Haralson NSG & Rehab Center

In the surveyor’s words

From the most serious findings on record at Haralson NSG & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 15, 2025

  Based on record review, observations, interviews, and a review of the facility policy titled Hot Beverage Policy, the facility failed to ensure that one of 14 sampled residents (R) (R4) was free from accident hazards. Harm was identified to have occurred on 11/12/2024 when staff served R4 hot liquids, which resulted in a second-degree burn.Findings included:An undated facility policy titled Hot Beverage Policy revealed that serving hot beverages that are at exceedingly high temperatures can increase the risk of burns and scalding amongst elderly residents. It is important to provide hot beverages at a safe temperature. Hot beverages should be served between 130 [degrees] and 160 [degrees]. […]

• Actual harm, isolatedF600Jul 21, 2022

  Based on record review, document review, interviews, and a review of facility policy, the facility failed to protect two of two residents (R) (R#205 and R#98) from abuse from R#204. On 7/20/21, the psychiatrist indicated there was an alarming change in R#204's impulsivity and recommended staff should watch R#204 more carefully while the medications get stabilized. However, there was no documented evidence the facility increased the resident's supervision to protect residents. On 7/30/21, staff found R#204 hitting the resident's roommate (R#205) in the face with a fist. The facility implemented interventions including moving the resident's roommate; however, the facility failed to implement interventions to supervise R#204. […]

• Actual harm, isolatedF689Jul 21, 2022

  Based on interviews, record review, and facility policy review, the facility failed to ensure a root cause was identified and person-centered interventions were developed after a fall for one of three sampled residents (R) (R#69) reviewed for falls. Specifically, R#69 had an unwitnessed fall in the resident's room on 4/2/22 and the root cause of the fall was not identified nor were new interventions developed. The resident experienced another unwitnessed fall in the resident's room on 6/27/22 and sustained a fracture to the left hand. Findings include: A review of the undated facility policy titled, Cypress Skilled Nursing Clinical Standard of Practice, revealed, Subject: Fall Management Standard: 1. […]

• No harm, potential for more than minimal, widespreadF812Sep 11, 2025

  Based on observation, staff interviews, and review of the facility policy titled Ice Machines and Ice Storage Chests, the facility failed to ensure the ice machine was maintained in a clean and sanitary condition. This deficient practice had the potential to place the 86 residents who received hydration and nutrition from the kitchen at increased risk of foodborne illness. Findings include:Review of the facility policy titled Ice Machines and Ice Storage Chests, dated 10/2022, revealed the Policy Statement section stated, Ice machines and ice storage/distribution containers will be used and maintained to assure [sic] a safe and sanitary supply of ice. The Policy Interpretation and Implementation section included, 1. […]

• No harm, potential for more than minimal, widespreadF880Sep 11, 2025

  Based on observations, staff interviews, record review, and review of the facility policies titled Handwashing/Hand Hygiene and Handling of Linen, the facility failed to ensure infection control practices were followed during disposal of soiled items, resident equipment maintenance, during laundry processes, and during meal tray delivery. These deficient practices had the potential to place the residents residing in the facility at increased risk of infections due to cross-contamination. The facility census was 100. […]