Rehabilitation Center Of South Georgia

F-F610)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or 38517 potential for actual harm Based on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition Policy and Residents Affected - Few Procedures, the facility failed to implement their abuse policy related to employee screening. The facility failed to ensure references were checked prior to employment for three of ten employees whose employee files were reviewed.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 12679 potential for actual harm Based on staff interviews, record review, and review of the facility policy titled, Abuse Investigation the facility Residents Affected - Few failed to ensure thorough investigations were conducted of resident-to-resident incidents for four of 25 residents (Residents (R) 60, Resident R55 Resident R90, and Resident R68) reviewed for abuse. This lack of investigation had the potential to place other dependent residents at risk for abuse/neglect.

Findings include:

Review of the facility's policy titled, Abuse Investigation dated 2008, indicated .All reports of resident abuse, neglect, misappropriation of resident property, and injuries of an unknown source shall be promptly and thoroughly investigated .An interview with the person(s) reporting the incident .Interviews with any witnesses to the incident .Witness reports shall be reduced to writing. Witnesses will be required to sign and date such reports. These reports will be sent in with other investigation information .

1. Review of Resident R60's electronic medical records (EMR) Admission Record indicated the resident was admitted to the facility on [DATE REDACTED].

Review of Resident R60's EMR quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 4/26/2024 indicated the resident had a Brief Interview for Mental Status (BIMS) score of zero out of 15 which revealed the resident was severely cognitively impaired.

2. Review of Resident R55's EMR Admission Record indicated the resident was admitted to the facility on [DATE REDACTED].

Review of Resident R55's EMR quarterly MDS with an ARD of 2/15/2024 indicated staff could not determine the resident's BIMS score.

3. Review of Resident R90's EMR Admission Record indicated the resident was admitted to the facility on [DATE REDACTED].

Review of the Resident R90's EMR quarterly MDS with an ARD of 2/26/2024 indicated the staff could not determine

the resident's BIMS score and determined the resident was cognitively impaired.

4. Review of Resident R68's EMR Admission Record indicated the resident was admitted to the facility on [DATE REDACTED].

Review of Resident R68's EMR quarterly MDS with an ARD of 4/16/2024 indicated the resident had a BIMS score of zero out of 15 which indicated the resident had severely impaired cognition.

Review of the facility's investigation dated 5/7/2024 and provided by the facility, which involved Resident R55 and Resident R60, failed to contain written statements collected from witnesses/staff.

Review of the facility's investigation dated 5/10/2024 and provided by the facility, which involved Resident R90, Resident R68, and Resident R60, failed to contain written statements collected from witnesses/staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0610 During an interview on 7/3/2024 at 8:58 am, Licensed Practical Nurse (LPN) 1 confirmed she witnessed the incident among Resident R60, Resident R90, and Resident R68 and stated she was not interviewed by the Administrator. LPN1 stated Level of Harm - Minimal harm or she documented what she witnessed in the clinical records. potential for actual harm

During an interview on 7/3/2024 at 4:28 pm, the Administrator stated she could not locate any interviews Residents Affected - Few conducted with witnesses/staff for any of the resident-to-resident incident files. The Administrator stated she would have interviewed witnesses and collected statements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 12679

Residents Affected - Some 28306

Based on observation, record review, interview, and review of the facility's policy titled, Care Plans-Comprehensive, the facility failed to implement a person-centered comprehensive plan of care with measurable goals and plans related to fall and activity interventions for five of six residents (R) Resident R43, Resident R84, Resident R60, Resident R55, and Resident R101) reviewed for care plans. This failure had the potential for residents with a diagnosis of dementia to be disruptive to other residents and staff due to the lack of engagement in daily activities and had the potential for injury without proper fall interventions in place as directed by the plan of care.

Findings include:

Review of the facility's policy titled, Care Plans-Comprehensive, dated 4/18/2017, indicated .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident .

Review of the facility's policy titled, Activities and Social Services, dated 2008, indicated .When developing

the resident's activity and social care plans, the resident will be given an opportunity to choose when, where, and how he or she will participate in activities and social events. Activities, social events, and schedules will be developed in conjunction with the resident's interests, assessment, and plan of care .

1. a. Review of Resident R43's electronic medical record (EMR) Admission Record located under the

Profile tab, indicated the resident was admitted to the facility on [DATE REDACTED].

Review of Resident R43's EMR Care Plan located under the Care Plan tab, dated 11/1/2018, directed the staff to place the bed in the lowest position since the resident was at risk for falls and had a history of rolling herself off the bed. Review of Resident R43's care plan indicated the resident was dependent on staff for all activities of daily living.

Observations were made on the following dates of Resident R43's bed not placed in the lowest position: 7/1/2024 at 9:52 am, 7/1/2024 at 12:30 pm, 7/1/2024 at 2:46 pm, and on 7/2/2024 at 1:42 pm.

