. I also train them to use soap and water after using hand sanitizer three times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 115507 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115507 B. Wing 08/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Taylor County Health and Rehabilitation 165 South Broad Street Butler, GA 31006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 8/27/2024 10:55 pm, the Administrator stated, The expectation is that staff use hand sanitizer or wash their hands between every resident and whenever providing care. They need to wash their Level of Harm - Minimal harm or hands after every third time using hand sanitizer or if they're visibly dirty. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 115507