rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
9978,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2010-08-12,279,D,0,1,55J411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a care plan to address the use of psychoactive medications related to monitoring of potential adverse side effects and/or if the medications are providing the intended affects for 2 residents, resident #59 and #21 and for resident ""C"" related to dental care on a sample of twenty-one (21) residents. The findings include: 1. Review of the Physician order [REDACTED].#59 revealed that she was on Klonopin 0.5 milligrams each day, [MEDICATION NAME] 25 milligrams at night, [MEDICATION NAME] 15 milligrams three times a day, [MEDICATION NAME] 100 milligrams in the morning and 50 milligrams at night for anxiety, depression and behaviors. Review of the care plan dated 7/2010 revealed that the facility had not addressed the use of these medications related to negative side effects or to determine if they were working as the physician intended. Interview with the MDS Coordinator on 8/12/2010 at 2:00 p.m. revealed that she had always included the use of the psychoactive medications to a falls or nutrition care plan. Review of the falls care plan revealed mention that the resident received [MEDICAL CONDITION] meds but did not address specifics to monitoring for behaviors or side effects monitoring. 2. During a family interview for resident ""C"" on 8/10/2010 at 9:30 a.m. they stated that the resident had recently had a tooth extraction. The resident had the extraction on 8/7/2010 with the family taking her to the dentist office for the service. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident did not have any problem with chewing and needed limited assistance with activities of daily living. Review of the plan of care for resident ""C"" on 8/11/2010 at 1:00 p.m. revealed that the facility had not developed a care plan related to dental or mouth care needs for this resident. Interview with the MDS Coordinator on 9/11/2010 at 1:30 p.m. confirmed that the resident did not have a care plan for dental or mouth care. She stated that she usually put dental care under nutrition concerns and that the CNA's are aware of the residents who require assistance with mouth care when ADL care is provided. 3. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed resident #21 was receiving antianxiety and antipsychotic medications seven (7) days a week. The resident was also assessed as having repetitive verbalizations of calling out for help daily or almost daily and that these behavior were easily altered. Review of MDS also documented the resident had a [DIAGNOSES REDACTED]. Review of the current August 2010 physician orders [REDACTED]. Review of the care plan revealed there was no specific care plan for the [MEDICAL CONDITION] medications with appropriate interventions listed. Interview with MDS Coordinator on 8/11/10 at 3:10 pm confirmed there was no specific care plan to address the residents use of [MEDICAL CONDITION] medications.",2015-03-01
9979,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2010-08-12,281,D,0,1,55J411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to clarify a medication order for the exact dosage the physician wanted for one (1) resident, resident #47 on a sample of twenty-one (21) residents. Findings include: During the medication pass observed on 9/11/2010 at 8:00 a.m. the nurse, Licensed Practical Nurse (LPN) ""MM"" was observed to give resident # 47 liquid [MEDICATION NAME] 5 cc's which equaled 50 milligrams. Review of the Physician order [REDACTED].=100 mg) by mouth each day at 8:30 a.m. Interview with LPN ""LL"" revealed that she would give 10 cc/ 100 milligrams of the [MEDICATION NAME]. Interview with Registered Nurse ""KK"" revealed that she would give the 10 cc of [MEDICATION NAME] but stated that the order was not clear. None of the three nurses interviewed stated that they would call the physician for clarification of the order. The physician was notified and the order clarified to read give liquid [MEDICATION NAME] 10 cc's to equal 100 milligrams. Review of the Nursing Practice and Regulation Acts of Georgia for Registered Nurses and Licensed Practical Nurses revealed that their responsibility was to seek clarification of physician orders [REDACTED].",2015-03-01
