Moultrie Creek Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Moultrie Creek Nursing and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF689Oct 3, 2024

  Based on resident record review, observations, interviews with the resident and staff, and a review of the facility's policy and procedure, the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible for one (Resident #17) of two residents reviewed for accident hazards, from a total survey sample of 33 residents. The findings include: An observation was made of Resident #17 on 9/30/2024 at 1:55 PM in his room. He was awake and lying in bed under the covers watching television. During the observation of the resident's room, one shaving razor was observed inside of a plastic container on the bedside table located over the resident's bed. No facility staff were present. […]

• No harm, potential for more than minimal, isolatedF759Oct 3, 2024

  Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on three errors from 27 opportunities for error, resulting in an error rate of 11%, and impacting three (Residents #48, #259 and #33) of five residents observed for medication administration, from a total survey sample of 33 residents. Failure to administer medications appropriately as ordered, could result in side effects and/or potential harm to the residents. The findings include: 1. During medication administration observation on 10/2/24 at 8:35 a.m., Licensed Practical Nurse (LPN) A was preparing medication for Resident #48. […]

• No harm, potential for more than minimal, isolatedF812Nov 17, 2022

  Based on observations, staff interviews, and a review of policies and procedures, the facility failed to serve food in accordance with professional standards for food service safety, by failing to ensure staff served food in a sanitary manner during two of two dining observations (lunch meals on 11/14/22 and 11/16/22) affecting Residents #34 and #18. The findings include: An observation of the lunch meal was conducted in the main dining room on 11/14/22 beginning at 11:57 AM. Certified Nursing Assistant (CNA) B was observed placing butter on Resident #34's roll using her bare hands. At 12:12 PM, CNA B used her bare hand to remove bread from a package (touching the bread with her bare hand) for Resident #49. […]

• No harm, potential for more than minimal, isolatedF880Nov 17, 2022

  Based on observations, interviews and record reviews, the facility failed to implement an effective infection control program, by failing to 1) Ensure staff followed infection control guidelines for hand hygiene during wound care for one (Resident #26) of two residents sampled for pressure ulcers, 2) Prevent cross contamination during catheter care for one (Resident #17) of one resident sampled for catheter care, 3) Ensure that the infection control committee was fully involved in the infection control program by offering feedback on infection control concerns during monthly meetings, and 4) Investigate an increase in urinary tract infections for one of two months available for review (October 2022). The findings include: 1. […]

• No harm, potential for more than minimal, isolatedF684Apr 1, 2021

  Based on record reviews and interviews, the facility failed to provide treatment in accordance with professional standards of practice for one (Resident #58) of 34 sampled residents, by failing to hold a medication for five days prior to a scheduled procedure, as ordered, requiring the procedure to be rescheduled for a later date. The delay resulted in the resident being transferred to the hospital for care prior to her rescheduled surgery date. The findings include: In an interview on 3/30/2021 at 11:29 AM with Resident #58's the niece (Health Care Proxy), she stated, My aunt was scheduled for a procedure about two weeks ago, but the facility forgot to hold her aspirin prior to the procedure, and this caused the procedure to be put off for another week. […]