Rehabilitation Center Of South Georgia
Rehabilitation Center of South Georgia in TIFTON, GA — inspection on July 4, 2024.
Found 19 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
During an interview on 7/2/2024 at 4:12 pm, the Central Supply (CS) 1 stated, I have ordered them, but we don't know where the (lift pads) go.
During an interview on 7/2/2024 at 5:15 pm, R36 stated, I cannot get up and go anywhere like I would like to. I like to get out in the facility and talk to other people here or go to Bingo.
Right now, I cannot do any of that if I cannot get up. I sit in here and look at the four walls.
When asked if he feels isolated because he cannot get out of bed, R36 replied, Yes I do.
During an interview on 7/3/2024 at 4:39 pm with the Administrator and the Corporate Nurse, they were notified that R36 had not been out of bed for seven days and R36 stated he felt isolated because he could not get out of bed.
The Administrator stated, I was not made aware of this. We have bought 150 lift pads since November 2023.
When asked what the expectation of staff was in regard to having enough lift pads so R36 could get out of bed, the Administrator stated, Staff need to let me know when they don't have the equipment to use for the residents and we will make sure this equipment is obtained and can be used for resident care.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
During an interview on 7/3/2024 at 10:57 am, LPN4 stated she observed R60 slap R101 and did not consider the incident abuse but behavior. LPN4 stated she was a mandated reporter. LPN4 stated both residents were not in their right mind and had no ability to understand their actions. LPN4 stated she was a witness when R93 grabbed the face of R60. LPN4 stated R93 shook the face of R60 but did not leave any mark. LPN 4 stated she reported the incident between R93 and R60 immediately and stated it was behavior and not abuse.
During an interview on 7/3/2024 at 4:28 pm, the Administrator stated abuse could happen between two residents.
The Administrator stated the actions of R60 and R55 were abusive but not intentional abuse since the residents did not understand their actions.
The Corporate Nurse was present during this interview. (Cross Reference F-F610)
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
The facility failed to ensure references were checked prior to employment for three of ten
Findings include: Review of the facility's policy titled, Abuse Prohibition Policy and Procedures, dated January 2017, revealed The facility will conduct a thorough investigation of the histories of individuals being considered for hire, in addition to the inquiry of the State Nurse Aide Registry or licensing authorities.
All reasonable efforts will be made to check references and information from previous and/or current employers to uncover information about any criminal prosecutions.
Review of documents provided by the facility, referred to as the employee file, for the Administrator indicated the date of hire was 10/19/2023 and the file failed to include reference checks for employment.
Review of documents provided by the facility, referred to as the employee file, for Director of Nursing (DON) indicated the date of hire was 12/01/2014 and the file failed to include reference checks for employment.
Review of documents provided by the facility, referred to as the employee file, for Certified Nursing Assistant (CNA) 5 indicated the date of hire was 11/19/2010 and the file failed to include reference checks for employment.
During an interview on 7/3/2024 at 10:42 pm, Human Resources (HR) confirmed there were no employment reference checks for the above-named staff.
Human Resources stated there was a previous Human Resource employee who had not completed references on employees, and she identified this when she completed an audit of the employee files.
During an interview on 7/3/2024 at 3:47 pm, the Administrator stated that reference checks were completed to determine if the applicants were suited to work in the residents' home.
The Administrator stated their expectation was for the references to be completed prior to hire.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
During an interview on 7/3/2024 at 4:28 pm, the Administrator stated she could not locate any
Administrator stated she would have interviewed witnesses and collected statements.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
Review of the facility's policy titled, Discharging the Resident, dated 1/18/2023, under the Policy Statement revealed, The purpose of this procedure is to provide guidelines for the discharge process.
Under the section titled, Policy Interpretation and Implementation revealed, . 6. If the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed, and telephone report is called to the receiving facility .
