Sadie G. Mays Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Sadie G. Mays Health & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 19, 2025

  Based on observation, interview, record review, and a review of the policy titled Food Preparation Guidelines, the facility failed to prevent avoidable accidents for two of three sampled residents (R) (R41 and R56) related to (1) hot chocolate burn and (2) fall risk. Harm was identified to have occurred on 3/18/2025 when R41 spilled hot chocolate on her left arm, causing a burn, blisters, and requiring transport to an acute care setting and wound treatment. Findings included:1. […]

• Actual harm, isolatedF684Jun 26, 2024

  Based on observation, record review, interviews, and facility policies, the facility failed to ensure two of 19 residents (R) (R6 and R15) weren't provided with nursing care and services to ensure their medical needs were met related to pain management for R6 and R15; administering medication without a physicians order for R15; and a pest infestation of gnats that were on the R6 left leg wound. Further, harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate. […]

• Actual harm, isolatedF755Jun 26, 2024

  Based on observation, record review, staff interviews, and the facility policy Administering Medications the facility failed to ensure one of forty-three sampled residents (R) (R15) was receiving medications as prescribed by the psychiatrist. The pharmacy continued to dispense Fluoxetine (Prozac) to R15 after it was discontinued on 6/29/2023 by the psychiatrist. Harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate. […]

• Actual harm, isolatedF757Jun 26, 2024

  Based on interviews, record review, and review of facility policy titled Administering Medications, the facility failed to ensure one of two residents (R) (R15) was free from unnecessary psychotropic medications. Resident (R15) was administered Fluoxetine (Prozac) during a medication observation. Harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate. […]

• No harm, potential for more than minimal, widespreadF570Dec 19, 2025

  Based on record review, staff interviews, and a review of the policy titled Management of Beneficiary Funds, the facility failed to ensure that the surety bond was sufficient to cover the resident trust fund deposits. This deficient practice had the potential to adversely affect 129 of 129 residents in the facility.Findings included:A review of the undated facility's policy titled Management of Beneficiary Funds describes the process of managing beneficiary funds, but does not address the Surety [NAME] review of the facility's Surety Bond Document dated 3/26/2025 through 5/26/2025, indicated the amount of the bond was $190,000.00.A review of six months of the facility's Bank Statements from May 2025 to November 2025 revealed that five out of six bank statements had daily balances that were… […]