George Regional Health & Rehab Center

F-F759

Findings included:

A review of the facility's policy titled, Medication Administration, revised 2/1/25, revealed, .Medications are administered .in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .17. Administer medications as ordered in accordance with manufacturer specifications .c .Do no crush medications with 'do not crush' instruction .Example guidelines for Medication Administration (unless otherwise ordered by physician) .Do Not Crush Medications: Crushed meds are not to be combined and given all at once, if via feeding tube .

A review of the facility's policy titled, Medication Administration via Enteral Tube, revised 1/20/25, revealed, It is the policy of this facility to ensure the safe and effective administration of medication via enteral feeding tubes by utilizing best practice guidelines .Policy Explanation and Compliance Guidelines: 1. Provider pharmacy or consultant pharmacist will be utilized as a resource concerning potential interactions between medications and feeding formulas .4. Prior to crushing tablets, nurses will consult the Medications Not to Be Crushed list .6. Medications may be combined or added to an enteral feed formula per MD orders .8. Physician or practitioner documentation will be provided in the medical record stating the medical rational for crushing a medication against a manufacturer's instructions .

A review of the clinical reference ISMP (Institute for Safe Medication Practices) Medication Safety Alert, dated 11/17/22, revealed Preventing errors when preparing and administering medications via enteral feeding tubes .Common inappropriate administration techniques include: 1) mixing multiple medications together to give at once .Safe Practice Recommendations .Seek expertise. Before a prescriber places a medication order, and prior to a nurse preparing and administering a medication via an enteral tube, consult

a pharmacist with any questions about the safety of a drug to be given via an enteral feeding tube .Prepare each medication separately. Avoid mixing two or more medications together, whether solid or liquid formulations, as this can create a new unknown entity with an unpredictable release and bioavailability .Flush . flush the tube with at least 15 mL (milliliters) of water .before and after the administration of each medication .Administer separately. Give each medication separately through the feeding tube .

A record review of the medication administration instructions from Drugs.com revealed for Aripiprazole, Swallow the regular table whole and do not crush, chew, or break it. Do not split the orally disintegrating tablet, and for Lansoprazole do not crush or chew tablets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 255333 Department of Health & Human Services Printed: 08/27/2025 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 255333 B. Wing 05/01/2025

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

George Regional Health & Rehab Center 859 Winter St Lucedale, MS 39452

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 0760 During a medication administration observation on 4/30/25 at 9:30 AM, Licensed Practical Nurse (LPN) #4 administered Resident #11 the following medications: Norvasc 2.5 mg (milligrams) per peg, aripiprazole Level of Harm - Minimal harm or (Abilify)15 mg per peg, Lansoprazole DR (Prevacid)15 mg per peg and pro stat 30 milliliters per peg. LPN #4 potential for actual harm mixed all four (4) medications together in a cup with water and administered them via syringe in the residents (PEG) tube. Residents Affected - Few

A record review of the Order Summary Report revealed Resident #11 had a Physician's Order, dated 11/22/2024, for .May crush all non-liquid meds together and mix together for administration. There was an order for Pro-state 30 milliliters per (PEG) tube, dated 3/21/25, Amlodipine Besylate tablet via G-Tube, dated 3/8/2021, Aripiprazole tablet via G-Tube, dated 3/21/25, and Lansoprazole tablet disintegrating via G-Tube, dated 3/21/25.

Record review of Resident #11's medical record revealed there was no evidence of individualized assessments or pharmacy review to evaluate the safety or appropriateness of crushing, combining, and administering the medications through the enteral feeding tube.

During an interview on 4/30/25 at 1:00 PM, LPN #4 stated that the facility has a standing order from the Medical Director allowing all PEG medications to be crushed and mixed for all residents with PEG tubes. She also stated she had never checked for compatibility or consulted a pharmacist to ensure it was safe to do so.

During an interview on 4/30/25 at 1:15 PM, the Director of Nursing (DON) confirmed that crushing and combining medications without checking for compatibility could cause problems and stated she was aware staff were combining medications per the physician's orders. She also confirmed that the facility had not conducted individualized reviews for PEG tube residents regarding medications being administered together.