Review of R86's undated admission Record located in the Electronic Medical Record (EMR) under the Profile tab, revealed R86 was admitted to the facility on [DATE] with diagnoses that included but not limited to nonrheumatic mitral (valve) insufficiency, occlusion and stenosis of right carotid artery, and hypertension.
Review of R86's Progress Notes located under the Notes tab, revealed a change in condition note, dated 6/26/2024, which revealed resident had another episode where she suddenly yells out this noise and becomes unresponsive .
Sternum rub brought resident back to consciousness .NP [Nurse Practitioner] ordered to send her out for Syncope (a sudden drop-in heart rate and blood pressure leading to fainting) evaluation .
Further review of R86's EMR failed to reveal any documentation or record of information that had been provided to the receiving facility.
During an interview on 7/3/2024 at 10:15 am with the Corporate Nurse (CN), when asked if there was documentation indicating what information was sent with the resident to the hospital, stated, When a resident is sent to the hospital we complete and print out the transfer form.
Looking at the resident record there is no documentation showing what was sent to the hospital with the resident.
During an interview on 7/3/2024 at 10:15 am, Licensed Practical Nurse (LPN) 5 stated, We give verbal updates to the hospital, there is no documentation of what was sent with the resident.
Cross Reference F-F623
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
Review of the facility's policy titled, Notice of Transfer/Discharge, dated March 2017, under the Policy Statement revealed, It is the intent of this facility to ensure an orderly transfer and/or discharge to another living environment in the event it is the choice or best interest of the resident.
Under the section titled, Policy Interpretation and Implementation revealed, Immediate Transfer/discharge: 1.
Notice of Transfer and Discharge will be made as soon as practicable when .f.
An immediate transfer or discharge is required by the resident's urgent medical needs. 2.
The notice will include the following: a.
The reason for the transfer or discharge; b.
The effective date of the transfer or discharge; c.
The location to which the resident is to be transferred or discharged , d. An explanation or the residents right to appeal the transfer or discharge to the State, and e.
The name, address, and telephone number of the state long-term care ombudsman . 3. A copy of the notice will go with the resident in the package of information to the Hospital and contact with the resident/responsible party as soon as practical Further review of the policy revealed that it failed to address providing written information to the resident and/or the resident representative and the Ombudsman regarding the need or transferring the resident.
Review of the undated admission Record, for R86 located in the Electronic Medical Record (EMR) under the Profile tab, revealed R86 was admitted to the facility on [DATE] with diagnoses that included nonrheumatic mitral (valve) insufficiency, occlusion and stenosis of right carotid artery, and hypertension.
Review of the EMR Progress Notes for R86 located under the Notes tab, revealed a change in condition note, dated 6/26/2024, which revealed resident had another episode where she suddenly yells out this noise and becomes unresponsive .
Sternum rub brought resident back to consciousness .NP [Nurse Practitioner] ordered to send her out for Syncope (a sudden drop-in heart rate and blood pressure leading to fainting) evaluation .
Further review of the record revealed no documentation that written notification containing information as to the reason for the hospital transfer was provided to the resident, the resident's responsible party, or the Ombudsman.
During an interview on 7/3/2024 at 10:15 am the Corporate Nurse (CN) stated, we do verbal notification to the families. We do not notify the Ombudsman when residents are transferred to the hospital.
During an interview on 7/3/2024 at 10:15 am, Licensed Practical Nurse (LPN) 5 stated, We only give verbal updates to the families regarding the reason for transfer.
Cross Reference F-F622
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
Review of the facility's policy titled, Bed Hold Policy, dated 1/19/2022 revealed, Policy Statement: Our facility informs residents of our bed-hold policy upon admission and prior to a transfer for hospitalization or therapeutic leave.
Policy Interpretation and Implementation: 1.
Information concerning our bed-hold policy is found in the body of the admission agreement and is provided to the resident and/or resident representative upon admission to the facility. 2. At the time a resident is transferred to the hospital or going on therapeutic leave, the facility will provide the resident with information regarding holding bed space. 3.