9980,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2010-08-12,156,B,0,1,55J411,"Based on record review and staff interview, the facility failed to provide three (3) residents (#3,107 and 123), with Medicare availability remaining, of the twenty-one (21) sample residents with the Notice of Provider Noncoverage (form CMS- ), notifying the resident of his/her right to an expedited review. The Findings include: Review the records for residents #3, #107 and #123 who had been discharge from Medicare services as no longer meeting the criteria for service revealed the form (CMS- ) which explained the resident's right for an expedited review and reconsideration of discharge. Review of the form CMS- for resident #123 with date of notice 5/18/10 revealed that he/she was no longer eligible for skilled therapy services on 5/19/10 and had an estimated cost of $190.00 per day, which was signed by authorized representative; however, the option to pay for the services themselves, was left blank. Review of the form CMS- for resident #107 with date of notice 4/20/10 revealed that he/she was no longer eligible for skilled therapy services as of 4/23/10 with an estimated cost of $119.03 per day, signed by authorized representative; however, the option box, was left blank. No evidence of form CMS- for all three (3) residents reviewed according to Liability Notices and Beneficiary Appeal Rights Review ""S&C0920."" Interview with the Social Service Director on 8/11/10 at 3:00 p.m., she indicated that she was unaware of the form CMS- . Reported that when these services are going to be discontinued, then staff gave her three (3) days notice and she gets information and fills out form CMS- . Also, she then calls the family and notifies the family of the residents discharge from service, which would be the date of notification and then the family would have seventy-two (72) hours from that date when services are discharged .",2015-03-01
9981,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2010-08-12,314,G,0,1,55J411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview it was determined that the facility failed to ensure that residents who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. This failure to monitor resident's at risk for skin breakdown affected one (1) resident (#21) on a sample of twenty-one (21) residents and resulted in actual harm. Findings include: Record review for resident #21 revealed all MDS assessments since her admitted on 2/05/09 revealed the resident had never been assessed as having had a pressure sore before. Review of the record revealed the resident had a [DIAGNOSES REDACTED]. Review of the MDS dated 7/18/10 assessed this resident as having one (1) Stage I and three (3) Stage IV pressure sores. Review of the Weekly [MEDICAL CONDITION] assessment dated [DATE] documented resident #21 had two (2) new Stage IV pressure sores on the right outer foot. One pressure sore was measured as being 1.0 by 1.0 centimeters, black in color and necrotic. The other pressure sore to the right foot was measured as being 1.2 by 1.2 cm, brown in color and necrotic. Review of a Nurses Note dated 7/13/10 documented the resident had a new skin problem with a three (3) cm pressure sore to the left lower buttock. Further review of the Weekly Skin Lesion assessment dated [DATE] documented the new Stage IV pressure sore that was found to the resident's left buttock measured as 2.0 by 3.0 cm, grey in color and necrotic. After the pressure sores were identified (7/13/10) a [MEDICATION NAME] level was done with a low result of 16.1 (normal range of 20-40). A [DIAGNOSES REDACTED]. Observation on 8/11/10 at 9:15 a.m. of the wound treatment to the resident's right foot revealed there were two (2) Stage IV pressure sores to the right foot one near the 5th digit and the other of the mid area of the outer foot. There was also a Stage IV pressure sore to the left buttocks. All the areas were treated individually using aseptic technique by cleaning the areas with normal saline then santyl ointment was applied to areas and covered with a dry dressing. The most current measurements on these Stage IV pressure sores were done on 8/04/10 with the 1st area