During an interview on 4/30/25 at 1:30 PM, the Medical Director (MD) stated that he expects the pharmacy to

review medications and check for compatibility. He confirmed that the facility asks for standing orders to administer medications together, but he did not know staff were combining all medications for PEG administration.

During an interview on 4/30/25 at 1:45 PM, the Consultant Pharmacist stated that she has explained to the nurses that safe practice standards for administering medication via PEG require medications to be given individually. She stated no blanket order should replace clinical judgment and individualized review and explained that combining crushed medications can lead to pharmacokinetic changes and tube blockage, especially in high-risk residents. She was aware staff were combining medications due to standing physician orders.

During an interview on 4/30/25 at 2:00 PM, the Administrator confirmed that the facility has standing orders to mix and give PEG medications together. He also confirmed that combining crushed medications can lead to pharmacokinetic changes and tube blockage.

A record review of Resident #11's Admission Record revealed the resident was admitted on [DATE REDACTED] with current diagnoses including Hypertension.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 255333 Department of Health & Human Services Printed: 08/27/2025 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 255333 B. Wing 05/01/2025

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

George Regional Health & Rehab Center 859 Winter St Lucedale, MS 39452

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 0760 A record review of Resident #11's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the Level of Harm - Minimal harm or resident's cognition was moderately impaired. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 255333 Department of Health & Human Services Printed: 08/27/2025 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 255333 B. Wing 05/01/2025

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

George Regional Health & Rehab Center 859 Winter St Lucedale, MS 39452

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 37415 potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to prevent the Residents Affected - Few possible spread of infection by not following manufacturer guidelines for cleaning and disinfecting the glucometer for one (1) of two (2) residents observed for blood glucose monitoring, Resident #95.

Findings include:

A review of the facility's policy, Blood Glucose Monitoring, dated 2/15/25, revealed, It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders . Policy Explanation and Guidelines . 2. The nurse will perform the blood glucose test utilizing the facility's glucometer as per manufacturer's instruction. 3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. 4. If possible, glucometers should not be shared between residents, but if this is not possible, the nurse is responsible for cleaning and disinfection of the machine between residents following the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy .

A review of the facility's policy, Glucometer Disinfection, revised 7/24/24, revealed, The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees . Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use. 2. The glucometers will be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective against HIV (Human Immunodeficiency Virus), Hepatitis C and Hepatitis B virus. 3. The Glucometer will be cleaned and disinfected after each use .

A review of the General Guidelines for use of the Super Sani-Cloth, dated 2021, revealed, .3b. Unfold a clean wipe and thoroughly wet surface 4. Allow treated surface to remain wet for two (2) minutes. Let air dry .

A record review of the Order Summary Report revealed Resident #95 had a physician's order, dated 4/22/25, for Accu-Chek AC (before meals) and HS (bedtime).

On 4/30/25 at 11:15 AM, during an observation, Licensed Practical Nurse (LPN) #4 was observed using a glucometer to check Resident #95's blood sugar. After the procedure, she used a Sani wipe disinfectant cloth and rubbed the top of the glucometer for ten (10) seconds.

On 4/30/25 at 1:00 PM, during an interview with LPN #4, she confirmed she failed to cleanse the glucometer with the Sani wipe for the required two (2) minutes. She stated she was not familiar with the manufacturer's guidelines that required a two (2) minute contact time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 255333 Department of Health & Human Services Printed: 08/27/2025 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 255333 B. Wing 05/01/2025

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

George Regional Health & Rehab Center 859 Winter St Lucedale, MS 39452

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 On 4/30/25 at 1:15 PM, during an interview with the Director of Nursing (DON), she stated that all nursing staff had been in-serviced on proper glucometer cleansing. The DON confirmed that the glucometer was Level of Harm - Minimal harm or shared among residents, and failure to cleanse it properly could lead to the transmission of blood borne potential for actual harm diseases. She confirmed the facility did not currently have any residents with a blood borne disease.

Residents Affected - Few On 4/30/25 at 2:00 PM, during an interview with the Administrator, she stated that she expected staff to follow the manufacturer's guidelines for using Sani wipes to prevent infections.

A record review of Resident #95's Admission Record revealed the facility admitted the resident on 4/22/25 with diagnoses including Type 2 Diabetes Mellitus.

A record review of Resident #95's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 255333