During an interview on 7/3/2024 at 1:40 pm, Registered Nurse (RN) 1 confirmed she was the unit manager for the 300 and 400 units. RN1 stated she was familiar with Resident R43. RN1 stated she was the one who updated

the care plans and Certified Nurse Aides (CNA) were to implement the care plan for Resident R43 and to have the resident's bed at the lowest position since she was considered a fall risk.

b. Review of Resident R84's undated Face Sheet located under the Profile tab in the EMR, revealed Resident R84 was originally admitted to the facility on [DATE REDACTED] and then readmitted to the facility on [DATE REDACTED] with diagnoses of dementia and history of falling.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0656 Review of Resident R84's Care Plan, dated 1/22/2024 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 Resident R84 was in the bed. Level of Harm - Minimal harm or potential for actual harm Observations were made on 7/1/2024 at 4:37 pm and on 7/2/2024 at 2:01 pm of the fall mat placed at the foot of the bed with Resident R84's wheelchair parked on top of the fall mat. Residents Affected - Some

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 7/3/2024 at 4:25 pm the corporate nurse confirmed the fall mat should have been placed on the right side of the bed for Resident R84.

2. a. Review of Resident R60's EMR Admission Record located under the Profile tab, indicated the

resident was admitted to the facility on [DATE REDACTED]. The resident resided in the memory care unit.

Review of Resident R60's EMR Care Plan located under the Care Plan tab, dated 1/25/2024, indicated Resident R60 was dependent on staff for meeting emotional, intellectual, and social needs due to a diagnosis of Alzheimer disease progresses.

b. Review of Resident R55's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE REDACTED] and resided in the memory care unit.

Review of Resident 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 Resident R101's EMR Admission Record located under the Profile tab, indicated the

resident was admitted to the facility on [DATE REDACTED] and resided in the memory care unit.

Review of Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 12679 potential for actual harm Based on observations, staff interviews, record review, and review of the facility policy titled, Activities and Residents Affected - Some Social Services, the facility failed to provide an ongoing activity program to meet the individual interests and needs to enhance the quality of life for four of six residents (Residents (R) 101, Resident R60, Resident R93, and Resident R55), who resided on the memory care unit and reviewed for activities. This failure had the potential for residents with diagnoses of dementia, to be disruptive to other residents and staff due to the lack of engagement in daily activities.

Findings include:

Review of the facility's policy titled, Activities and Social Services, dated 2008, indicated .Residents shall have the right to choose the types of activities and social events in which they wish to participate .Residents who wish to meet with or participate in the activities of social, religious, and other community groups, at or away from the facility, will be encouraged to do so .Activities will be scheduled throughout the day, as well as

during evenings, weekends, and holidays .

1. Review of Resident R101's electronic medical record (EMR) Admission Record located under the

Profile tab, indicated the resident was admitted to the facility on [DATE REDACTED] with a diagnosis of unspecified dementia.

Review of Resident R101's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/30/2024, indicated the staff was unable to determine the Brief Interview for Mental Status (BIMS) and the resident was severely cognitively impaired. The assessment revealed the resident was ambulatory. The assessment indicated the resident's representative stated it was very important for the resident to listen to music she liked and to participate in religious activities. The resident's representative stated it was somewhat important for the resident to have access to books and magazines and to participate in activities that she enjoyed.

2. Review of Resident R60's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE REDACTED] with a diagnosis of Alzheimer's disease.

Review of Resident R60's EMR admission MDS with an ARD of 1/25/2024 indicated the BIMS score was zero out of 15 which indicated the resident was severely cognitively impaired. The assessment revealed the resident was ambulatory. The assessment indicated the resident's representative stated it was very important for the resident to listen to music she liked and to participate in religious activities. The resident's representative stated it was somewhat important for the resident to do things with groups of people.

3. Review of Resident R93's EMR Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE REDACTED] with a diagnosis of unspecified dementia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0679 Review of Resident R93's EMR admission MDS with an ARD of 8/21/2023 indicated the resident was severely cognitively impaired. The assessment revealed the resident was ambulatory. The assessment indicated the Level of Harm - Minimal harm or resident's representative stated it was very important for the resident to go outside and to participate in potential for actual harm religious activities. The resident's representative stated it was somewhat important for the resident to listen to music she liked, to do things with groups of people, and to participate in activities she liked. Residents Affected - Some 4. Review of Resident R55's EMR Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE REDACTED] with a diagnosis of unspecified dementia.

Review of Resident R55's EMR admission MDS with an ARD of 11/15/2023 indicated the BIMS score was two out of 15 which indicated the resident was severely cognitively impaired. The assessment indicated the resident was ambulatory. The assessment revealed the resident stated it was very important to her to have books and magazines for her to read and to keep up with the news. The resident stated it was somewhat important to her to listen to music and to participate in religious activities.