to right outer foot measuring 0.8 cm by 1.0 cm by 0.3 cm. The 2nd area to the right outer foot measured 1.2 cm by 1.5 cm by 0.3 cm. The left buttock measured 1.8 cm by 2.8 cm x 0.3 cm. Interview with the Director of Nurses (DON) on 8/11/10 at 9:35 a.m. revealed that these Stage IV pressure sores were acquired at the facility on 7/12/10 and 7/13/10. She revealed that the Certified Nursing Assistants (CNA) who gave showers to this resident twice weekly and are to document and report any skin problems they see, however, she could find no evidence that they were reporting or documenting any of these pressure areas for this resident. She stated at the current time no routine skin assessments were being conducted by the nursing staff. She revealed that a nurse found the two (2) stage IV pressure sores on the resident's right outer foot on 7/12/10 and called the physician for treatment orders. She further stated the nurse did not do a head to toe skin assessment on the resident on 7/12/10. She stated that the staff discussed the pressure sores on the resident's right foot in the Patient at Risk (PAR) meeting on 7/13/10 and a policy was developed regarding skin assessments. When a head to toe assessment was conducted for resident #21 on 7/13/10 another Stage IV pressure sore to the resident's left buttock was discovered. Review of the last skin note dated 7/07/10 completed by a CNA, who bathed the resident, documented there were no bruises on the body old or new. However, interview with two (2) CNAs, ""BB"" and ""CC"" on 8/12/10 at 9:45 a.m. and 9:55 a.m. revealed they had both noticed a red open area to the resident's buttock and stated they had reported it to a nurse. In addition, a wound culture was collected on 7/14/10 that revealed there was a heavy growth of proteus mirabilis in the wound and the resident was started of antibiotic therapy to treat the infection. An arterial duplex doppler study conducted of both lower extremities on 7/26/10 documented no significant arterial occlusive disease.",2015-03-01
9982,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2010-08-12,282,G,0,1,55J411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow the care plan for one (1) resident (# 21) on a sample of twenty one (21) residents related to skin assessments and reporting of skin conditions that contributed to an identified pressure sores that resulted in actual harm to the resident. Findings include: Review of the Resident Assessment Protocol dated 1/25/10 for resident #21 documented the resident was at risk for skin breakdown related to impaired bed mobility and incontinence of bowel and bladder and to proceed to the care plan. Review of the care plan dated 1/24/10 documented that visual skin assessments were to be done with the resident's bath and activities of daily living and to report any red or open areas. Review of the Weekly [MEDICAL CONDITION] Assessment sheets dated 7/12/10 documented the resident was found with two (2) stage IV pressure sores to her right foot and on 7/14/10 was found with one (1) stage IV pressure sore to her left buttock. During interview with the Director of Nurses (DON) on 8/11/10 at 9:35 am she revealed that the Certified Nursing Assistants (CNA) gave a shower to this resident twice weekly and they are responsible for documenting and reporting any skin problems/observations. She could not provide evidence that they were reporting or documenting any of these areas on resident #21. There were no routine skin assessments being conducted on any of the residents in the facility by licensed (LPN or RN) nurses. Weekly assessments are conducted for resident with identified pressure ulcers. Interview with one CNA ""BB"" on 8/12/10 at 9:45 am revealed she had provided care for this resident during the month of July 2010 and she had noticed a blood red area on the resident's ""bottom"". She was applied a ""cream"" to the area. She stated she had reported the area to a nurse but could not recall which nurse. Interview with CNA ""CC"" on 8/12/10 at 9:55 am who also cared for the resident during the time the pressure sores occurred revealed she had noticed a dark red open area on the residents buttocks around the first of July 2010 and reported it to a nurse but could not recall which nurse. She revealed the resident had had a raw open area on her buttocks for ""awhile"". Both CNA's stated they had not noticed a skin problems on the right foot. Review of skin notes written on shower days revealed that the last one was completed for resident #21 was dated 7/07/10 , documented no bruises on the body old or new and completed by CNA ""CC"".",2015-03-01
