Southland Healthcare And Rehab Center

F-F580.

Interview on [DATE REDACTED] at 1:34 pm with Physician QQ revealed that a resident with an 83 percent pulse oxygenation should have been sent to the emergency room (ER) immediately and needed an advanced level of care. Physician QQ stated that Resident R1 had no respiratory care needs, was cognitive, and could verbalize his needs and tell you what was wrong. Physician QQ further revealed that this was the first he had heard that Resident R1 had expired and Resident R1 was on his monthly follow-up for the next week. Physician QQ stated there was no excuse for this, and a Do Not Resuscitate (DNR) status does not mean withholding care.

An interview on [DATE REDACTED] at 2:12 pm with the DON revealed that Resident R1 should have been sent to the hospital and

the physician should have been called. The DON stated that she was not aware of Resident R1's death circumstances. The DON further revealed that the RN Supervisor told her in the morning meeting that Resident R1 had passed in his sleep and was a DNR.

An interview on [DATE REDACTED] at 3:18 pm with the Administrator revealed he was not aware of Resident R1's death circumstances until the surveyor started interviewing the staff. The Administrator stated that once he was made aware, he held an Ad Hoc meeting and began education on notification and documentation of changes

in condition and code status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 115376 Department of Health & Human Services Printed: 09/17/2025 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 115376 B. Wing 07/11/2024

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

Southland Healthcare and Rehab Center 606 Simmons St Dublin, GA 31040

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34318

Residents Affected - Few Based on staff interviews, record reviews, and review of the facility policy titled Clinical Documentation, the facility failed to ensure clinical records contained complete and accurate documentation for one of seven sampled residents (R) (Resident R1).

Findings include:

A review of the facility's policy titled Clinical Documentation, dated [DATE REDACTED], revealed the section titled Clinical Documentation Overview stated, Facility nursing staff documents the provision of nursing care according to nursing standards and regulatory requirement. Documentation tools are designed to demonstrate the clinical care provided to the resident and to ensure the appropriate information is available to all interdisciplinary team members regarding treatment interventions and responses. Frequency of nursing documentation is based on resident clinical status, clinical need and regulatory requirements. Components of the nursing documentation proves include but are not limited to documentation in progress notes that reflect the ongoing clinical condition of the resident.

A review of Resident R1's Progress Notes dated [DATE REDACTED] through [DATE REDACTED] revealed an entry dated [DATE REDACTED] that Licensed Practical Nurse (LPN BB) was alerted by staff to the resident's room in response to the resident being unresponsive. Upon entry to the room, the resident had no pulse noted and his eyes were closed with no respiration noted. The Director of Nursing (DON) was notified of resident status.

A late entry dated [DATE REDACTED] revealed Registered Nurse (RN) AA pronounced Resident R1 deceased at 1:05 am.

A review of Resident R1's medical records revealed that there was no evidence of documentation of vital signs or documentation of the events prior to Resident R1's death. The last documented vital signs were dated [DATE REDACTED].

In an interview on [DATE REDACTED] at 7:49 pm, Certified Nursing Assistant (CNA) DD revealed on [DATE REDACTED] around 8:30 pm, Resident R1 asked for assistance. She stated she assisted him to the nurse's station, and two nurses assessed him, including checking his pulse, oxygenation, vital signs, and administering oxygen. She stated Resident R1 exhibited sweating, shaking and holding his chest. She further stated the two nurses took Resident R1 to his room and placed him in his bed.

In an interview on [DATE REDACTED] at 2:12 pm, the Director of Nursing revealed that staff should document during the shift and enter missing documentation within 24 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 115376

F-F600. safety 2. The facility failed to notify the physician of a significant change in condition for Resident R1 who exhibited shortness Residents Affected - Few of breath, tripoding (leaning forward to maximize lung expansion), and had a decreased oxygen saturation reading of 83 percent on room air.

Cross refer