River Brook Healthcare Center

Federal health inspectors cited RIVER BROOK HEALTHCARE CENTER in HOMERVILLE, GA for a deficiency under regulatory tag F-F0583 during a standard health inspection conducted on 2025-09-28.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Keep residents' personal and medical records private and confidential.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of RIVER BROOK HEALTHCARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-09.

sitting up in the Geri-chair with the dining room table in front of her, and the wall was noted to the other side of the resident.

The position of the Geri-chair prevented the resident from ambulating freely.During an interview on 9/27/2025 at 3:30 pm, Licensed Practical Nurse (LPN) CC revealed that R49 is currently using the Geri-chair due to the resident having an unsteady gait and having had several falls.

Continued interview also revealed that R49 was recently admitted to hospice services, who ordered the Geri-chair for the resident.

During an interview on 9/28/2025 at 8:20 am, the Director of Nursing (DON) revealed that residents in Geri-chairs should not be reclined back so that their movement is restricted.

Continued interview revealed that the expectation is for staff to ensure residents are in the least restrictive and safest environment.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

River Brook Healthcare Center

390 Sweat Street Homerville, GA 31634

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview, record review, and review of the facility policy titled The Care Plan, the facility failed to implement the care plan interventions related to falls for one of five residents (R) (R12).

This failure resulted in actual harm on 9/19/2025, when R12 had a fall from her bed, resulting in two fractured ribs, a hematoma to the right side of her head, and a laceration to her upper lip.

Findings included:

Review of the facility policy titled, The Care Plan, dated January 2025, under Standard: Care plans are to be accessible for clinical staff in order to facilitate care plan interventions or to update as indicated due to resident condition change.

Record review for R12 revealed the resident was admitted to the facility with the diagnoses of, but not limited to, seizures, anxiety disorder, major depressive disorder, and generalized muscle weakness.

Review of the residents' care plan indicated a focus of R12 was at risk for falls related to (r/t) history of falls, poor safety awareness, chairfast, totally dependent upon staff, restlessness and agitation, contracture of multiple muscle sites, muscle weakness, seizures, sacrococcygeal disorders, and spastic mobility.

Goal: R12 will be free from fall-related injuries through nursing/therapy interventions by the next review.

Target Date: 10/13/2025.

She will have pain r/t fracture (fx) secondary to a fall, managed through the next review date.

Interventions included: Bilateral Fall mat at bedside, Certified Nursing Assistant (CNA) to assure proper positioning in bed, utilizing appropriate wedges, and keep bed in lowest position.

Review of the Post Fall Evaluation documentation located in the Electronic Health Record (EHR) under progress notes dated 9/19/2025 in the contributing factors section revealed Recent change in environment: Yes.

Was fluid spilled on the floor: No.

Clutter present on the floor: No.

Floor mat was on the floor: Yes.

Poor lighting in the area: No.

The bed was at an improper height: Yes.An interview on 9/28/2025 at 8:15 am with the Director of Nursing (DON) revealed R12 had a fall on 9/19/2025 from the bed after the CNA moved the resident to a different room and did not ensure the resident's bed was in the lowest position, causing the resident to sustain a cut lip, hematoma, and fractured ribs.

Continued interview also revealed that the nursing staff is expected to ensure that the residents' plan of care is followed at all times.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

River Brook Healthcare Center

390 Sweat Street Homerville, GA 31634

SUMMARY STATEMENT OF DEFICIENCIES

Findings included:

Record review for R12 revealed the resident was admitted to the facility with the diagnoses of, but not limited to, seizures, anxiety disorder, major depressive disorder, and generalized muscle weakness.

Review of the Quarterly Minimum Data Set, dated [DATE], Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score not assessed due to the resident rarely/never understood.

Section GG (Functional Abilities) indicated the resident was dependent on staff for dressing, bathing, transfers, and toileting.A review of the residents' care plan indicated that R12 was at risk for falls r/t a history of falls, poor safety awareness. It was noted that R12 would be free from fall-related injuries through the nursing/therapy interventions by the next review.

Interventions included, but were not limited to, keeping the bed in the lowest position.A review of the Post Fall Evaluation documentation located in the Electronic Health Record (EHR) under progress notes dated 9/19/2025 in the contributing factors section revealed: The bed was at an improper height: Yes.A review of the documentation of the fall incident that occurred on 9/19/2025 in the EHR under Progress Notes revealed 9/19/2025 15:43 Incident Note: This nurse was notified @ 1515 by a CNA walking by the room that the resident was on the floor.

The resident was lying on the left side of her bed on the floor.

The resident had a small laceration to her upper lip, a hematoma to the right side of her forehead, and redness to her right side of her abdomen.

Resident unable to voice pain/description of fall.

Upon head-to-toe assessment resident was placed back into bed with the bed positioned in the lowest position.

Neuros were initiated @ time of fall. MD notified and ordered to send to ER for eval. 911 called @ 1519. {sic} 9/19/2025 21:54 Health Status Note: Note Text: returned to Facility via EMS.

Right temple abrasion noted. 4th and 5th rib fx noted.