When emergency transfers are necessary, the facility will provide the resident or representative (sponsor) with information concerning our bed-hold policy within twenty-four (24) hours of such transfer via telephone or mail. 4.
The bed-hold information will include any charges that the resident may incur as well as the time limit established by the State Medicaid Plan for which the facility will reserve the resident's bedspace . 12. A copy of the Transfer/Discharge Notice will be sent with the resident to the hospital. A copy will be sent to the Business Office.
The Business office/designee will contact the resident and/or responsible party by mail or by phone in order to ascertain the resident/responsible party's wishes regarding holding the bed privately .
Review of R86's undated admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R86 was admitted to the facility on [DATE].
Review of the EMR Progress Notes located under the Notes tab, revealed a change in condition note, dated 6/26/2024, which revealed resident had another episode where she suddenly yells out this noise and becomes unresponsive .
Sternum rub brought resident back to consciousness .NP [Nurse Practitioner] ordered to send her out for Syncope (a sudden drop-in heart rate and blood pressure leading to fainting) evaluation .
Further review of the resident EMR failed to reveal documentation that the resident and/or the resident's representative were given written notice that specified the duration of the facility's bed hold policy.
During an interview on 7/3/2024 at 10:15 am, the Financial Coordinator (FC) stated, If the resident is out three days or more then I usually give the resident representative a phone call on the third day to see if they want to do a bed hold. We do not send them anything in writing concerning the bed hold notice.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
During an interview on 7/3/2024 at 4:25 pm the corporate nurse confirmed the fall mat should have been placed on the right side of the bed for R84.
- a.
Review of R60's EMR admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE].
The resident resided in the memory care unit.
Review of R60's EMR Care Plan located under the Care Plan tab, dated 1/25/2024, indicated R60 was dependent on staff for meeting emotional, intellectual, and social needs due to a diagnosis of Alzheimer disease progresses. b.
Review of R55's EMR admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] and resided in the memory care unit.
Review of R55's EMR Care Plan located under the Care Plan tab, dated 11/15/2023, indicated the resident preferred to watch television movies and news programs.
The care plan also revealed the resident enjoyed socializing with the facility staff and her family. c.
Review of R101's EMR admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] and resided in the memory care unit.
Review of R101's Care Plan located under the Care Plan tab, dated 7/6/2023 indicated the resident's preferred activities included to read, watch television. and to listen to music.
Observations were made on the memory care unit on 7/2/2024 and 7/3/2024.
The residents were observed to be lined up against two walls which faced each other.
There was limited engagement from the staff who were present. On 7/2/2024, the television was on during the observations. On 7/3/2024 music was playing on a television station.
There were no games, programs, or other simple, personalized engagement activities which would meet the individual activity needs of the residents.
During an interview on 7/4/2024 at 2:59 pm, Licensed Practical Nurse (LPN) 5 confirmed she was the Unit Manager for the 500 and 600 units. LPN 5 stated the expectations were for staff to implement care plan interventions for the residents.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
During an interview on 7/3/2024 at 4:28 pm, the Administrator stated she was new to her position.
The Administrator stated there used to be a staff member from the activity department scheduled in the memory care unit.
The Administrator stated she was unsure what happened to the previous staff member and was aware the current Activity Director was attempting to bring activities to the memory care unit and stated she had identified the lack of activities on the secured unit last week.
The Administrator stated there was no performance improvement plan that currently addressed this issue.
The Corporate Nurse was present during this interview.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
Review of R84's undated Face Sheet located under the Profile tab in the EMR revealed R84 was originally admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with diagnoses of dementia and history of falling.
Review of R84's quarterly MDS with an ARD date of 3/15/2024 located in the EMR under the MDS tab, revealed R84 had a BIMS score of three out of 15 which represented R84 was severely cognitively impaired.
The MDS also coded R84 as having one fall since admission to the facility which resulted in an injury.
