Dekalb County Rehab & Nursing

In the surveyor’s words

From the most serious findings on record at Dekalb County Rehab & Nursing, in the surveyor’s own words.

• Immediate jeopardy, patternF880Sep 13, 2023

  Based on observation, interview, and record review facility, failed to ensure sure staff doffed PPE (personal protective equipment) in a manner to prevent cross-contamination after caring for COVID-19 positive residents; failed to ensure residents were not exposed to staff exhibiting symptoms of COVID-19; failed to implement transmission-based precautions for residents exhibiting symptoms of COVID-19; failed to have a system in place to accurately track/trend resident and staff exposures to COVID-19 during a facility outbreak; failed to have an effective system in place to test staff and residents for COVID-19 during a facility outbreak; and failed to ensure COVID negative residents were not exposed to COVID positive residents. […]

• Immediate jeopardy, patternF880Jan 22, 2021

  Based on observation, interview, and record review, the facility failed to implement infection control policies and recommendations from the local health department and the Centers for Disease Control regarding isolation of COVID-19 residents, and the facility failed to ensure staff were knowledgable in the use of personal protective equipment. This failure has the potential to spread COVID-19 disease to negative residents. This applies to five of five residents (R1, R5, R6, R8, and R10) reviewed for infection control practices in the sample of 11. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/18/21 when R1, R5, R6, R8, and R10 were not separated from their COVID-19 positive roommates during the facility's current outbreak. […]

• Immediate jeopardy, isolatedF689Jun 22, 2023

  Based on interview and record review, the facility failed to reassess a resident for change of diet after losing dentures, and failed to supervise residents in the dining room at mealtime for 1 of 3 residents (R4) reviewed for choking. This failure resulted in R4 choking in the dining room on [DATE] and expiring at the hospital on [DATE]. The Immediate Jeopardy began on [DATE] when R4's lower dentures were noted to be missing. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 11:30 AM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. […]

• Actual harm, isolatedF689Jun 4, 2026

  Based on interview and record review, the facility failed to have fall prevention interventions in place for one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in R1 experiencing a fall and injury which required eight staples to the top of his head. The findings include:R1's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including dementia, malnutrition, repeated falls, need for assistance with personal care, cognitive communication deficit, unsteadiness on feet, weakness, low back pain, anxiety disorder, and unspecified visual disturbance.R1's Care Plan initiated on April 28, 2026, shows R1 has a VERY HIGH RISK for falls & has impaired safety related to his cognition secondary to Dementia w/ Anxiety, history of… […]

• Actual harm, isolatedF689Jan 24, 2024

  Based on interview and record review, the facility failed to ambulate residents with the assistance of a gait belt to ensure residents were ambulated in a safe manner. This failure applies to 2 of 4 residents (R1, R2) in the sample of 4 reviewed for safety and supervision. This failure resulted in R1 falling while ambulating with staff, resulting in R1 fracturing her left femur (upper leg) and requiring hospitalization . The findings include: 1. The facility's Witnessed Fall incident report, dated 1/10/24, showed R1 was walking in her room, with the use of her walker and with V7, Certified Nursing Assistant (CNA), present, when R1's knees buckled and R1 fell to the floor. The report showed R1's left leg got caught under a bedside dresser during the fall. […]