Dawson Health And Rehabilitation
DAWSON HEALTH AND REHABILITATION in DAWSON, GA — inspection on February 6, 2025.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 02/02/25 at 6:41 PM, the Director of Nursing (DON) stated, We don't have anyone that self-administers their own medication. It is our policy that nursing staff do not leave meds at the bedside. We have to do a self-administration of meds assessment with the resident, discuss it with the IDT and family.
There must be a doctor's order for it as well. My staff know they are not allowed to leave any meds at the bedside.
Review of a list compiled on 02/02/25 and provided by the DON, revealed there were two independent ambulatory residents and seven residents that were mobile by propelling themselves in a wheelchair residing on the hall with R11 that potentially could have access to R11's room while he was not in his room.
Review of the facility's policy titled, Pharmacy Services: Self-Administration of Medication by Patients, undated, indicated under the section Intent: To facilitate a process for safe self-administration of medications by patients when appropriate.
Indicated under the section Guideline: Each patient who desires to self-administer medication is permitted to do so if the nursing center's IDT has determined that the practice would be safe for the patient and other patients of the nursing center and that the patient is able to accurately self-administer.
Ability to appropriately self-administer medications should be documented in the patient's care plan.
Indicated under the section Guideline: Nurses and aides are required to report to the charge nurse on duty on duty any medications found at the beside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party.
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
Review of R23's code status revealed there was a discrepancy in the documentation between the physician's order, electronic medical record (EMR), and the Physician Orders for Life-Sustaining Treatment (POLST).
Review of R23's current physician's order located under the Orders tab of the EMR revealed she had an order for a full code.
The order had a start date of [DATE].
The top section of the EMR stated R23 was a full code.
Review of a document located in the Document tab of the EMR titled Georgia Department of Public Health Physician Orders for Life-Sustaining Treatment (POLST) signed by R23's daughter on [DATE] and the physician on [DATE] revealed Section A Code Status had a check mark on Allow Natural Death and Do Not Attempt Resuscitation [DNR].
During an interview on [DATE] at 2:54 PM, the Director of Nursing (DON) and Social Service Director (SSD) each verified that both the top portion of the resident's record in the EMR and the physician's order stated R23's code status was documented as a Full Code.
The SSD stated R23 must be a DNR since the POLST was marked DNR and was signed by the physician and a Family Member (FM)1.
Review of R23's quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating R23's was severely cognitively impaired.
Her admission date was [DATE].
Review of her diagnosis located in the Diagnosis tab of the EMR revealed her diagnoses included but was not limited to Alzheimer's disease and dementia.
On [DATE] at 3:50 PM, Licensed Practical Nurse (LPN) 2 was asked if R23 were to code or be found without vital signs what she would do. LPN2 she would check the EMR for R23's code status.
After checking R23's EMR, LPN2 stated R23 was a full code so she would start CPR.
On [DATE] at 4:10 PM the SSD stated she spoke to FM1 on the phone on [DATE] and explained to her that the code status was a full code in the EMR and orders but that the POLST signed when R23 was admitted was for a DNR.
She stated FM1 responded by saying let's just leave her code status a DNR as signed on the POLST when R23 was admitted to the facility.
On [DATE] at 4:23 PM Assistant Director of Nursing (ADON) was asked about the facility's process for code status, and she stated the EMR would be checked and if it stated full code she would initiate
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
F 0578 CPR.
Review of the facility policy titled Skilled Nursing Services Cardiopulmonary Resuscitation with a
who do not have an order to allow for natural death.
The policy for Advanced Directives was requested on [DATE] at 2:54 PM.
The DON provided a copy of an undated form titled Advanced Directives which was a form the resident/responsible representative completes to document the if they have an advanced directive.
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
During an interview on 02/06/25 at 9:27 AM, the Director of Nursing (DON) stated when R29's medication did not arrive to the facility from the pharmacy on 09/10/24, it was her expectation LPN4 would have notified the provider that the tramadol had not arrived and get an order to hold the medication, and request an alternate medication be given.
The DON also stated it was her expectation when R29 did not complete the x-ray as ordered on 09/11/24 due to being in pain, RN1 would have notified the provider that the x-ray could not be fully completed due to the resident being in pain and get further instruction from the provider.
During an interview on 02/06/25 at 8:40 AM, in regard to R29's Nurses Note, dated 09/11/24 completed by RN1, RN1 stated she did not notify the resident's physician or another provider that R29 was not able to complete the ordered x-ray due to being in pain.
The RN stated she should have notified the resident's physician.
During an interview on 02/06/25 at 11:58 AM, NP1 stated on 09/10/24 she was notified R29 was complaining of increased pain. NP1 stated she ordered tramadol and an x-ray for R29.
Continued interview revealed when the x-ray was not able to be fully completed as ordered because the resident was in pain, NP1 stated it was her expectation RN1 would have notified her or the physician to get further direction on what to do for R29's pain.
During an interview on 02/06/25 at 1:59 PM, the Medical Director, who was also R29's attending physician, stated when R29 could not complete all of the x-ray because of being in pain, it was his expectation that the nurse would have notified him to get an order to treat the resident's pain.
The Medical Director also stated that when R29's ordered tramadol did not arrive on 09/11/24 and the resident was in pain, the nursing staff should have notified himself or another provider to get an order to use the E-Kit.
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
jeopardy to resident health or 12/29/23 stated residents in our center will not be subject to abuse by anyone and any person safety observing any abuse must immediately report it to the Administrator, DON, SSD, or any person in charge.
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
Review of R40's electronic medical record (EMR) revealed an admitting and current diagnosis located under the Diagnosis tab of Undifferentiated Schizophrenia and mild intellectual disabilities.
Review of the Admission section of the EMR revealed R40 was admitted to the facility on [DATE].
Review of the Comprehensive Social Assessment V2.0 located in the Assessment tab of the EMR with completion dates of 02/3/25, 11/08/24, 07/31/24, 05/9/24, 02/5/24, and 11/13/23 revealed no diagnoses of Undifferentiated schizophrenia and/or Mild intellectual disability.
Each of these assessments was signed by the Social Service Director (SSD). In the Mental Development section of each of these assessments the SSD wrote No history of Mental Illness.
On 02/06/25 at 9:05 AM, the SSD was asked about the mental illness and mild intellectual disability diagnosis., The SSD stated she was not aware R40 had those diagnoses.
On 02/06/25 at 10:15 AM, Registered Nurse Resident Assessment Instrument (RAI) Director stated the SSD was expected to review the comprehensive social assessments to ensure they were accurate.
The RAI Director stated the facility did not have a policy but followed the instructions in the RAI manual.
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
Review of R40's electronic medical record (EMR) revealed his admitting and current diagnosis located under the Diagnosis tab included Undifferentiated Schizophrenia and mild intellectual disabilities.
Review of the Admission section of the EMR revealed he was admitted to the facility on [DATE].
Review of the Comprehensive Social Assessment V2.0 located in the Assessment tab of the EMR with completion dates of 02/3/25, 11/08/24, 07/31/24, 05/9/24, 02/5/24, and 11/13/23 revealed no diagnoses of Undifferentiated schizophrenia and/or Mild intellectual disability.
Each of the assessments were signed by the Social Services Director (SSD). In the Mental Development section of each of these assessments the SSD wrote No history of Mental Illness.
The resident's EMR was reviewed in its entirety and was silent for a Level I or Level II Preadmission Screening/Resident Review (PASRR).
On 02/06/25 at 8:38 AM the SSD provided a Level I PASRR that the hospital completed.
Review of the document titled Preadmission Screening/Resident Review (PASRR) Level I Assessment Form DMA-613,dated 10/23/23 revealed No was marked for the question Does the resident have a primary diagnosis of serious mental illness, developmental disability, or related condition? The SSD stated the hospital inaccurately completed the Level I PASRR and as a result a Level II was never completed.
On 02/06/25 9:05 AM the SSD was asked about the Mild Intellectual Disability diagnosis, and she stated she was not aware R40 had that diagnosis.
The SSD stated she would update the application and send in per the PASSR company's request.
The SSD provided an undated document titled Best Practice for PASRR and stated the facility followed the document as they did not have a policy for PASRR.
Review of the document revealed PASRR status should be reviewed for all new admissions; the SSD should maintain an active, ongoing, and a current list of PASRR patients; and the list should contain, at a minimum, the patient's name, DMI or ID/DD, if they require services or do not require services.
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
Review of the facility's policy titled, Baseline Care Plan, reviewed 12/27/24 revealed .To promote person-centered continuity of care and communication with the resident and representative, if applicable, regarding the initial plan for delivery of care and services .The center will complete and implement a baseline care plan within 48 hours of a resident's admission in collaboration with the resident and the representative, if applicable .
Review of R45's undated Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE].
Review of R45's entire electronic medical record (EMR) revealed no documented evidence a baseline care plan was developed for R45.
During an interview on 02/05/25 at 2:53 PM, the Resident Assessment Instrument Director (RAI) stated the facility did not develop a baseline care plan for R45.
The RAI stated she was responsible for completing resident's baseline care plans.
The RAI also stated during the time the baseline care plan was supposed to be developed for R45, she was on leave and someone in the facility's corporation was covering for her remotely.
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
complained of pain on 09/08/24 and then complained of increased pain on 09/10/24.
attending physician stated it was his expectation R29's care plan would have included pain as a
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
12/27/24 revealed it was the facility policy to provide the resident with adequate supervision,
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
During an interview on [DATE] at 1:57 PM, the Regional Corporate Nurse (RCN) stated the facility did
education on the risks vs benefits of the mobility bed rail use and then have the responsible party sign consent for the resident to use the rails.
The Regional Nurse stated the facility did not obtain consent and/or educate the R155's responsible party on the risks vs benefits.