Review of an activity calendar, for the secured unit, dated 7/2024, indicated group activities such as Bible study, music, and crafts were scheduled once a day at 2:00 pm. There were no weekend activities identified

on the calendar.

During an observation on 7/2/2024 from 9:12 am through 10:25 am, residents were observed lined up on each side of the television/dining area, sitting in chairs. The television was on. The television had the Hallmark station on.

During an observation on 7/2/2024 from 11:57 am through 1:15 pm, the residents were lined up against two walls, opposite from each other. The television was still on the Hallmark station. At 12:01 pm, staff moved tables to the center of the area and assisted residents to the tables in preparation for the lunch meal. Resident R60 was being assisted with her lunch meal by staff. The television continued to play the Hallmark station.

During an observation on 7/2/2024 from 4:09 pm through 4:43 pm, the television was on. Residents again were lined up on opposite sides of the television/dining area sitting in chairs. Four residents were sleeping while sitting in their chairs. Certified Nurse Assistant (CNA) 2 entered a resident room and showed where the activity calendars were for the residents. According to CNA2 the posted activity calendar was for the residents off the secured unit. CNA2 stated she was not sure if the posted activities were for residents who may come off the secured unit and into the general population. The television/dining area continued to have

the Hallmark station on. CNA2 was asked if the activity department provided items for the residents on the memory care unit. CNA2 stated the activity department did not. CNA2 entered an adjacent room for staff and opened the cabinets. There were no items for the residents to be engaged with, such as puzzles, arts and crafts, or other items that might be appropriate for cognitively impaired residents. At 4:40 pm, the staff moved tables to the center of the room and began to assist the residents to sit at the tables in preparation for the dinner meal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0679 During an observation on 7/3/2024 from 8:56 am through 10:30 am, Licensed Practical Nurse (LPN) 1 stated

she was regularly placed on the memory care unit. LPN1 stated that she and the staff would dance with the Level of Harm - Minimal harm or residents and take them for walks to keep the residents busy. LPN1 stated she has not seen the activity potential for actual harm department do individual activities for the residents. LPN1 stated she has seen the activity department do group activities. At 9:04 am, the residents were observed eating breakfast and music was playing from the Residents Affected - Some television. Some of the residents who had completed breakfast were sitting back against the wall lined up facing the center of the room. At 9:29 am, the Activity Director (AD) brought in tambourines for some of the residents. The Activity Director asked questions from the Bible and sang a few hymns with the residents. Resident R60 smiled and was observed to dance to religious music. Multiple residents were lined up against two walls which faced the center of the room. At 9:51 am, the Activity Director ended the activity for the residents. Music was turned back on from the television. Staff were observed to walk with Resident R60.

During an interview on 7/3/2024 at 2:19 pm, the AD stated she has been in her position for the past five months. The AD stated for the residents on the memory care unit, the department provided music on one day, on another day it would be arts and crafts. The AD stated she was aware of the residents who resided

on the memory care unit and some of them had behaviors and were difficult to engage. The AD stated she has not implemented the weekend schedule for the memory care unit, since the facility just recently hired two new employees. The AD stated there needed to be activity staff on the unit to be the hands for these residents. The AD stated the television was on all the time and on channels which had music. The AD stated

the facility participated in Music and Memory (a non-profit program trained individuals to set up music tracks

on IPODs for adults with poor cognition) and showed the equipment that would be offered to a resident with memory impairments. The AD stated the facility had not implemented this program yet. The AD stated she was attempting to implement individual activities for the five residents but had only focused on the residents outside of the memory care unit. The AD stated the implementation of more activities was a goal for her on

the memory care unit.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 12679

Residents Affected - Few 28306

Based on observations, interview, record review, and review of the facility's policy titled, Fall Management,

the facility failed to ensure an accident prevention measure (bed in lowest position and/or fall mat in place) was implemented for two of five residents (R) Resident R43 and Resident R84. This failure had the potential to cause harm if

the residents fell from their bed and the proper fall interventions were not in place.

Findings include:

Review of the facility's policy titled, Fall Management, dated 5/17/2017, revealed .staff will provide a safe environment for all residents .The facility will assess residents for fall risk, will evaluate each resident individually and provide, to the best of the facility's ability, interventions to decrease the likelihood of falls .

1. Review of Resident R43's electronic medical record (EMR) Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE REDACTED] with a diagnosis of other paralytic syndrome following a cerebral infarction (stroke).

Review of Resident R43's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/11/2024 indicated the resident had a Brief Interview for Mental Status (BIMS) score of zero out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the Resident R43 was dependent

on staff for all activities of daily living (ADLs) and had no recent falls.

Review of Resident R43's EMR Care Plan located under the Care Plan tab, dated 11/1/2018, directed the staff to place the bed in the lowest position since the resident was at risk of falls and had a history of rolling herself off the bed. Review of Resident R43's care plan indicated the resident was dependent on staff for all activities of daily living.