Review of R84's Care Plan, dated 1/22/2024 and located in the EMR under the Care Plan tab, revealed fall mats were to be placed on the resident's right side of the bed when R84 was in the bed.
Review of R84's Fall Assessment, dated 6/8/2024 and located in the EMR under the Evaluations tab, revealed R84 had a score of 14 out of 15 which indicated R84 was a high risk for falls.
During observations on 7/1/2024 at 4:37 pm and on 7/2/2024 at 2:01 pm the fall mat was placed at the foot of the bed with R84's wheelchair parked on top of the fall mat.
During an interview on 7/2/2024 at 2:46 pm, CNA 6 stated, The fall mat should be on the right side of the bed, and it is not in the right place right now. CNA 6 confirmed observation of the fall mat at the end of the bed with a wheelchair parked on top of it.
During an interview on 7/2/2024 at 2:55 pm CNA 7 confirmed the fall mat was at the foot of the bed with a wheelchair parked on top of the fall mat.
During an interview on 7/2/2024 at 3:00 pm, Licensed Practical Nurse (LPN) 7 stated, The fall mat should be on the right side of the bed and not at the foot of the bed like it is now.
During an interview on 7/2/2024 at 3:12 pm, RN 1 confirmed the fall mat should have been on the right side of the bed and the observation at this time revealed the fall mat was at the foot of the bed with a wheelchair parked on top of the fall mat.
During an interview on 7/3/2024 at 4:25 pm, Corporate Nurse confirmed the fall mat should have been placed on the right side of the bed for R84.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
Review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, dated 5/1/2020, revealed .Reorder medication four to five days in advance of need .to assure an adequate supply is on hand .The refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy .
Review of R9's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed R9 was originally admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with the diagnoses of Alzheimer's disease with late onset and dementia.
Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/2/2024 revealed R9 had a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated R9 was severely cognitively impaired.
Review of R9's Physician Orders located in the EMR under the Orders tab, revealed an order dated 6/25/2024, for rivastigmine (Exelon) 24-hour 4.6 mg (milligram) per 24 hours apply one patch transdermally one time a day for dementia.
During the Medication Administration observation on 7/3/2024 at 8:43 am, Licensed Practical Nurse (LPN) 6 stated, The medication was never ordered, and I do not have a patch to replace the one that I removed.
During an interview on 7/3/2024 at 2:18 pm, the Corporate Nurse stated, If you are down to one or two patches, you should be reordering these [patches].
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
administered and we must make changes.
The infection control program in the EMR does not keep an
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
During medication administration two medication errors for one resident
medication error rate of 7.41 percent.
These failures had the potential to increase or decrease the effectiveness of these medications.
Findings include: Review of the facility's policy titled, Crushing Medications, dated 3/22/2017, revealed Medications shall be crushed only when it is appropriate to do so .
Review of the facility's policy titled, Administrating Oral Medications, dated 3/22/2017, revealed .Check the label on the medication and confirm the medication name and dose with the eMAR [Electronic Medication Administration Record].
Review of R77's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed R77 was admitted to the facility with the diagnoses of dementia, constipation, and cardiac murmur.
Review of R77's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 4/1/2024 revealed R77's Brief Interview for Mental Status (BIMS) score was five out of 15 which indicated R77 was severely cognitively impaired.
Review of R77's Physician Orders located in the EMR under the Orders tab, revealed an order dated 3/31/2023 for aspirin (pain reliever) 81 mg (milligram) chewable tablet one time a day and an order dated 3/31/2023 for Colace (laxative) 100 mg one time a day.
There was also a banner on the top of the computer screen which stated to Crush meds (medications).
During an observation on 7/3/2024 at 9:03 am, Licensed Practical Nurse (LPN) 6 prepared aspirin enteric coated 81 mg and crushed this medication. LPN6 stated, [R77] always refuses the Colace and proceeded to document the mediation was refused by R77 on the Medication Administration Record (MAR). LPN6 then administered the crushed aspirin to R77.
