Reserve At Fort Gaines Of Journey Llc, The
Reserve at Fort Gaines of Journey LLC, The in FORT GAINES, GA — inspection on April 30, 2025.
Found 5 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
Review of R49's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R49 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of brain, unspecified epilepsy, and repeated falls.
Review of R49's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/25 and located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed R49 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated R85 had severe impaired cognition.
Review of R49's Care Plan, located in the EMR under the Care Plan tab and last revised 02/27/25, revealed R49 .
Requires mod-max [moderate to maximum] assist from staff with baths, prefer showers on Tuesdays and Thursdays, bed bath on alt. [alternate] days .
During an observation and interview on 04/27/25 at 10:50 AM, R49 was observed sitting in her room. R49's fingernails were noted to be greater than a quarter an inch over her fingertips. [NAME] debris was noted under the nails.
When asked if she preferred her fingernails to be this long and unclean, R49 stated, No I really want them trimmed.
During an observation on 04/28/25 at 9:30 AM, R49's nails remained greater than a quarter of an inch over her fingertips with brown debris under her nails.
2.
Review of R24's Face Sheet, located under the Profile tab of the EMR, revealed R24 was admitted to the facility on [DATE] with diagnoses which included hypertension, paroxysmal atrial fibrillation, and legal blindness.
Review of R24's significant change MDS, with an ARD of 04/02/25 and located under the RAI tab of the EMR, revealed R24 had a BIMS score of eight out of 15, which indicated R24 had moderate impaired cognition.
Review of R24's Care Plan, located in the EMR under the Care Plan tab and last revised 03/27/25, revealed, .
Resident has difficulty in performing tasks of daily living such as feeding self, dressing, bathing, toileting .
115696
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 115696 B.
Wing 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851
Review of Preventing Medication Errors in Nursing, located at https://www.nursingcenter. com/clinical-resources/nursing-drug-handbook/medication-errors/prevention, revealed, .
Reducing medication errors is critical. In addition to recognizing common medication error risk factors, nurses must implement workplace strategies to prevent adverse drug events .
Clarify drug, dosage, frequency and other details with the pharmacist or prescribing healthcare provider if there is any uncertainty .
Review of R11's Admission Record, located under the profile tab in the electronic medical record (EMR) revealed R11 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder depressive type, epilepsy, anxiety disorder, and delusional disorders.
Review of R11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/24, located in the resident's EMR under the MDS tab, revealed the resident was receiving an antidepressant medication and had a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated she was moderately cognitively impaired.
Review of R11's current care plan, located under the Care Plan tab of the EMR, revealed a Focus area, with a creation date of 03/31/16, which identified R11 as having behavior problems with a diagnosis of schizoaffective disorder. A care plan intervention indicated, Administer medications as ordered.
Monitor/document for side effects and effectiveness.
Review of R11's September 2024 Order Summary Report, located in the Misc [Miscellaneous] tab of the EMR, revealed an order for Duloxetine HCL [an antidepressant medication] Capsule Delayed Release Particles 30 MG [milligrams] Give 1 capsule by mouth two times per day related to schizoaffective disorder, depressive type.
This medication order had a start date of 05/31/22.
115696
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 115696 B.
Wing 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851
Review of R15's Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R15 was admitted to the facility on [DATE] with the diagnosis of cerebral infarction.
Review of R15's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 03/22/24, indicated R15 had a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated R15 was severely cognitively impaired.
Review of R15's Care Plan, located under the Care Plan tab in the EMR and dated 12/31/17, revealed, . [R15] has dx [diagnosis] and cva [sic] [Cerebral Vascular Accident] with hemiplegia .
Interventions were Notify md [Medical Doctor] if blood pressure is outside perimeters.
Give cardiac/antihypertensive meds [medications] as ordered, monitor for effectiveness and adverse effects.
Monitor blood pressure as scheduled and as needed.
Monitor for and document any edema.
Notify MD .
Review of R15's Nursing Progress Notes, located under the Progress Note tab in the EMR indicated documentation and dated 06/01/24 at 8:24 AM, revealed, .
