Brown Health And Rehabilitation
Brown Health and Rehabilitation in ROYSTON, GA — inspection on September 11, 2025.
Found 2 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
Based on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition, the facility failed to protect residents from sexual abuse by another resident by not reporting to the State Survey Agency (SSA) within the required timeframe for one resident (R) (R85) reviewed for abuse and neglect.
The deficient practice had the potential of future unreported abuse.Findings include:
Review of the facility policy titled Abuse Prohibition review date 4/7/2025 revealed under Policy: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion.
The purpose of these identified procedures is to assure that we are doing all that is withing our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse or misappropriation of any patient and, or their property.
The procedures herein establish standards of practice for protection of patients and for identification and prevention of abuse.
Under Identification of coverage and responsibility: Any person observing abuse, neglect, or exploitation as previously defined, should immediately report it to the Administrator or the direct supervisor (i.e.
Charge Nurse, Director of Nursing, Departmental Leaders) present at the time of the incident.
Review of the Five-Day follow-up dated 4/28/2025 summarized the details of the incident:Certified Medication Aide (CMA) JJ approached Administrator during a resident care meeting and states she observed male resident inappropriately touch R85 several months ago. CMA JJ stated she doesn't remember exactly when, but she told the nurse who said they would report. CMA JJ could not remember who she told about incident.
She heard R85 giggling and turned to see male resident reaching across and grabbing R85's breast. CMA JJ told male resident to stop immediately and moved R85 away.
Further review revealed that CMA JJ received 1:1 (one to one) education regarding immediately reporting to the Administrator as Abuse Coordinator.Interview with the Administrator on 9/11/2025 at 10:00 am revealed that CMA JJ was no longer employed by the facility.
The incident took place before the current Administrator accepted their position.
The Administrator confirmed that staff received regular in-services related to abuse and abuse reporting.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Brown Health and Rehabilitation
545 Cook Street Royston, GA 30662
SUMMARY STATEMENT OF DEFICIENCIES
Based on observations, staff interviews and review of the facility's policy titled, Infection Prevention Plan, the facility failed to ensure proper infection control procedures were followed for four residents (R) (R5, R11, R1 and R78), creating cross-contamination.
This failure had the potential to contribute to the transmission of infectious diseases among residents and staff.
Findings include:
Review of the facility's policy titled, Infection Prevention Plan, dated 12/27/2024 revealed, under Scope Prevention of Infections - Policies, procedures, and aseptic practices are followed by personnel when performing procedures and disinfecting equipment.Observation on 9/10/2025 at 8:25 am, Certified Medication Aide (CMA) AA was performing a medication pass for R5 in Dining Room Three. CMA AA was observed with a paper towel placed on the medication cart as a barrier.
She proceeded to administer medications to R11 and then R1 without changing the barrier, creating cross contamination.
Interview on 9/10/25 at 9:00am with CMA AA, confirmed she used a barrier on her medication cart and did not change it between residents. CMA AA confirmed it should have been changed between residents.
Observation and subsequent interview on 9/10/25 at 8:44 am revealed CMA BB administering medications to R78 with a paper towel taped to the medication cart surface as a barrier. CMA BB completed the medication pass for R78 and proceeded to the next room without changing the barrier, creating cross contamination. CMA BB confirmed the barrier was not changed between residents.
Interview on 9/10/2025 at 9:26 am with the Director of Nursing (DON) confirmed the nursing staff were expected to change barriers between residents during medication administration to prevent cross contamination.
Facility ID:
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ROYSTON, GA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Brown Health and Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.