Dawson Health And Rehabilitation

F-F700: Bedrails. The Administrator was notified on [DATE REDACTED] at 4:29 PM of the Immediate Jeopardy.

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 REDACTED].

Findings include:

Review of a document titled, Resident Room List, dated [DATE REDACTED] 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 Resident R155's undated Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE REDACTED] and expired at the facility unexpectedly on [DATE REDACTED].

Review of Resident R155's Bed Rail/ Assist Bar Assessment V.20, dated [DATE REDACTED] 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 REDACTED] at 11:56 AM, a surveyor discovered Resident R155 halfway off the bed and it appeared he had fallen from the bed. The surveyor immediately got assistance.

During an observation on [DATE REDACTED] at 11:57 AM, the surveyor and the Social Services (SS) returned to the resident's room and observed Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 23 115483 Department of Health & Human Services Printed: 09/09/2025 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 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

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 0700 During an observation and interview with the Maintenance Director on [DATE REDACTED] at 1:13 PM of Resident R155's bed frame, mattress, and mobility bedrails, the surveyor moved the mobility bed rail on each side of the resident's Level of Harm - Immediate bed. The mobility bed rails had movement from side to side. The Maintenance Director measured the right jeopardy to resident health or mobility bed rail to have 2 ,d+[DATE REDACTED] inches between the mattress and mobility bed rail at its widest position. safety The Maintenance Director measured the left mobility bed rail to also be 2 ,d+[DATE REDACTED] inches between the mattress and mobility bed rail. The Maintenance Director stated the mobility bed rails were adjustable to be Residents Affected - Many able to slide out and make wider if the mattress was a bariatric mattress and that was why the mobility bed rails had as much play (movement) as they did.

During an interview on [DATE REDACTED] at 12:56 PM, Registered Nurse (RN) 1 stated she assisted the SS and lifted Resident R155's lower extremities back into bed. RN1 stated Resident R155's knees were on the floor and his upper body was against the left mobility bed rail.

During an interview on [DATE REDACTED] at 1:11 PM, the SS stated when she arrived to his room, Resident R155's left arm was

in between the mobility bedrail and the mattress. SS stated the bedrail prevented Resident R155 from falling to the floor. The SS stated the resident was in a fetal like position with his legs hanging off the side of the bed. The SS stated she could not have lowered the mobility side rail by pushing the red button to lower it because Resident R155's arm was in there (in between the mattress and bedrail) and had she been able to lower the rail, the resident would have ended up in the floor.

During an observation and interview on [DATE REDACTED] at 2:25 PM, the Maintenance Director measured the dimensions of a Geo-Matt Prob mattress which was the same mattress Resident R155 utilized with the bed frame manufactured by Drive. The dimensions of the mattress were 80 inches long, 35 inches wide, and 6 inches tall.

Review of a medical supplies invoice dated [DATE REDACTED] and provided by the Maintenance Director revealed the Geo-Matt Pro mattresses the facility ordered for the Drive bed frames were 80 inches long, 35 inches wide, and 6 inches tall.

Review of the Manufacturer's Manual for the Drive bed frame dated [DATE REDACTED] revealed .Entrapment Warning . Incompatible mattress .can create hazards. Make sure the mattress is the correct size for bed frame and the assist bars [mobility bed rails] are secured to frame to decrease the risk of entrapment .Mattress Specifications Warning. Possible ENTRAPMENT Hazard may occur if you do not use the recommended specification mattress. Resident entrapment may occur leading to injury or death .It is recommended that a 36'', 39'', or 42'' wide mattress that is made to fit an 80'' .length bed frame is used .WARNING Incompatible mattress and rotating assist bars/rails can create hazards .Rotating Assist Bar/Rails add 3'' to each side of

the bed .Inspections .Quarterly Inspection .Inspect bed and Rotating Assist Bars/Rails .if loose tighten and if missing replace .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 23 115483 Department of Health & Human Services Printed: 09/09/2025 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 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

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 0700 During an interview on [DATE REDACTED] at 4:12 PM, the Maintenance Director confirmed the mattress on Resident R155's bed frame did not meet the manufacturer's recommendation of 36 inches. The Maintenance Director stated the Level of Harm - Immediate bed frame was approximately one year old and he did not install the mobility bed rails until given the ok by jeopardy to resident health or nursing staff. The Maintenance Director stated he inspected the bed frame every three months which safety included inspecting the mobility bed rails. He also stated he was aware the rails were loose as he installed them per the manufacturer's manual and them having play (movement) was the characteristics of the bed Residents Affected - Many frame and the rails. The Maintenance Director stated he was not aware the bed frame recommendations were for a mattress measuring 36 inches as the medical supply company matched the bed frame and the mattress together. The Maintenance Director stated if the mattress had been 36 inches, there would have been less space between Resident R155's mattress and mobility bed rail.

Review of the facility's undated Tels Logbook Documentation and Work History Report revealed the bed frames were inspected [DATE REDACTED] and [DATE REDACTED].

During an interview on [DATE REDACTED] at 4:45 PM, the Maintenance Director stated he inspected the bed frames every six months and not every three months as indicated in the manufacturer's manual. He stated corporate set the schedule of the bed frame inspection in the Tels system and that was what he went by.

During an interview on [DATE REDACTED] at 1:57 PM, the Regional Corporate Nurse (RCN) stated the facility did not have a policy or procedure related to bed rails use; however, it was best practice to provide 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 Resident R155's responsible party on the risks vs benefits.

During an interview on [DATE REDACTED] 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.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 115483 Department of Health & Human Services Printed: 09/09/2025 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 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

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36898

Residents Affected - Few Based on interview, record review, and review of the facility's policy, the facility failed to ensure pain medication was procured from the pharmacy and administered as ordered by the physician for one of 19 sampled residents (Resident (R) 29). The facility's failure increased the potential for Resident R29 to have untreated pain when three doses of the pain medication were not available from the pharmacy.

Findings include:

Review of the facility's undated policy titled, Pharmacy Services Medication Unavailable for Administration, revealed .DEA [drug enforcement agency] Schedule II through V controlled substance medications require a signed prescription from the physician. At times, medications may become unavailable due to no prescription

on file. The administering nurse should contact the dispensing pharmacist for further instruction on the necessary steps needed to obtain the medication .At any time a medication is not available for a specified time of administration, the nurse notifies the prescriber that the medication is not available and obtains a 'hold until medication available from pharmacy .

Review of the facility's undated policy titled, Pharmacy Services Emergency Medication Kits (portable), revealed Intent. To facilitate emergency needs for medication by special delivery from the pharmacy or by using the center's approved emergency medication supply. Emergency pharmacy is available on a 24-hour basis. A limited supply of medications used in emergencies and/or starter doses of antibiotics is maintained

in the center by the provider pharmacy in portable, sealed containers. The Emergency Kit is the property of

the pharmacy .

Review of the facility's Controlled Substances Emergency Box, dated 05/01/20 and provided by the facility revealed a list of medications kept in the facility's E-Kit. Included in the inventory was Ultram [tramadol] tablets, 50mg, and the quantity of 5 tablets.

Review of an email from the facility's pharmacy dated 02/06/25 and provided by the facility revealed .Below is a timeline from the pharmacy's perspective for [Resident R29's Name] Tramadol, a CIV [controlled schedule IV] prescription drug. 9/10 358 pm-received order for Tramadol 50 [mg] bid [twice a day] x [times] 7 days; pharmacist processed that order by 445pm; he did not fax that order to MD [medical doctor] because there was another order (below) that would have included these tabs within it on the prescription from the MD. 9/10 358PM-received a second order for Tramadol 50 mg bid prn to start after the 50 mg routine is complete; pharmacist processed that order at 446pm; requested prescription for tramadol electronically from [Medical Director's Name] @ [at] 447pm. 9/11 828am-received signed prescription back from [Medical Director's Name] electronic prescribing software; pharmacist processed medication @ 1121am and sent to filling station to be filled. 9/11 1206pm-meidcation filled and checked by second pharmacist then prepared for delivery to center on regular courier. 9/11 956pm-medication accepted at center .

Review of Resident R29's undated Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 115483 Department of Health & Human Services Printed: 09/09/2025 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 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

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 0755 Review of the electronic medical record (EMR) revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/24. Review of this MDS revealed Resident R29 was not interviewable Level of Harm - Minimal harm or due to her cognitive status. potential for actual harm

Review of Resident R29's Nurses Note, dated 09/08/24, located in the EMR under the Nurses Notes, tab revealed Residents Affected - Few Summoned to resident's room by CNA [Certified Nursing Assistant] @ [at] 2:00 am. CNA stated, 'She said

she is hurting.' Resident observed lying in bed C/O [complain of] lower back pain. Resident stated, 'It hurts a little bit.' CNA stated, 'Upon movement resident yelled and Hollard [sic] out. Notified [Nurse Practitioner's (NP) name] @ 2:06 am. Received TO [telephone order] : Give PRN [as needed] Tylenol and Get X-Ray of Lumbar and Spine. Notified Mobile Images @ 2:10 am. Mobile Image operator stated, We will have someone come out on tomorrow. Will pass on to oncoming nurse.