Review of Resident R43's EMR Fall Risk located under Evaluations tab, dated 6/5/2024, indicated the resident was considered a high fall risk.

Review of Resident R43's EMR undated Kardex located on the dashboard, directed the Certified Nurse Assistant (CNA) to place the resident's bed in the lowest position.

During observations on 7/1/2024 at 9:52 am, at 12:30 pm, at 2:46 pm and on 7/2/2024 at 1:42 pm, Resident R43 was

in bed and her bed was not in the lowest position.

During an interview on 7/3/2024 at 8:49 am, CNA 1 stated she did not work the 300 unit in which Resident R43 was on, but entered the resident's room and confirmed the bed was not in the lowest position. CNA 1 stated she would learn about a resident's status or change when she documented, and the change of the resident came up through the care plan and/or the Kardex.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0689 During an interview on 7/3/2024 at 1:40 pm, Registered Nurse (RN) 1 who was the Unit Manager for 300 and 400 units, stated Resident R43 was a fall risk. RN 1 confirmed the resident's bed was to be in the lowest position to Level of Harm - Minimal harm or prevent her from being injured if the resident fell from her bed. RN1 stated her expectation was for the CNA potential for actual harm staff to ensure the bed was in the lowest position to prevent injuries.

Residents Affected - Few During an interview on 7/3/2024 at 4:26 am, the corporate nurse stated her expectation was for staff to implement accident prevention measures.

During an interview on 7/4/2024 at 1:28 pm, RN 1 stated she would walk the units once or twice a shift to ensure residents were getting the things they needed. RN 1 stated she did not complete any audit of placement of a resident's bed who was considered a fall risk.

2. Review of Resident R84's undated Face Sheet located under the Profile tab in the EMR revealed Resident R84 was originally admitted to the facility on [DATE REDACTED] and then readmitted to the facility on [DATE REDACTED] with diagnoses of dementia and history of falling.

Review of Resident R84's quarterly MDS with an ARD date of 3/15/2024 located in the EMR under the MDS tab, revealed Resident R84 had a BIMS score of three out of 15 which represented Resident R84 was severely cognitively impaired.

The MDS also coded Resident R84 as having one fall since admission to the facility which resulted in an injury.

Review of Resident 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 Resident R84 was in the bed.

Review of Resident R84's Fall Assessment, dated 6/8/2024 and located in the EMR under the Evaluations tab, revealed Resident R84 had a score of 14 out of 15 which indicated Resident 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 Resident 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 Resident R84.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306

Residents Affected - Few Based on observation, staff interview, record review, and review of the facility policy titled, Medication Ordering and Receiving from Pharmacy, the facility failed to have a physician ordered medication available for administration for one of seven residents (Resident (R) 9) during the medication administration

observation. This failure had the potential to decrease the effectiveness of the medication rivastigmine (Exelon) patch which was used for dementia.

Findings include:

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 Resident R9's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed Resident R9 was originally admitted to the facility on [DATE REDACTED] and then readmitted to the facility on [DATE REDACTED] with the diagnoses of Alzheimer's disease with late onset and dementia.

Review of Resident R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/2/2024 revealed Resident R9 had a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated Resident R9 was severely cognitively impaired.

Review of Resident 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].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43050

Residents Affected - Few Based on staff interview, record review, and review of the facility policy titled, Consultant Pharmacist Reports, the facility failed to ensure pharmacy medication regimen reviews (MRR's) included appropriately monitored medication regimens to include antibiotic usage and ensure that medications received were clinically indicated for one of six residents (Resident (R) 63) reviewed for medication regimens. The failure had the potential to affect resident safety related to antibiotic use.

Findings include:

Review of the facility's policy titled, Consultant Pharmacist Reports, dated 5/1/2007, revealed The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains

the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medical director and /or the administrator.

Reivew of the facility's policy titled, Antibiotic Stewardship Program Overview, dated 8/11/2022, revealed under Drug Expertise: The Pharmacy Consultant will be engaged to review and report antibiotic usage data to the team.

Review of R63s Admission Record located under the Profile tab of the electronic medical record (EMR), revealed Resident R63 was admitted to the facility on [DATE REDACTED] with diagnoses that included diabetes, chronic kidney disease, dementia, psychotic disorder with hallucinations, and a personal history of urinary tract infections (UTI) during stay with an onset date of 3/13/2024.

Review of Resident R63's MRR's from 6/2023 to 6/2024 did not contain any information about antibiotic use, or the number of antibiotics prescribed with the number of residents treated each month.

Review of Resident R63's Progress Notes located under the Progress Notes tab of the EMR, revealed that on 3/28/2024, the resident was sent to the hospital for altered mental status and dysuria (discomfort, pain, or burning while urinating). The emergency room doctor started Resident R63 on the antibiotic Bactrim from 3/28/2024 until 4/4/2024. This antibiotic was not susceptible to Escherichia Coli (E-Coli) and Extended Spectrum Beta-Lactamase (ESBL) which are enzymes produced by some bacteria that may make them resistant to some antibiotics. The facility then started Resident R63 on Macrobid for E-Coli ESBL Positive from 4/15/2024 to 4/25/2024.

During an interview on 7/3/2024 at 4:27 pm, the Corporate Nurse was asked if she could get the number for

the Consultant Pharmacist. On 7/4/2024 at 8:07 am, the Corporate Nurse stated that she had sent the Consultant Pharmacist a message through Facebook and that she was now off for the day and tomorrow (7/4/2024) and was unavailable to talk to the survey team. The pharmacist would be available after the survey on 7/5/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0756 During an interview on 7/4/2024 at 9:44 am, the Infection Preventionist (IP) revealed Pharmacy does monthly medication reviews, but it does not include antibiotic reviews. For [Resident R63], we missed the big picture. We did Level of Harm - Minimal harm or not see the timeline of all the catheterizations and antibiotics. Every time a straight catheterization is potential for actual harm completed, it is a possibility for an infection. We missed the wrong antibiotic administered and we must make changes. The infection control program in the EMR does not keep an order of events. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 28306 potential for actual harm Based on observation, staff interviews, record review, and review of the facility policies titled, Crushing Residents Affected - Few Medications, and Administrating Oral Medications, the facility failed to ensure a medication error rate below five percent. During medication administration two medication errors for one resident (Residents (R) 77) were made of 27 opportunities during medication administration resulting in a 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 Resident R77's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed Resident R77 was admitted to the facility with the diagnoses of dementia, constipation, and cardiac murmur.

Review of Resident 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 Resident R77's Brief Interview for Mental Status (BIMS) score was five out of 15 which indicated Resident R77 was severely cognitively impaired.

Review of Resident 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, [Resident R77] always refuses the Colace and proceeded to document the mediation was refused by Resident R77 on the Medication Administration Record (MAR). LPN6 then administered the crushed aspirin to Resident 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 [Resident R77] always refused the Colace, so I went ahead and documented that [Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0759 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 Level of Harm - Minimal harm or correctly. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306 Residents Affected - Few Based on observation, interviews, record review, and review of the facility's policy titled, Medication Administration-General Guidelines, the facility failed to ensure one of six medication carts were locked and a cup of medications was not readily accessible while left unattended with the potential to affect one of two residents (R) Resident R79. This failure had the potential for Resident R79 to have access to medications that were not prescribed for him that could lead to adverse side effects.

Findings include:

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 Resident R79's undated Face Sheet located in the EMR under the Profile tab, revealed Resident R79 was originally admitted to the facility on [DATE REDACTED] and readmitted to the facility on [DATE REDACTED] 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 Resident R106 when Resident 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. Resident R79 continued to sit at the medication cart while the medicine cup of pills was sitting on top of the medication cart unattended. Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 30347 potential for actual harm Based on observations, staff and family interviews, and review of the facility's policy titled, Food Serving Residents Affected - Many Temperatures, the facility failed to provide food at a safe and appetizing temperature for one observed meal.

This failure had the potential to affect the satisfaction of food and palatability for 115 of 119 residents consuming food from one of one kitchen at the facility.

Findings include:

Review of the facility's undated policy titled, Food Serving Temperatures, under the section titled, Policy revealed, Foods will reach proper temperature to insure food safety. Foods will be maintained at proper holding temperature to insure (sic) food safety. Foods at point of service will be served to insure (sic) food safety. Under the section titled, Holding Temperatures revealed, The cook is responsible to see that all foods maintain proper holding temperatures . 2. The temperature of hot foods will have a minimum holding temperatures of 140 degrees F (Fahrenheit) . Under the section titled, Point of Service Temperatures revealed, Food is at an acceptable temperature at point of service of the resident. 1. The point of service temperature to residents will be within the range of 120-140 degrees and or based on resident's preference .

During a phone interview on 7/1/2024 at 2:05 pm, Family Member (F) 13 stated, when I visit [Resident R13] during mealtimes her food is always cold.

During an observation on 7/3/2024 at 11:25 am, the temperature of the lunch items on the steam table being served were taken by staff under the supervision of the Dietary Manager (DM). Staff used the facility digital thermometer for the readings. The temperatures taken during the observation were as follows: Beef tips measured 200 degrees F for regular texture, 183 degrees F for mechanically altered, and 185 F degrees for pureed texture: Mashed potatoes measured 166 degrees F: Lima beans measured 198 degrees F for regular and mechanical, and 206 degrees F for pureed texture. All temperatures were confirmed by the DM.

Observation on 7/3/2024 at 11:35 am revealed lunch service was started for residents eating in the main dining room. Dining room service ended at 11:50 am and service of the 500 hallway was started. Service of

the 500 hallway was ended and a test tray was requested and plated at 11:55 am. The test tray plate was taken to the 500 Hallway which was the first resident hallway to be served. The cart was delivered to the hallway at 11:58 am and delivery of the trays began at 11:59 am. Food service ended at 12:06 pm. The test tray was the last tray served and was removed from the cart by the DM. The tray was taken to a nearby counter and the DM then took the temperature of the food items using a different analog thermometer that

she had recently calibrated. The temperatures of the test tray were taken at 12:07 pm and were as follows:

-Beef tips measured 100 degrees F:

-Mashed potatoes measured 130 degrees F; and

-Lima beans measured 104 degrees F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0804 All temperatures were taken and confirmed by the DM. The items were evaluated alongside the DM, who reported the food items were found to be cold to warm. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Many

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 30347 potential for actual harm Based on observation, staff interview, and review of the facility's policy titled, Garbage and Rubbish Residents Affected - Many Disposal, the facility failed to ensure garbage was properly disposed of and contained for two of three dumpsters with the side doors pushed back and left open. This had the potential to attract pests and affect

the residents and staff at the facility. The facility census was 119 residents.

Findings include:

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, . 5. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306 potential for actual harm 43050 Residents Affected - Few Based on observation, interview, record review, and review of the facility's policies titled, Handwashing/Hand Hygiene, Dressing Change, Contact Precautions, and Administering Oral Medications, the facility failed to use proper infection control guidelines for a dressing change, during medication pass, and for contact isolation for three of three residents (R) Resident R8, Resident R75, and Resident R77 reviewed for infection control. This failure had the potential for the spread of infections.

Findings include:

Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 11/5/2018 indicated, This facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall be trained and have regular in-services on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .Use an alcohol-based hand rub or soap and water before and after direct contact with residents .before moving from a contaminated body site to a clean body site during resident care . after removing gloves. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Review of the facility's procedure guide titled, Dressing Change, dated 1/17/2023 indicated, .Use a barrier on over bed table to place supplies on; place plastic bag for discarded dressing and used gloves; perform hand hygiene and apply gloves; remove old dressing and remove gloves and discard in plastic bag; perform hand hygiene and apply gloves; clean wound from center outward and remove gloves and hand sanitize; perform hand hygiene and apply gloves; apply medication and new dressing then remove gloves and discard; remove the plastic bag and dispose of in trash container on treatment cart; perform hand hygiene.

Review of the facility's policy titled, Contact Precautions, dated 11/2019 revealed, Contact Precautions are intended to prevent transmission of infectious agents .that are spread by direct or indirect contact with the resident or the resident's environment .Contact Precautions Everyone Must: Clean their hands, including

before entering and when leaving the room. Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit .

Review of the facility's policy titled, Administering Oral Medications, dated 3/22/2017 revealed, .Do not touch

the medication with your hands .

1. Review of Resident R8's undated Face Sheet, located in the electronic medical record (EMR) under the Profile tab, indicated Resident R8 was admitted to the facility on [DATE REDACTED] with diagnoses of peripheral vascular disease, diabetes, and stroke affecting the right dominant side.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0880 Review of the [Name] Wound Physicians report located in the EMR under the Documents tab and dated 6/4/2024 revealed, Open area to left second toe, approximately 1.4 x 1.7 cm [centimeters], clean hyper Level of Harm - Minimal harm or granulation to wound bed. Wound consistent with trauma from heavy blankets on top of foot, with right toes potential for actual harm intact and bilateral heels intact. Chemical cauterization of hyper granulation tissue performed on toe wound with topical anesthetic to facilitate healing. Treatment plan: leptospermum honey applied to wound once daily Residents Affected - Few for 30 days. Gauze island with bandage once daily for 30 days.

During observation and interview on 7/1/2024 at 3:04 pm upon entry to Resident R8's room, Licensed Practical Nurse (LPN) 8 wound nurse was beginning to complete wound care. The resident was crying out and LPN 8 was attempting to cut a bandage off her left second toe. LPN 8 had scissors directly on top of the wound and this was Resident R8's pain. LPN 8 did not ask the resident if she needed anything for pain and when the bandage was removed, Resident R8 stopped hollering. There was not a barrier on the bedside tabletop. The dirty bandage was lying

on the bed and blood was on the sheets. A plastic bag for dirty items was not in the room and a trash receptacle was not by the bedside. LPN 8 had on gloves but did not change them after cleaning the resident's toe and redressing the wound. LPN 8 left the room and proceeded to clean the bottles that were in

a plastic container. A barrier was not placed on the treatment cart before placing the plastic container down. LPN 8 used a disinfectant to clean the items but had on the same gloves from in the room. The dry time for

the disinfectant was two minutes; after cleaning, the bottles were placed directly in the cart before the two minutes dry time. The treatment cart surface was not disinfected. LPN 8 then removed her gloves, pulled out

a notebook and wrote in it, then returned the notebook back into the treatment cart. LPN 8 scratched her head and then proceeded down the hall with her cart. I stopped her at the end of the hall and asked if she washed her hands and she stated, I used hand sanitizer when I left the room. When asked how that happened when she had gloves on she replied, I should have washed my hands. When asked if she used a barrier on the bedside tabletop she stated, I did not.

During an interview on 7/3/2024 at 9:26 am, Registered Nurse (RN) 2 wound nurse, revealed Anytime gloves come off, we hand sanitize. [LPN8] and I went through the [Name] program for wound care. I do not know why [LPN 8] did not follow proper wound care procedures. This is my department, and we answer to the Director of Nursing (DON). I take this personally and standards do not change. [LPN 8] will be retrained. I did not know that this was happening.

During an interview on 7/4/2024 at 12:27 pm, the Administrator revealed My expectations for wound care are to follow the proper infection control procedures and do hand hygiene.

2. Review of Resident R77's undated Face Sheet located in the EMR under the Profile tab, revealed Resident R77 was admitted to the facility on [DATE REDACTED] with diagnoses of dementia, constipation, and cardiac murmur.

Review of Resident 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 Resident R77's Brief Interview for Mental Status (BIMS) score was five out of 15 which indicated Resident R77 was severely cognitively impaired.

During an observation on 7/3/2024 at 9:03 am, LPN 6 placed two pills on the note pad in which LPN 6 was writing on then proceeded to pick those pills up with her bare hands and placed them in a pouch before she crushed the pills. LPN 6 picked up the potassium chloride capsule with her bare hands and poured the powder from the capsule into pudding before this was administered to Resident R77.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0880 During an interview on 7/3/2024 at 9:21 am, LPN 6 stated, I should have worn gloves to pick the pills up and I should have placed the pills in a medicine cup instead of placing them on my writing pad. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/3/2024 at 10:28am, RN 1 stated, .medications are to be placed in a medicine cup instead of laying then on a note pad. RN 1 also confirmed that the nurse should have worn gloves instead of Residents Affected - Few touching medications with bare hands.

During an interview on 7/3/2024 at 11:00 am, the Infection Preventionist (IP) confirmed the nurses should not handle medications with their bare hands, instead they should wear gloves.

During an interview on 7/3/2024 at 2:18 pm, the Corporate Nurse confirmed, The policy says you are not to touch the medications with your hands. When asked if the policy was saying not to pick up the medications with your bare hands and the Corporate Nurse stated, Yes.

3. Review of Resident R75's undated Face Sheet located in the EMR under the Profile tab, revealed Resident R75 was readmitted to the facility on [DATE REDACTED] with the diagnoses of obstructive and reflux uropathy, unspecified, and history of urinary tract infections.

Review of Resident R75's quarterly MDS with an ARD of 3/18/2024 revealed Resident R75's BIMS score was 12 out of 15 which indicated Resident R75 was moderately cognitively impaired and was also coded as having an indwelling catheter.

Review of Resident 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 Resident 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 Resident R75's room and took a lunch tray to Resident R75's roommate. RA 1 did not apply PPE (Personal Protective Equipment) prior to entering Resident R75's room.

During an observation and interview on 7/1/2024 at 12:47 pm, Housekeeper (HSK) 1 went inside of Resident R75's room talking to the resident and while there, HSK 1 touched the linens on Resident R75's bed. When HSK1 came out into the hallway from Resident R75's room she confirmed she should have had a gown and gloves on when she went into Resident R75's room.

During an observation on 7/1/2024 at 12:49 pm, Certified Nurse Assistant (CNA) 10 entered Resident R75's room and donned (put on) her gown and gloves once inside.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0880 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, Level of Harm - Minimal harm or Yes, it is. potential for actual harm

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 Residents Affected - Few 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43050 potential for actual harm Based on staff interview, record review, and review of the facility policy titled, Antibiotic Stewardship Program Residents Affected - Few Overview, the facility failed to monitor, evaluate antibiotic use, and track measures of antibiotic usage for one of three residents (Resident (R) 63) reviewed for antibiotic usage. This failure had the potential to affect resident safety related to antibiotic usage.

Findings include:

Review of an undated, untitled CDC [Centers for Disease Control and Prevention] document located at http://uprevent.[NAME].com/2855wp/wp-content/uploads/2018/01/nh-hac_mcgreercriteriarevcomp_2012-1. pdf; revealed The Core Elements of Antibiotic Stewardship for Nursing Homes indicated .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority .Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use' .CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use . Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Below are examples of antibiotic use and outcome measures .Process measures: Tracking how and why antibiotics are prescribed . Antibiotic use measures .Tracking how often and how many antibiotics are prescribed .Antibiotic outcome measures .Tracking the adverse outcomes .

Review of a facility's policy titled, Antibiotic Stewardship Program Overview, dated 8/11/2022, revealed Antibiotic Stewardship Program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use.

This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment-related costs .Accountability; the ASP team will review infections and monitor antibiotic usage patterns on a regular basis .Tracking: The Infection Preventionist (IP) will be responsible for infection surveillance and tracking . IP will collect and review type of antibiotic ordered, whether appropriate tests such as cultures were obtained before ordering antibiotics, and whether the antibiotic was changed during the course of treatment. The pharmacy consultant will review and report antibiotic usage data including numbers of antibiotics prescribed and number of residents treated each month.

Review of Resident R63's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed Resident R63 was admitted to the facility with diagnoses that included diabetes, chronic kidney disease, dementia, psychotic disorder with hallucinations, and a personal history of urinary tract infections (UTI)

during stay with an onset date of 3/13/2024.

Review of Resident R63's Progress Notes, located under the Progress Notes tab of the EMR, revealed Resident R63 had multiple UTI's starting in 11/24/2023. Each time Resident R63 was straight catheterized due to urinary incontinence.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0881 Review of the untitled Timeline provided by the facility, alongside the IP on 7/4/2024 at 9:44 AM, revealed

the following: Level of Harm - Minimal harm or potential for actual harm -11/24/2023-Resident had burning upon urination and straight catheterized in the facility. Culture showed Proteus Mirabilis (a gram-negative bacteria) and enterococcus faecalis (a gram-positive bacteria). Resident Residents Affected - Few was given the antibiotic Cefuroxime from 11/27/2023 to 12/4/2023 for Proteus Mirabilis. An order was also given for the antibiotic Linezolid which was not covered by insurance. From 12/4/2023 to 12/14/2023, Resident R63 took Macrobid for Enterococcus Faecalis.

-1/1/2024-Resident was straight catheterized in the facility for burning upon urination and it was contaminated.

-1/4/2024-Resident was straight catheterized in the facility for burning upon urination and the culture showed Klebsiella Pneumonia (a common type of bacteria caused by not performing hand sanitizing or urinary catheters) and Escherichia Coli (bacteria from the anus). Resident R63 was given an antibiotic Levofloxacin that was started on 1/8/2024 to 1/14/2024.

-3/11/2024-Resident R63 was straight catheterized in the facility for increased confusion. The culture showed no growth, and no antibiotics were given.

-3/28/2024-Resident R63 was sent to the hospital where she was straight catheterized for altered mental status and burning upon urination. The hospital started the resident on the antibiotic Bactrim. The culture which takes three days for a result showed Escherichia Coli ESBL positive (a strain of bacteria that produces extended -spectrum beta-lactamases [ESBL], that could make the bacteria resistant to certain antibiotics). The resident was given the antibiotic Bactrim from 3/28/2024 to 4/4/2024. This antibiotic was not susceptible to the bacteria. The Nurse Practitioner (NP) and the two IPs did not realize that the hospital gave the wrong antibiotic.

-4/10/2024-Resident was straight catheterized in the facility for burning upon urination. The culture showed Escherichia Coli ESBL. The resident took the antibiotic Macrobid from 4/15/2024 to 4/25/2024. This antibiotic was susceptible to the bacteria.

-5/10/2024-Resident R63 was sent to the hospital for burning upon urination. The hospital did not get a culture and started the resident on the antibiotic Cephalexin from 5/11/2024 to 5/17/2024.

-5/14/2024-Resident R63 was again straight catheterized in the facility when it was realized that a culture was not obtained. The culture showed no growth.

During an interview on 7/4/2024 at 9:44 am, the IP revealed Pharmacy does monthly medication reviews, but

it does not include antibiotic reviews. For [Resident R63], we missed the big picture. We did not see the timeline of all

the catheterizations and antibiotics. Every time a straight catheterization is completed, it is a possibility for an infection. We missed the wrong antibiotic administered and we must make changes. The infection control program in the EMR does not keep an order of events. When asked why a urology consultation was not made for the resident, the IP stated We did not see what we are seeing now. This is black and white, and I cannot dispute any of this. We need to make changes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 115676 Department of Health & Human Services Printed: 09/18/2025 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 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

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 0881 During an interview on 7/4/2024 at 9:52 am, the NP revealed when asked if she had looked at the big picture with Resident R63 with all the catheterizations and antibiotics, she did not respond to the question. When asked if Resident R63 Level of Harm - Minimal harm or was referred to a Urologist, the NP stated, I do not think so. When the issue was presented to the NP, she potential for actual harm stated I do not order an antibiotic unless the resident has had a urinalysis (UA) and culture. When the NP was made aware that on 3/11/2024, a UA and culture was ordered by her for increased confusion, and this Residents Affected - Few did not meet the criteria that the facility used for a resident to be straight catheterized, the NP stated, The medical director wants all residents straight catheterized when a UTI is suspected. When the NP was asked

on 5/10/2024, why she ordered another UA and culture after the resident had been on an antibiotic from 5/11/2024 to 5/17/2024, The NP stated, Because a culture had not been done.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 115676