9983,RIVERDALE CENTER,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2010-04-07,309,E,0,1,I0Y711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician's orders for insulin administration and wound care for fifteen (15) residents (#3, #4, #5, #7, #20, #21, #22, #26, #32, #33, #34, #35, #36, #37 and #38), of the sampled thirty-eight (38) residents. Findings include: 1. Review of the clinical record for resident # 5, revealed a physician's order dated 1/13/2010 for [MEDICATION NAME] R Sliding Scale Insulin to be administered as follows: if the blood sugar is: 250-300=6 units (U); 301-350=8U; 351-400=10U; and 401-450=12U. Continued review revealed a current physician's order for glucose monitoring before meals and at bedtime. Review of the Medication Administration Record [REDACTED]. There is no evidence that the [MEDICATION NAME] R Insulin Sliding Scale was administered per the physicals's parameters. The resident should have received 8U. Further review revealed no evidence that in March, 2010 the resident an glucose monitoring done or sliding scale Insulin administered on 2/21 at 4:30 p.m. and 9:00 p.m. and on March 23 and 24 at 4:30 p.m. 2. Review of the clinical record for resident #26, revealed a physician's order dated 1/18/10 for Sliding Scale Insulin to be administered as follows: if the blood sugar is 250-300=6U; 301-400=8U; 401-500=10U if .500=12U and notify the physician. Continued review revealed a current physician's order for Glucose monitoring two (2) times a day at 6:30 a.m. and 4:30 p.m. Review of the MARs revealed no evidence that in December, 2009 that the resident had an glucose monitoring done or Insulin administered on 12/17, 12/24, 12/29, and 12/30 at 6:30 a.m.; on 12/21, 12/26, 12/27 and 12/31 at 4:30 p.m.. Continued review revealed no evidence that in January, 2010 that the resident had an glucose monitoring done or Insulin administered on 1/07, 1/14, and 1/26 at 4:30 p.m. and that in February, 2010 there was no evidence that the resident had an glucose monitoring done or Insulin administered on 2/10 and 2/11 at 4:30 p.m. Further review revealed no evidence that in March, 2010 the resident had an glucose monitoring done or Insulin administered on 3/04, 3/08, 3/19, and 3/20 at 6:30 a.m. 3. Review of the clinical record for resident #32, revealed a physician's order dated 1/14/10 for [MEDICATION NAME] R Sliding Scale Insulin to be administered as follows: if the blood sugar is 250-300=6 U; 301-350=8U; 351-400=10U and 401-450=12U. Continued review revealed a current physician's order for glucose monitoring two (2) times a day. Review of the MAR for March, 2010 revealed no evidence that the resident had had an glucose monitoring done or Insulin administered on 3/7/10 and 3/19/10. 4. Review of the clinical record for resident #33, revealed a physician's order dated 1/18/10 for Sliding Scale Insulin to be administered as follows: if the blood sugar is 250-300=6U; 301-400=8U; 401-500=10U if .500=12U and notify the physician. Continued review revealed a current physician's order for Glucose monitoring two (2) times a day at 6:30 a.m. and 4:30 p.m. Review of the MARs revealed no evidence that in January, 2010 that the resident had an glucose monitoring done or Insulin administered on 1/26 and 1/31 at 4:30 p.m. 5. Review of the clinical record for resident #34, revealed a physician's order dated 1/18/10 for [MEDICATION NAME] R Sliding Scale Insulin to be administered as follows: if the blood sugar is 250-300=6U, 301-400=8U, 401-500=10U and 501=12U. Continued review revealed a current physician's order for glucose monitoring two (2) times a day at 6:30 a.m. and 4:30 p.m. Review of the MARs revealed no evidence that in January, 2010 that the resident had an glucose monitoring done or Insulin administered on 1/31/10 at 4:30 p.m. and that in February, 2010 no evidence that the resident had an glucose monitoring done or Insulin