Abrasion to the right side of lip noted.

The hospital reports no bleeding in the brain.

Respirations are even and non-labored. {sic}Review of R12's hospital records dated 9/19/2025 revealed under Emergency Department (ED) Course statement: Patient has a contusion to her right temporal region and right rib fractures X 2. CT brain and CT c spine show no acute process. X-ray of the right ribs shows minimally displaced fractures involving the right fourth and fifth ribs. {sic}An interview on 9/28/2025 at 8:15 am with the Director of Nursing (DON) revealed R12 had a fall on 9/19/2025 from the bed after the Certified Nurse Aide (CNA) moved the resident to a different room and did not ensure the resident's bed was in the lowest position, causing the resident to sustain a cut lip, hematoma, and fractured ribs.

Continued interview also revealed that the nursing staff is expected to ensure that residents who are at risk for falls have all interventions in place and utilized at all times.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

River Brook Healthcare Center

390 Sweat Street Homerville, GA 31634

SUMMARY STATEMENT OF DEFICIENCIES

Based on observations, staff interviews, and review of the facility policy titled Medication Administration, the facility failed to ensure the disposal of expired and discharged medications in one of one drug storage rooms.

Findings included:A review of the facility's policy titled Medication Administration, dated January 2025, documented that medication destruction is per pharmacy policy.

The Consultant Pharmacist and the Director of Nursing (DON) follow the policy for destruction of medications.

See Pharmacy Policy Manual.A review of the Pharmacy Policy Manual, with a revision date of 7/1/2024, revealed that the facility should destroy discontinued or outdated medications by one of three (3) methods:11.1 Prior to destruction, an authorized facility staff member should remove medications, including pills, capsules, liquids, creams, etc., from their dispensing containers and pour the medications into a container or plastic bag. An authorized facility staff member may add a substance that renders the medications unusable to the plastic container or bag.11.2 An authorized Facility staff member should place medication containers in a container or box.

The facility staff member should then seal the box with strong tape and label the box as MEDICATION FOR DESTRUCTION.

The container or box should be secured in a locked cabinet or room until it is disposed of or picked up by a licensed waste disposal company. If the facility chooses to dispose of the box by using a licensed waste disposal company.

The facility should call the waste disposal company to pick up the waste and accept responsibility for the proper destruction by incineration.11.3 Facility-approved commercially available drug disposal kits.During an observation of the medication room on 9/27/2025 at 9:05 am, a large box was observed filled to the top with medication packs and vials.

There was no lid on the box of medications, there was no description of what the medications were, and there was no quantity of medications in the box.

During an interview on 9/27/2025 at 9:12 am, Registered Nurse (RN) AA stated that the box of medications in the medication room was discharged , and the expired medications were removed.

She stated that she empties the box of medications in the medication room monthly by putting the medications into smaller boxes, and she then gives the smaller boxes to the DON. RN AA stated that she does not log or label what is in the small boxes.

She stated that the DON gives the boxes of discharged and expired medications to the pharmacist when they come into the facility. RN AA stated that the pharmacist comes in monthly and takes the boxes and destroys the medicines, but she is not part of that process.

During an interview on 9/27/2025 at 9:35 am, the DON stated that the pharmacist comes in and scans the medications and does a return slip.

She stated that the pharmacist comes in and scans the discharged and expired medications, but she does not take them with her.

She stated that someone else would come in within one to two weeks or sooner and pick the meds up.

The DON stated that the medications in the box in the med room are not narcotics.

She stated that she does not log the discharge or expired medications that are in the box.

She stated that there is no account for what is in the box until the pharmacist comes in and scans the medications.

She stated that the facility does not log discharged or expired medications anywhere.

She stated that it sits in the box in the medication room until the pharmacist comes in monthly.

During an interview on 9/28/2025 at 7:59 am, Licensed Practical Nurse (LPN) BB stated that when she has an expired or discontinued medication, she removes it from the medication cart and puts it in a box in the medication room.

She stated that she does not log the medications anywhere; she just puts them in the box. LPN BB stated that the DON scans the medications, but she does not know when it is scanned.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

River Brook Healthcare Center

390 Sweat Street Homerville, GA 31634

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited RIVER BROOK HEALTHCARE CENTER in HOMERVILLE, GA for a deficiency under regulatory tag F-F0914 during a standard health inspection conducted on 2025-09-28.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Provide bedrooms that don't allow residents to see each other when privacy is needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of RIVER BROOK HEALTHCARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-09.

the facility lacks a policy for environmental management. An interview on 9/27/2025, at 9:00 am, with the Maintenance Director revealed that his responsibilities included performing minor repairs within the facility.

He confirmed that the air conditioning filters should be checked weekly by maintenance housekeeping. He stated that he will ensure regular monitoring of the filters, changing them when needed to ensure that staff check and change them as needed. An interview on 9/27/2025, at 9:05 am with the Director of Nursing (DON) revealed that maintenance is responsible for ensuring the air conditioning unit filters are monitored by both housekeeping and maintenance. DON confirmed that the filters will be changed immediately.

Facility ID: