Tifton Health And Rehabilitation Center

F-F697

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 8 115412 Department of Health & Human Services Printed: 09/04/2025 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 115412 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harborview Tifton 1451 Newton Drive 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 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Actual harm 34318

Residents Affected - Few Based on observations, record review, staff interviews, and a review of the facility policy titled Administering Pain Management, the facility failed to ensure that two of three sampled residents (R) (Resident R1 and Resident R3) were free from pain during wound care treatment. Harm was determined to have occurred on 3/5/2025 when Resident R1 and Resident R3 experienced pain that was not addressed during wound care treatment.

Findings included:

A review of the undated policy titled Administering Pain Management, it was documented that the pain management program was based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. It was noted that Pain Management was defined as the process of alleviating

the resident's pain based on his/her clinical condition and established treatment goals and that Pain Management was a multidisciplinary care process that included the following: assessing the potential for pain; recognizing the presence of pain; identifying the characteristics of pain; and addressing the underlying causes of the pain.

1. A review of the electronic medical record (EMR) revealed that Resident R1 was admitted to the facility with diagnoses of type 2 diabetes mellitus, chronic gout, metabolic encephalopathy, pressure ulcer, hypertensive heart disease, dementia, pain, and glaucoma.

During an observation on 3/5/2025 at 10:39 am, Resident R1 was lying in bed on an airflow mattress with bilateral assistive rails in the upper position and had a wedge and a pillow for positioning. Wound Nurse/Licensed Practical Nurse (LPN) CC was being assisted by LPN DD and Certified Nurse Certified (CNA) SS to provide

the resident with wound care treatment. LPN CC washed her hands, and CNA SS removed the resident brief and provided perineal care. The wound bed was 80% yellowish slough and 20% reddish granulation. LPN CC cleaned the wound with wound cleanser, and while cleaning the wound, Resident R1 was observed voicing, Ouch, ouch, ouch. That hurts. LPN CC continued to obtain wound measurements of 8.5L x 3.1W x 4.7D. LPN CC began checking for undermining using her finger and again the resident began saying, Oh, oh and tried moving away from LPN CC's hand. LPN DD told Resident R1 to take a deep breath and that it was almost over. LPN CC continued applying the Dakin solution on a kerlix and packing the Dakin-moistened kerlix into the wound bed. LPN CC then placed an adhesive border dressing over the moistened kerlix. Resident R1 continued squirming on

the bed throughout the dressing change (moving away from the nurse's hands). Further observation revealed a sign on Resident R1's door documenting that enhanced barrier precautions were in place. LPN CC, LPN DD, and CNA SS were not wearing a gown as they performed wound care and/or perineal care.

A review of the Order Summary Report dated 3/5/2025 revealed Resident R1 had an order for Tylenol 325 milligrams (mg) tablet, to administer two tablets orally every six hours as needed for pain related to pressure ulcer of the sacral region with an order and start date of 3/4/2025.

A review of the Medication Administration Record (MAR) dated 3/1/2025 through 3/31/2025 revealed no evidence that Tylenol was administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 8 115412 Department of Health & Human Services Printed: 09/04/2025 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 115412 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harborview Tifton 1451 Newton Drive 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 0697 2. A review of the EMR revealed that Resident R3 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, cirrhosis of the liver, emphysema, atherosclerotic heart disease Level of Harm - Actual harm of native coronary, hypertensive heart disease, and fibromyalgia.

Residents Affected - Few During an observation on 3/5/2025 at 11:04 am, an enhanced barrier precaution sign was posted on Resident R3's door. The resident was observed lying on an airflow mattress with bilateral quarter-side rails in the up position. Resident R1's designated Power of Attorney (POA) was also in the room. LPN CC and LPN DD entered the room and neither nurse was wearing a protective gown. The nurses repositioned the resident turning her to face the door and Resident R3's face was pressing against the quarter side rail. LPN CC removed the dressing from Resident R3's coccyx area and as the dressing was being removed the resident was moaning and grimacing in pain.

The resident wound bed was observed with red granulation. The nurse cleaned the wound bed with wound cleaner; obtained measurements 4.0L x 31W; and LPN DD began peeling an adhesive dressing from the right lower buttock. As she was peeling the dressing from the resident skin, the resident began squirming in bed, trying to move away from the removal of the dressing. LPN DD stated that the wound was not open yesterday and that she would call hospice to inform them of the opening of the lower right buttock wound. LPN CC measured the lower right buttock wound and obtained measurements (7.3L x 2.1). The upper part of

the wound was red, and the lower half of the wound was dark red. The resident started complaining about her face being pressed against the bed rail, and LPN DD told the resident that they were just about done.

The POA, who was standing at the head of the bed, put her hand between the rail and the resident's face. LPN CC began to skin-prep the outer skin surrounding the wound bed, placed calcium alginate on the wound bed, placed a 4x4 gauze over the wound, and covered the area with an adhesive dressing.

A review of the order summary report dated 3/5/2025 revealed a wound order to clean Resident R3's coccyx with normal saline, skin prep, alginate calcium, and dressing with border gauze once a day (every Tuesday, Thursday, and Saturday.)

There was an order for pain medication of hydrocodone-acetaminophen tablet 10-300 mg that was discontinued on 11/6/2024; Tramadol 50 mg that was discontinued on 9/21/2023, and hydromorphone HCL tablet 4 mg that was discontinued on 10/21/02021. There was no active order for pain medication until Resident R3 was admitted to hospice care on 3/5/2025 later in the afternoon after the wound care treatment.

During an interview on 3/5/2025 at 11:33 am, Resident R3 confirmed that she was uncomfortable and that the wound treatment hurt.

During an interview on 3/11/2025 at 12:55 pm, the Nurse Practitioner (NP) revealed that staff should be educated on pre-medication and the stages of wounds and that she will follow up on residents with wounds for pain management.

During an interview on 3/11/2025 at 2:11 pm, LPN DD revealed that when a resident has pain during wound care treatment, the staff are supposed to stop the treatment and administer pain medication; call the NP for

an order for pain medication and send the order to the pharmacy; or if the physician sends a prescription in,

the pharmacy will allow nurses to get the pain medication from the pixel as soon as the doctor signs the prescription.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 8 115412 Department of Health & Human Services Printed: 09/04/2025 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 115412 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harborview Tifton 1451 Newton Drive 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 0697 During an interview on 3/11/2025 at 2:17 pm, LPN CC revealed that she should have stopped and asked Resident R1 if she needed anything for pain. LPN CC confirmed that she had not assessed Resident R1 or Resident R3 for pain. LPN CC Level of Harm - Actual harm stated that she was focused on the wound care treatment and that is why she did not administer pain medication to Resident R1 or get an order for pain medication for Resident R3. Residents Affected - Few

During an interview on 3/12/2025 at 1:26 pm, the Director of Nursing (DON) revealed that the staff should have assessed the residents for pain and determined the cause of the pain.

Cross Reference F 656

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 115412 Department of Health & Human Services Printed: 09/04/2025 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 115412 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harborview Tifton 1451 Newton Drive 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 34318 potential for actual harm Based on observations, record review, staff interviews, and a review of the facility policy titled Infection Residents Affected - Some Prevention and Control Program, the facility failed to ensure that the staff wore the appropriate personal protective equipment (PPE) while providing care for three of three sampled residents (R) (Resident R1, Resident R2, and Resident R3)

during wound care and perineal care.

Findings included:

A review of the Infection Prevention and Control Program dated 5/23/23 and last revised on 3/1/2024, revealed that it is standard precaution that all staff shall use PPE according to established facility policy governing the use of PPE.

A review of the Enhanced Barrier Precautions (EBP)sign noted that doctors and staff must wear gloves and

a gown for high-contact resident care activities such as dressing, bathing/showering, transferring, changing lines, providing hygiene, changing briefs, assisting with toileting, device care or use of a central line, urinary catheter, feeding tube, tracheostomy, wound care, and any skin opening requiring a dressing. It was further noted that staff are not to wear the same gown and gloves for the care of more than one person.

1. A review of the electronic medical record (EMR) revealed that Resident R1 was admitted to the facility with diagnoses of type 2 diabetes mellitus, chronic gout, metabolic encephalopathy, pressure ulcer, hypertensive heart disease, dementia, pain, and glaucoma.

During an observation on 3/5/2025 at 10:39 am, there was a sign on the outside of Resident R1's door that read, Enhanced Barrier Precautions. Resident R1 had a bowel movement and Certified Nurse Aide (CNA) SS performed perineal care. Resident R1 had a stage IV coccyx pressure ulcer. Licensed Practical Nurse (LPN) CC and LPN DD provided wound care. CNA SS, LPN CC, and LPN DD did not wear a protective gown during the

observations.

During an observation on 3/11/2025 at 11:24 am, CNA GG was assisting CNA HH in providing perineal care to Resident R1. During the observation, CNA HH and CNA GG were not wearing protective gowns. While CNA HH and CNA GG were providing perineal care, LPN CC came into the room and replaced the soiled dressing. LPN CC was not wearing a protective gown.

During an interview on 3/11/2025 at 3:21 pm, CNA HH revealed she didn't have a gown because she didn't read the sign on the door and had not seen any PPE by the door.

During an interview on 3/11/2025 at 12:47 pm, CNA GG revealed that she should have put on the protective gown but that she didn't think about it.

2. A review of the ERM revealed that Resident R2 was admitted to the facility with diagnoses of type 2 diabetes mellitus, hypertension, pressure ulcer of sacral stage 4, and pleural effusion. It was revealed in the EMR that Resident R2 was on EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 115412 Department of Health & Human Services Printed: 09/04/2025 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 115412 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harborview Tifton 1451 Newton Drive 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 observation on 3/5/2025 at 2:01 pm, LPN CC was providing wound care to Resident R2 and was not wearing a protective gown. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/11/2025 at 2:17 pm, LPN CC revealed that she did not know why she didn't put on

a gown. Residents Affected - Some 3. A review of the EMR revealed that Resident R3 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, cirrhosis of the liver, emphysema, atherosclerotic heart disease of native coronary, hypertensive heart disease, and fibromyalgia.

During an observation on 3/5/2025 at 11:04 am, there was an EBP sign on the door. The Wound Care Nurse/LPN CC was being assisted by LPN DD. They were providing wound care treatment to Resident R3. Neither LPN CC nor LPN DD were wearing protective gowns during the observation of the wound care treatment.

A review of the Order Summary Report dated 3/5/2025 revealed an order date and start date for Enhanced Barrier Precautions: Resident is placed on this precaution due to having a colostomy and a wound. The use of PPE when providing care in high-contact resident care activities where gowns and gloves are appropriate, two times a day.

During an interview on 3/11/2025 at 2:11 pm, LPN DD revealed that she had no answer for why she didn't put on the protective gown and stated that she just forgot.

During an interview on 3/11/2025 at 2:17 pm, LPN CC revealed she didn't know why she didn't put on a protective gown.

During an observation on 3/3/2025 at 11:29 am, observed a staff (identified as AA) with a cart loaded with boxes of gloves. She went into the residents' room and brought out partially empty glove boxes to her cart took an open box of gloves on the cart took gloves out with her bare hand and stuffed gloves into the box brought from the residents. If the resident had an empty box, she would replace it with a full box. She continued to go into each resident's room either stuffing gloves with her bare hand into partially empty boxes or placing a box of gloves in the room in the absence of a box of gloves in the room. AA was observed going into each resident's room in the halls and annexes.

During an interview on 3/12/2025 at 1:55 pm, Infection Control Preventionist/Registered Nurse (RN) QQ stated that they had one box containing 50 gowns in the outside shed.

During an observation on 3/12/2025 at 1:58 pm, two boxes of 50 protective gowns were observed in the medication room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 115412 Department of Health & Human Services Printed: 09/04/2025 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 115412 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harborview Tifton 1451 Newton Drive 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 3/11/2025 at 3:38 pm, Central Supply/Medical Record AA revealed that if the glove boxes have four or five gloves, she will replace the entire box with a new box of gloves. If the box was half Level of Harm - Minimal harm or full and two boxes were the same size, she would take one box out and put the half-full box in another room. potential for actual harm If the gloves box is less than half full, she would put the gloves from the box on the cart and put the gloves in

the box that came from the room. She stated that she was not wearing gloves when transferring gloves into Residents Affected - Some another glove box. She confirmed that the resident rooms had hand sanitizer, but she didn't use it. She continued to state that she normally does the glove boxes twice a week unless they (the staff) use a lot of gloves. She stated that she would order some, keep a few supplies in the medication room, and keep some

in the shed. She had two or three cases of gown and had recently ordered two more cases.

During an interview on 3/12/2025 at 2:47 pm, the Administrator revealed that the staff will be retrained on the use of PPE and keeping a clean cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 115412