During an interview on [DATE] at 2:11 PM, the Medical Director stated it was at the discretion of the nurse and provider to implement the use of bedrails on a resident's bed until they had a chance to sit down and discuss it with the resident and/or the resident's family and he would not expect the facility to obtain consent for the use of bedrails prior to the use of them.
The Medical Director also stated it was his expectation that if the facility had the bed frame manufacturer's manual, then they facility should have had the correct mattress on the bed frame; however, he is not sure if a nursing home facility would know that unless it was during the acquisition of the mattress.
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
During an interview on 02/06/25 at 9:27 AM, the Director of Nursing (DON) stated when R29's medication did not arrive at the facility for it to be administered to the resident, it was her expectation that the nurse would have notified the provider that the tramadol did not arrive for it to be administered.
The DON stated she had reviewed the information provided by the pharmacy and learned the pharmacy was waiting for a signed prescription from the physician.
The DON stated the nurse could have called the pharmacy to see if the tramadol could have been pulled from the E-Kit and then the physician would needed to be notified for an order.
During an interview on 02/06/25 at 11:58 AM NP1 stated on 09/10/24 she was notified R29 was complaining of increased pain. NP1 stated she ordered tramadol and an x-ray for R29. NP1 stated when the tramadol did not arrive at the facility for the resident's 09/11/24 dose, it was her expectation nursing would have called the pharmacy to get permission for tramadol to be used from the E-Kit (emergency medicine kit) and to get the expected arrival time of the ordered tramadol.
During an interview on 02/06/25 at 1:59 PM, the Medical Director, who was also R29's attending physician, stated when R29's ordered tramadol did not arrive on 09/11/24 and the resident was in pain, the nursing staff should have notified himself or another provider to get an order to use the E-Kit which included tramadol.
115483 02/06/2025
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
Review of the Skilled Inpatient Services Job Description, revised 02/2022 revealed Job Title: Administrator for Inpatient Services .Responsible for directing the day-to-day functions of the Nursing Center in accordance with current federal, states, and local regulations that govern long-term care centers, and as may be directed by the Regional [NAME] President, to provide appropriate care for our patients .Essential Duties and Responsibilities .Assumes responsibility for and honors patients' rights .Assumes responsibility for procedural guidelines relative to the prevention and reporting of patient abuse .Skills and Abilities .Provides for the purchase and availability of all necessary supplies .Language Skills.
Ability to read and interpret document such as safety rules, operating and maintenance instructions procedure manuals .
- The facility ordered mattresses which did not meet the bed frame's manufacturer's
recommendations for the dimensions of the mattresses.
The facility identified 47 out of 55 bed frames with bedrails had the incorrect mattress size.
The facility's failure placed the 47 residents at risk of entrapment. On [DATE], Resident (R) 155 was found unresponsive with his upper left extremity in between the mattress and bedrail which prevented him from falling to the floor. R155 was unable to be revived.
Cross Reference: F700L
The facility failed to protect R23 from witnessed physical abused by facility staff.
Three additional staff members witnessed the abuse and failed to intervene to protect the resident.
Cross Reference: F600L The facility's Administrator, the DON, and the Regional Corporate Nurse were informed on [DATE] at 4:29 PM that Immediate Jeopardy existed at F-F835: Administration related to F600L and F700L.
The Immediate Jeopardy at F835L began on [DATE] when the survey team identified systemic failures that resulted in F600L and F700L.
The survey team was able to validate the IJ was removed on [DATE] prior to the survey team exiting.
The survey team validated the implementation of the removal plan through observations, staff interviews, and review of resident records.
The immediacy of IJ was removed on [DATE].
Findings include:
Review of a document titled, Resident Room List, dated [DATE] and provided by the facility revealed the facility identified 47 out of 55 residents who resided at the facility had a bed frame with bedrails that was equipped with the wrong mattress dimensions.
Review of R155's undated Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE] and expired at the facility unexpectedly on [DATE].
Review of R155's Bed Rail/ Assist Bar Assessment V.20, dated [DATE] and provided by the facility revealed Current Status.
Does the patient need assistance to get out of bed? [answered] Yes.
The assessment did not include any further assessment information including medical necessity and/or other alternatives prior to the bed rails being applied to the bed.
During an observation on [DATE] at 11:56 AM, a surveyor discovered R155 halfway off the bed and it appeared he had fallen from the bed.
The surveyor immediately got assistance.
During an observation on [DATE] at 11:57 AM, the surveyor and the Social Services (SS) returned to the resident's room and observed R155 unresponsive with his upper body on his bed and his lower extremities hanging from the side of the bed.
The resident's left upper body was against the left mobility bed rail which prevented the resident from sliding to the floor.
115483
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 115483 B.
Wing 02/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Dawson Health and Rehabilitation 1159 Georgia Ave. S.E.
Dawson, GA 39842
The survey team was able to validate the IJ was removed on [DATE] prior to the survey team exiting.
43353
115483
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.