During an interview on 7/3/2024 at 9:21 am, LPN6 stated, I gave the wrong aspirin. It should have been the one you can crush. I knew that [R77] always refused the Colace, so I went ahead and documented that [R77] refused to take the Colace.
When asked when the nurse should document the refusal of any medication, LPN6 stated, I guess I should have asked her before I documented that she had refused to take the Colace.
During an interview on 7/3/2024 at 2:18 pm, the Corporate Nurse confirmed the enteric coated aspirin could not be crushed and the nurse should have asked the resident if he/she wanted to take a certain medication that was often refused and then go back to the medication cart and document the resident refused the medication.
During an interview on 7/4/2024 at 4:30 pm, the Administrator was asked her expectation of the nursing staff when administrating medications and the Administrator stated, the nurses are to give the medications correctly.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
Review of the pharmacy policy titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, dated 5/1/2020 revealed .During administration of medications, the medication cart is kept closed and locked when out of sight if the medication nurse or aide. No medications are kept on top of the cart.
The cart must be clearly visible to the personnel administering medications, and all outward side must be inaccessible to residents or others passing by .
Review of R79's undated Face Sheet located in the EMR under the Profile tab, revealed R79 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnoses of diabetes, bipolar disorder, and heart failure.
During observation on 7/4/2024 at 8:32 am, Licensed Practical Nurse (LPN) 9 was preparing the medication to be administered to R106 when R79 wheeled up to the medication cart and began to sit there in the hallway. LPN 9 left the cart unlocked and proceeded to go inside the doorway of a resident's room and asked her how she would like her powder medication mixed this morning. LPN 9 returned to the cart and started preparing the medication. At 8:42 am, LPN 9 locked the medication cart but left the medicine cup of pills on top of the medication cart and went to the doorway of the resident's room to ask the resident a question. R79 continued to sit at the medication cart while the medicine cup of pills was sitting on top of the medication cart unattended. R79 had access to the drawers on the medication cart as well as the cup of pills that were left on top of the medication cart unsupervised.
During an interview on 7/4/2024 at 8:51 am, LPN 9 was asked if she could see the front side of the medication cart when it was left unlocked and if she could see the medicine cup of pills that were left unattended on top of the medication cart when she went into the doorway to talk with another resident. LPN 9 went inside of the doorway and turned around to come back to the medication cart and confirmed she could not see the front side of the medication cart, nor could she see the cup of medications that were left when she was talking to the other resident.
During an interview on 7/4/2023 at 9:03 am, LPN 5 stated, The cart should always be locked when you (nurse) are not with it.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
During an interview on 7/3/2024 at 12:07 pm the DM stated, The food items are found to be below acceptable levels using a reasonable person standard and were considered cold and in need of reheating.
During an observation on 7/3/2024 at 12:20 pm, the different thermometers revealed a difference in readings of 45 degrees with the analog being 45 degrees cooler.
The analog was rechecked for proper calibration using the ice water method and was found to be properly calibrated.
These results were confirmed by the DM.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
Review of the facility's policy titled, Garbage and Rubbish Disposal, dated 1/8/2009 under the Policy Statement revealed, Garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters.
Under the section titled, Policy Interpretation and Implementation revealed, .
- Garbage and rubbish containing food wastes shell be stored so as to be inaccessible to vermin . 8.
Outside dumpsters provided by garbage pickup services must be kept closed and free of litter around the dumpster area.
Observation on 7/1/2024 at 9:40 am, with the Dietary Manager (DM) of the area in the parking lot, behind the kitchen where the trash dumpster was located, revealed two of three dumpsters used to contain the facility trash and recycling material were open.
The side doors were pushed back and left open.
This exposed boxes and bags of trash.