administered on 2/05 at 4:30 p.m. and 2/22 at 6:30 a.m. Continued review revealed no evidence that the resident had glucose monitoring done or Insulin administered on 3/01/10. Continued review of the March, 2010 MAR indicated [REDACTED]. and on 3/18/10 the resident's blood sugar was recorded as 293. There is no evidence that the resident received the [MEDICATION NAME] R Insulin Sliding Scale coverage as ordered. The resident should have received 8U of Insulin for the blood sugar of 381 and 6U of Insulin for the blood sugar of 293. Interview on 4/6/10 at 11:45 a.m. with Licensed Practical Nurse (LPN) ""KK"", revealed that the MARs were incomplete and that the resident should have received Insulin coverage for the elevated blood sugars on 3/17 and 3/18/10. 6. Review of the clinical record for resident #35, revealed a current physician's order for [MEDICATION NAME] R Sliding Scale Insulin to be administered as follows: if the blood sugar is 250-300=6U, 301-350=8U, 351-400=10U. Continued review revealed a current physician's order for glucose monitoring two (2) times a day at 7:30 a.m. and 5:00 p.m. Review of the MARs revealed no evidence that in January, 2010 the resident had glucose monitoring done or Insulin administered on 1/01, 1/02, 1/03, 1/07, 1/08, and 1/09 at 5:00 p.m. and on 1/01, 1/04, 1/10 and 1/11 at 7:30 a.m. 7. Review of the clinical record for resident #36, revealed a physician's order dated 1/03/10 for Sliding Scale Insulin to be administered as follows: if the blood sugar is 250-300=6U, 301-350=8U, 351-400=10U, and 401-450=12U. Continued review revealed a current physician's order for glucose monitoring two (2) times a day at 7:30 a.m. and 5:30 p.m. Review of the MARs revealed no evidence that in January, 2010 the resident had glucose monitoring done or Insulin administered on 1/01, 1/03, 1/04, 1/10, and 1/10 at 7:30 a.m. and on 1/07, 1/08, and 1/09 at 5:30 p.m. 8. Review of the clinical record for resident #37, revealed a current physician's order for Sliding Scale Insulin to be administered as follows: if the blood sugar is 250-300=5U, 301-400=8U, 400-500=10U, and 501=12U and notify the physician. Continued review revealed a current physician's order for glucose monitoring two (2) times a day at 6:30 a.m. and 4:30 p.m. Review of the MARs revealed no evidence that in January, 2010 the resident had glucose monitoring done of Insulin administered on 1/05, 1/11 and 1/12 at 4:30 p.m. 9. Review of the clinical record for resident #38, revealed a current physician's order for Sliding Scale Insulin to be administered as follows: if the blood sugar is 250-300=6U, 301-350=8U, 351-400=10U, 401-450=12U and notify the physician. Continued review revealed a current physician's order for glucose monitoring before meals and at bedtime. Review of the MARs revealed no evidence that in March, 2010 the resident had glucose monitoring done or Insulin administered on 3/13 at 11:30 a.m., 4:30 p.m. and 9:00 p.m., on 3/17 at 11:30 a.m. and on 3/18 and 3/19 at 9:00 p.m.. Interview on 4/7/10 at 11:00 a.m., the Director of Nurses (DON) acknowledged that if the glucose monitoring and Insulin dosages were not recorded then they were not given. 10. Review of the clinical record for resident #4, revealed a physician's order dated 02/24/10 for Sliding Scale Insulin to be administered as follows: if the blood sugar is 250-300=6U; 301-400=8U; 401-500=10U, greater than 500=12U and notify the physician. Continued review revealed a current physician's order for Glucose monitoring four (4) times a day before meals and at bedtime. Review of the MARs revealed no evidence that in March 2010, the resident had glucose monitoring done or Insulin administered on 3/04/10 for 6:30 a.m. and on 3/12/10 and 3/13/10 at 11:30 a.m. and at 9:00 p.m. on 3/29/2010. 11. Review of the clinical record for resident #22, revealed a physician's order dated 1/23/10 for Sliding Scale Insulin to be administered as follows: if the blood sugar is 250-300=6U; 301-350=8U; 350-400=10U, 401-450=12 U, greater than 450, notify the physician. Continued review revealed a current physician's order for glucose monitoring two (2) times a day at 6:30 a.m. and 2:30 p.m.. Review of the MARs revealed no evidence that in February 2010, the resident had Insulin administered on 02/09/10 for a blood sugar of 331 at 2:30 p.m. and on 02/11/10 at 2:30 p.m. for a blood sugar of 342. Review of the MAR for 02/10/10 at 6:30 a.m. revealed a blood sugar of 320 with coverage of 4 units and per the Sliding Scale 8U should have been administered. 12. Review of the clinical record for resident #4, included multiple [DIAGNOSES REDACTED]. Observation of resident #4 on 4/05/10 at 9:30 a.m., revealed the the resident sitting in a wheel chair, with the right foot on the floor with a loose gauze dressing wrapped around the right ankle/heel. Continued observation on 4/05/10 at 11:00 a.m. revealed the right foot was placed into a black strap shoe-like device with a sock in place over the lower portion of the foot and the gauze dressing still in place over the ankle/heel area of the foot. Observation of wound care for resident #4 and interview with LPN ""MM"" on 4/05 10 at 11:20 a.m. revealed a necrotic area with a cracked black raised open line, approximately one (1) millimeter in length, surrounded by a necrotic area of at least three (3) millimeters in length on the right heel. LPN ""MM"" confirmed the assessment of the wound on the right heel and indicated that there was a whitish moist or water logged appearing area on the entire bottom area of the heel. Continued interview with LPN ""MM"", revealed that she was unaware of a physician's orders to treat the right heel. Continued interview with LPN ""MM"", LPN Treatment Nurse ""NN"", and LPN West Unit Manager revealed no current knowledge of the necrotic wound on the right heel and confirmed that there was no evidence on the Treatment Administration Record (TAR) of a treatment to the right heel wound. Interview on 4/05/10 at 11:39 a.m. with the LPN Treatment Nurse ""NN"", revealed that a physician order was found on the computer screen dated 02/24/10 to treat the right heel with [MEDICATION NAME] and leave the wound open to air. Review of the Treatment Administration Records revealed no evidence of treatment to the right heel for the the months of April and March, 2010 and for February 26, 27, and 28, 2010. 13. Review of the clinical record for resident #3, revealed a physician's order dated 2/16/10 for Sliding Scale Insulin to be administered as follows: if the blood sugar is 250-300: 6 units, 301-350: 8 units, 351-400: 10 units and 401-450: 12 units. Continued review revealed a current physician's order for glucose monitoring two (2) times a day at 6:30 a.m. and 2:30 p.m. Review of the MARs revealed no evidence that in February, 2010 the resident had glucose monitoring done on 2/28 at 4:30 p.m., and no evidence that Sliding Scale Insulin was given on 2/22 at 6:30 a.m. for a glucose result of 328 and on 2/24 at 6:30 a.m. for glucose result of 479. Review of the March, 2010, MAR indicated [REDACTED]. Review of the April 2010, MAR indicated [REDACTED]. 14. Review of the clinical record for resident #7, revealed a physician's order dated 10/01/09 for [MEDICATION NAME] R Insulin Sliding Scale to be administered as follows: if blood sugar results are: 201 -300=5U; 301 -400=8U; 401 -500=10U; if greater than 500 =12U and call the physician. Continued review revealed a physician's order for glucose monitoring two (2) times a day at 6:30 a.m. and 4:30 p.m. Review of the January, 2010, MAR indicated [REDACTED]. Continued review of the physician's orders revealed an order dated 01/18/10 for [MEDICATION NAME] R Insulin Sliding Scale to be administered as follows: 250 -300= 6U; 301 -400=8U; 401 -500=10U; if greater than 501 =12U and call the physician. Review of the February, 2010, MAR indicated [REDACTED] Review of the March, 2010, MAR indicated [REDACTED]. 14. Review of the clinical record for resident #20, revealed a physician's order dated 10/08/09 for Regular Insulin Sliding Scale to be administered as follows: if blood sugar results are: 201 -300=5U; 301 -400=8U; 401 -500=10U; if greater than 500 =12U and call the physician. Continued review revealed a physician's order for glucose monitoring two (2) times a day at 6:30 a.m. and 5:30 p.m. Review of the October, 2009, MAR indicated [REDACTED] Review of the December, 2009, MAR indicated [REDACTED]. On 12/12 at 6:30 a.m., the glucose result was 305, no insulin was administered, and 8U was ordered and on 12/31 at 6:30 a.m. the glucose result was 272, 5U of insulin was ordered, no insulin was administered. 