Regency Park Health And Rehabilitation
Inspection Findings
F-Tag F0880
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, staff interviews, record review, and review of the facility policy titled, Hand Hygiene, the facility failed to ensure that staff used proper infection control practices as evidenced by staff not performing appropriate hand hygiene between glove changes during catheter and perineal care for one of four residents (R) (Resident R3) with catheters. The deficient practice had the potential to transfer pathogens and increase the risk of infection transmission for Resident R3.Findings include:Review of the facility's policy titled titled Hand Hygiene with a revision date of 3/20/2024 revealed under Policy:.A. Hand Hygiene.1. Hand hygiene will be performed by washing hands with soap (anti-microbial) or using alcohol-based hand rub (ABHR) on hands. 2. Healthcare personnel (HCP) will perform hand hygiene with ABHR or soap and water for the following clinical indications that include but are not limited to after removing gloves or other personal protective equipment. Review of the electronic medical record (EMR) for Resident R3 revealed that he was admitted to the facility with diagnoses that included but were not limited to osteomyelitis of ankle and foot, methicillin resistant staphylococcus aureus infection (MRSA), acute respiratory failure with hypoxia, traumatic hemorrhage of the cerebrum, and neuromuscular dysfunction of bladder.Review of the physician's orders revealed that there was an order for indwelling Foley catheter for diagnoses of neurogenic bladder.Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED] a Brief Interview for Mental Status (BIMS) score of 13, which means that he is cognitively intact. Review of section H (Bladder and Bowel) revealed that he has an indwelling catheter.Review of the care plan for Resident R3 revealed that he is at risk for a multi-drug-resistant organism (MDRO) related to the presence of a foley catheter and Enhanced Barrier precautions (EBP) were implemented for that risk.An observation of perineal and catheter care occurred on 8/14/2025 at 11:11 am. Certified Nursing Assistant (CNA) AA provided catheter and perineal care for Resident R3.
CNA AA removed a soiled pair of gloves after cleaning the resident's perineal area. Without performing hand hygiene, she then put on a new pair of gloves and continued care by wiping and then disposing of the soiled cleaning wipes. She then removed her gloves a second time and donned (put on) another pair without performing hand hygiene. She concluded the procedure by adjusting the resident's incontinence brief and completed care without any visible hand hygiene between glove changes.An interview on 8/14/2025 at 10:25 am with CNA AA confirmed that she did not perform hand hygiene between glove changes.An interview with the Director of Nursing (DON) on 8/14/2025 at 10:35 am revealed that it was her expectation that hand hygiene was performed between glove changes.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
REGENCY PARK HEALTH AND REHABILITATION in DALTON, GA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DALTON, GA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from REGENCY PARK HEALTH AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.