During an interview on 7/1/2024 at 9:40 am, the DM stated, The dumpsters should be closed, others use the dumpsters but it's our responsibility to keep them closed.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
Review of R75's undated Face Sheet located in the EMR under the Profile tab, revealed R75 was
unspecified, and history of urinary tract infections.
Review of R75's quarterly MDS with an ARD of 3/18/2024 revealed R75's BIMS score was 12 out of 15 which indicated R75 was moderately cognitively impaired and was also coded as having an indwelling catheter.
Review of R75's Progress Notes located in the EMR under the Notes tab, revealed a progress note, dated 6/27/2024 at 1:23 pm, which revealed .resident being placed on contact precautions related to a UTI [urinary tract infection] with Proteus Mirabilis, E-Coli, and ESBL [Extended Spectrum Beta-Lactamases which is a type of enzyme or chemical produced by some bacteria] .
During the initial tour of the facility on 7/1/2024, contact precautions signage was on R75's door which revealed Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room.
Providers and Staff must Also: Put on gloves before room entry.
Discard gloves before room exit.
Put on gown before room entry.
Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person.
Use dedicated or disposable equipment.
Clean and disinfect reusable equipment before use on another person.
During an observation on 7/1/2024 at 12:44 pm, Resident Assistant (RA) 1 went into R75's room and took a lunch tray to R75's roommate. RA 1 did not apply PPE (Personal Protective Equipment) prior to entering R75's room.
During an observation and interview on 7/1/2024 at 12:47 pm, Housekeeper (HSK) 1 went inside of R75's room talking to the resident and while there, HSK 1 touched the linens on R75's bed.
When HSK1 came out into the hallway from R75's room she confirmed she should have had a gown and gloves on when she went into R75's room.
During an observation on 7/1/2024 at 12:49 pm, Certified Nurse Assistant (CNA) 10 entered R75's room and donned (put on) her gown and gloves once inside.
During an interview on 7/1/2024 at 12:51 pm, RA 1 stated, If I am not doing direct care, then I don't have to put on the gown and gloves.
When asked if this is what she followed for contact precautions, RA 1 stated, Yes, it is.
During an interview on 7/1/2024 at 3:19 pm, CNA 10 stated, I should put the gown and gloves on to go into a contact isolation room.
During an interview on 7/1/2024 at 3:2 pm, RN 1 stated, .For Contact Isolation you will don your gown and gloves [personal protective equipment-PPE] before entering the room and doff the PPE before you leave the door.
During an interview on 7/1/2024 at 3:32 pm, the Infection Preventionist (IP) confirmed staff should apply their PPE at the door before entering the resident's room and then remove their PPE at the resident's door before entering the hallway.
115676 07/04/2024
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
During an interview on 7/4/2024 at 12:32 pm, the Administrator revealed We all have to be on the same page with infection control and antibiotic stewardship.
The entire team needs to be informed and that includes pharmacy.
Review of documents provided by the facility, referred to as the employee file, for the Administrator indicated the date of hire was 10/19/2023 and the file failed to include reference checks for employment.
Review of documents provided by the facility, referred to as the employee file, for Director of Nursing (DON) indicated the date of hire was 12/01/2014 and the file failed to include reference checks for employment.
Review of documents provided by the facility, referred to as the employee file, for Certified Nursing Assistant (CNA) 5 indicated the date of hire was 11/19/2010 and the file failed to include reference checks for employment.
During an interview on 7/3/2024 at 10:42 pm, Human Resources (HR) confirmed there were no employment reference checks for the above-named staff.
Human Resources stated there was a previous Human Resource employee who had not completed references on employees, and she identified this when she completed an audit of the employee files.
During an interview on 7/3/2024 at 3:47 pm, the Administrator stated that reference checks were completed to determine if the applicants were suited to work in the residents' home.
The Administrator stated their expectation was for the references to be completed prior to hire.
115676
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 115676 B.
Wing 07/04/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Rehabilitation Center of South Georgia 2002 Tift Avenue North Tifton, GA 31794
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.