15. Review of the clinical record for resident #21, revealed a physician's order dated 9/10/2009, for glucose monitoring once a day at 6:30 a.m. with no Sliding Scale Insulin to be administered. Continued review of the physician orders revealed an order dated 9/10/09, to administer [MEDICATION NAME] 70/30 Insulin 8U twice a day at 6:30 a.m. and 4:30 p.m. Review of the November, 2009, MAR indicated [REDACTED]. Interview on 4/07/10 at 12:44 p.m. with the Director of Nursing, revealed that glucose monitoring had not been completed as ordered.",2015-03-01
9984,RIVERDALE CENTER,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2010-04-07,315,D,0,1,I0Y711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure that an indwelling urinary catheter was secured to prevent injury and failed to provide incontinence care in a manner to decrease the likelihood of a Urinary Tract Infection [MEDICAL CONDITION] for for two (2) residents (#7 and ""T"") of the thirty-eight (38) sampled residents. Findings include: 1. Observation on 4/06/10 at 11:28 a.m., of indwelling urinary catheter care, for resident ""T"" performed by Certified Nursing Assistant (CNA) ""ZZ"", revealed that the resident did not have a urinary catheter strap to secure the catheter drainage system to the leg. Interview on 4/07/10 at 9:00 a.m. with resident ""T"", who is cognitively intact, revealed there was no leg strap securing the catheter, the resident continued to reveal that a staff member said that the facility did not supply catheter straps. Interview on 4/07/10 at 9:15 a.m., CNA ""ZZ"", confirmed that there was no catheter strap in place and there should be a leg strap used. Interview on 4/07/10 at 9:30 a.m. with the Licensed Practical Nurse ""JJ"", revealed that there was a supply of leg straps available for use in the medication room. Review of the current physician orders [REDACTED]. 2. Observation on 4/06/10 at 11:45 a.m., of incontinent care for resident #7, performed by CNA ""DD"", revealed that the CNA failed to retract the foreskin to cleanse the head of the penis during incontinent care. Interview on 4/07/10 at 12:24 p.m. with Staff Development Coordinator (SDC), revealed that staff are instructed to retract the foreskin. Review of the facility's policy for male residents receiving incontinent care revealed that for uncircumcised males the foreskin should be retracted and the skin should be cleaned and rinsed using a circular motion.",2015-03-01
9985,RIVERDALE CENTER,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2010-04-07,281,D,0,1,I0Y711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to follow the facility policy related to Blood Sugar Checks and failed to clarify physician orders for blood sugar checks prior to the administration of Insulin for three (3) residents (#15, #16, and #23) of the sampled thirty-eight (38) residents. Findings include: 1. Review of the clinical record for resident #15, revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]=6 units (U); 301-350=8 U; 351-400=10 U; and 401-450=12 U. Review of the February MAR, dated 2/26/10 through 2/28/10, revealed blood sugar checks were only completed three (3) times a day at 6:00 a.m., 11:00 a.m., and 4:00 p.m., not four (4) times a day as ordered. Review of the March 1 through March 24, 2010, MAR indicated [REDACTED]. Review of the clinical record revealed no evidence of a physician's order to complete blood sugar checks and no physician's order to administer any Insulin, as written on the February and March MARs. Review of a hospital transfer physician order dated 3/24/10, revealed an order to administer [MEDICATION NAME] 20 U every night, and administer [MEDICATION NAME] Sliding Scale Insulin; however there was no parameters of Insulin to be administered and no physician's order to complete blood sugars checks. 2. Review of the clinical record for resident #16, revealed an admission date of [DATE] with a [DIAGNOSES REDACTED].