Review of Resident R29's Electronic Medication Administration Record [eMAR], dated September 2024 and located in

the resident's EMR under the Medications tab revealed on 09/08/24 the resident's pain was assessed to be a 10 on a scale of 1-10, with 10 being the highest pain level possible. Continued review of the eMAR revealed Resident R29 was administered the ordered PRN acetaminophen on 09/08/24 at 2:13 AM with a post pain level documented as one.

Review of Resident R29's physician order Summary Report, provided by the facility revealed on 09/10/24 the resident was ordered tramadol [opioid pain medication] 50 mg tablet, 1 tablet by mouth 2 times per day 7 days .Dx [diagnosis]: Acute pain due to trauma [fall on 09/07/24] .

Review of Resident R29's Nurses Note, dated 09/10/24 and located in the resident's EMR under the Nurses Notes tab revealed Tramadol did not come in tonight, will start when it arrives from pharmacy.

Review of Resident R29's Nurses Note, dated 09/11/24 and located in the resident's EMR under the Nurses Notes tab revealed 8am medication Tramadol 50mg not administered[.] Medication not in from pharmacy. F/U [follow up] with pharmacy stated medication will be in tonight. Will pass to on-coming nurse.

Review of an email provided by the facility, dated 02/06/25 and from the x-ray contractor revealed 9/11/24 exam: PAIN .Best obtainable, PT [patient] was in pain and could not hold position for long .Nurse decided to stop exam before finishing due to PT pain .

Review of Resident R29's Nurses Note, dated 09/11/24 and located in the resident's EMR under the Nurses Notes tab revealed Resident was scheduled for x-ray today due to pain. Writer assisted x-ray tech [technician] with the task but was unable to complete all the test due to the resident being in too much discomfort. Review of the eMAR for September 2024 revealed no acetaminophen was administered for pain other than on 09/08/24 at 2:13 AM.

Review of Resident R29's Nurses Note, dated 09/11/24 and located in the resident's EMR under the Nurses Notes tab revealed 6pm medication Tramadol 50 mg not administered[.] F/U with pharmacy[.] Stated medication will be

in tonight. Will pass to on-coming nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 115483 Department of Health & Human Services Printed: 09/09/2025 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 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

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 0755 Review of Resident R29's Electronic Medication Administration Record [eMAR], dated September 2024 and located in

the resident's EMR under the Medications tab revealed the eMAR for tramadol 50 mg tablet was scheduled Level of Harm - Minimal harm or to be administered starting on 09/10/24 and ending on 09/17/24 at 8:00 AM and 6:00 PM. Continued review potential for actual harm of the eMAR revealed Resident R29 was not administered the 6:00 PM dose on 09/10/24, the 8:00 AM dose, nor the 6:00 PM dose of the tramadol medication on 09/11/24, which indicated the resident missed three doses of Residents Affected - Few the physician ordered medication.

During an interview and record review on 02/06/25 at 11:16 AM, Licensed Practical Nurse (LPN) 1 stated on 09/10/24 Resident R29 was complaining about being sore and when the CNA touched Resident R29, she did not want to be touched. LPN1 stated Resident R29 did not indicate a pain level; however, Resident R29 never complained of pain so when she said she was in pain, she immediately notified NP1 who ordered tramadol for pain and an x-ray. The LPN stated she put in both orders around 3:30 PM and the medication should have been delivered by the pharmacy that night.

During an interview on 02/06/25 at 9:27 AM, the Director of Nursing (DON) stated when Resident 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 Resident R29 was complaining of increased pain. NP1 stated she ordered tramadol and an x-ray for Resident 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 Resident R29's attending physician, stated when Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 115483 Department of Health & Human Services Printed: 09/09/2025 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 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

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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36898 jeopardy to resident health or safety Based on record review and review of the facility's Administrator's Job Description, the facility failed to be administered in a manner that 1. ensured mattresses were the correct size for 47 out of 55 beds and the safe Residents Affected - Many use of bed rails for resident (Resident (R) 155) and 2. ensured staff did not abuse resident (Resident R23) and additional staff protected the resident from further abuse.

Findings include:

Review of the Skilled Inpatient Services Job Description, revised ,d+[DATE REDACTED] 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 .

1. 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 REDACTED], 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. Resident R155 was unable to be revived. Cross Reference: F700L

2. The facility failed to protect Resident 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 REDACTED] 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 REDACTED] 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 REDACTED] prior to the survey team exiting.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 115483