Received report that resident vomited throughout the night. [Name of Certified Nursing Assistant (CNA)] reported to [Name of Licensed Practical Nurse (LPN)2] that the resident did not look like herself.
Upon further evaluation, we discovered the resident has left sided facial droopiness.
She [R15] is also not alert and responding at this time. MD notified of situation and instructed us to send her [R15] out .
During an interview on 04/30/25 at 11:00 AM, LPN1 stated, If I was working on her [R15] hallway and she [R15] had a change in condition that I was aware of, I would document the change and the assessment if I had to perform one. I can't remember back that far if I worked with her [R15] or not.
During an interview on 04/30/25 at 11:15 AM, LPN2 stated, I remember working with another nurse that day. I can't remember who told me about her [R15] not acting like herself but as soon I was told, I went and assessed her [R15] and told the other nurse that I was working with that day, and we worked together getting her [R15] out of the facility. LPN2 was asked if the assessment would be something that LPN2 would have documented. LPN2 stated, Yes, I would have documented it. LPN2 was notified the only documentation on 06/01/24 was from another nurse and not LPN2. LPN2 was asked if she should have documented this assessment. LPN2 stated, Yes.
115696
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 115696 B.
Wing 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851
Review of the McGeer's Criteria (11/5/24) revealed, Table 1.
Constitutional Criteria for Infection Fever, Leukocytosis, Acute Mental Status Change, Acute Functional Decline .
Table 2.
Urinary Tract Infection (UTI) Surveillance Definitions Syndrome: UTI without indwelling catheter Criteria: 1. At least one of the following sign or symptom: Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate Fever or leukocytosis, and one or more of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency If no fever or leukocytosis, then greater than 2 of the following: suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency 2. At least one of the following microbiologic criteria greater than or equal to 100,000 Colony Forming Units (CFU) per milliliter (mL) of no more than 2 species of organisms in a voided urine sample greater than or equal to 100 of any organism(s) in a specimen collected by an in-and-out catheter .
Selected Comments: The following two comments apply to both UTI with or without catheter: UTI can be diagnosed without localizing symptoms if a blood isolate is the same as the organism isolated from urine and there is no alternate site of infection In the absence of a clear alternate source of infection, fever, or rigors with a positive urine culture resulting in the non-catheterized resident or acute confusion in the catheterized resident will often be treated as UTI.
However, evidence suggests that most of these episodes are likely not due to infection of a urinary source.
Urine specimens for culture should be processed as soon as possible, preferably within 1-2 hours If urine specimens cannot be processed within 30 minutes of collection, they should be refrigerated and used for culture within 24 hours.
1.
Review of R33's Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed R33 was admitted to the facility on [DATE] with diagnoses of but not limited to urinary tract infection and dementia.
115696
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 115696 B.
Wing 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851
Review of CDC website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed 09/12/24, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older.
The tables below provide detailed information .
For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you .
Give one dose of PCV20 [pneumococcal conjugate vaccines] or PCV21 . If PCV15 is used, this should be followed by a dose of PPSV23 [pneumococcal polysaccharide vaccine] at least one year later.
The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 or PCV21 is used, Give a dose of PCV15 at least one year later .
For adults [AGE] years or older who have only received a PPSV23, CDC recommends you .
May give one dose of PCV20 or PCV21 .
The PCV20 or PCV15 dose should be administered at least one year after the most recent PPSV23 vaccination.
Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it.
For adults [AGE] years or older who have only received PCV13, CDC recommends you .
Give PPSV23 as previously recommended.
For adults who have received PCV13, Give one dose of PCV20 or PCV21 or PPSV23 to be administered at least a year later. If PCV20 and PCV21 are used, their pneumococcal vaccinations are complete .
Review of R24's Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R24 was admitted to the facility on [DATE] with diagnoses that included heart failure and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. R24 was currently over [AGE] years old.
Review of R24's Immunizations, located under the Immunizations tab in the EMR, revealed R24 had not received a pneumococcal vaccine since being admitted to the facility on [DATE].
There was no documentation of historical administration or refusal of any pneumococcal vaccine for R49.
115696
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 115696 B.
Wing 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851