=6 units (U); 301-350=8 U; 351-400=10 U; and 401-450=12 U. However there was no evidence of a physician ordered frequency for blood sugar checks. Continued review of the March MAR, dated 3/5/10 through 3/31/10, revealed that blood sugars checks were completed at 6:00 a.m. a total of twenty-seven (27) times; and at 4:00 p.m. beginning on 3/12/10, for a total of nineteen (19) times, all completed without a physician's order. Continued review of the March MAR indicated [REDACTED]. 3. Review of the clinical record for resident #23, revealed an admissision date of 3/3/10 and a discharge date of [DATE], with a [DIAGNOSES REDACTED]. Continued review revealed the resident was receiving [MEDICATION NAME] 70/30 Insulin, 30 units in the morning and 25 units in the afternoon. Continued review revealed no evidence that a Physician's Order had been obtained for blood glucose monitoring prior to administration of the Insulin. Review of the plan of care dated 3/7/10, included Accucheck monitoring. Interview on 4/6/10 at 4:05 p.m. with the Director of Nursing (DON), revealed that any resident recieving Insulin should be receiving Accuchecks per the facility's policy. Continued interview revealed that during this resident's stay there were no Accuchecks completed. Interview on 4/6/10 at 4:40 p.m., with the Regional Registered Nurse (RN), revealed that all Accuchecks (blood sugar checks) should be ordered by the physician with the times of the blood sugar checks. The Regional RN continued and confirmed that the nurses should have clarified with the physician if he/she wanted Accuchecks completed.",2015-03-01
9986,RIVERDALE CENTER,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2010-04-07,252,C,0,1,I0Y711,"Based on observation and staff interview the facility failed to ensure that the resident environment was free of odors on three (3) of four (4) halls ( North Wing, North East Wing and West Wing). Findings include: 1. Observation on 4/5/10 at 8:45 a.m., of the North Unit, revealed a strong urine odor in the hallway near room N-22. Observation of room N-22 on 4/5/10 at 8:45 a.m. revealed that a bedside commode had a urinal hanging from the left side which was half (1/2) filled with amber colored urine. Continued observation of the unit revealed a urine odor at the end of the hall, by the emergency exit doors. Observation on 4/6/10 at 8:25 a.m., of the North Unit, revealed a fecal odor at the end of the hall, near rooms N-26, N-28 and the emergency exit. Observation on 4/7/10 beginning at 12:50 p.m. and ending at 1:20 p.m., with the Maintenance and Housekeeping Supervisor revealed a strong urine odor in the hallway outside room N-23. Interview on 4/7/10 at 12:50 p.m., with the Housekeeping Supervisor, revealed that there are complaints of odors all the time and that although housekeeping deodorizes, the odors are still present. 2. Observation on 4/05/10 at 8:45 a.m., of the North East Wing revealed a strong odor of urine which lingered into the North Wing. 3. Observation on 4/06/10 at 3:20 p.m., of the West Wing revealed a strong odor of urine near the nurses station.",2015-03-01
9987,RIVERDALE CENTER,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2010-04-07,334,E,0,1,I0Y711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility Immunization Program policy, review of the facility Immunization Report and staff interview, the facility failed to offer the Influenza and/or Pneumococcal vaccine and/or failed to obtain a signed consent/refusal for the immunization for thirteen (13) residents (#2, #4, #8, #19, #14, #22, #26, #27, #28, #29, #30, #31, and #38) of the sampled thirty-eight (38) residents. Findings include: 1. Review of the clinical record for resident #26, revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and review of the facility Immunization report revealed no evidence that the resident had been offered or received the Influenza or Pneumococcal vaccines. 2. Review of the clinical record for resident # 27, revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and the facility Immunization report revealed no evidence that the resident had been offered or received the Influenza or Pneumococcal vaccines. 3. Review of the clinical record for resident #28, and review of the facility Immunization report revealed that the resident received the Influenza vaccine on 9/11/09. Continued review of the clinical record revealed no evidence that a consent form for administration of the vaccine had been signed. 4. Review of the clinical record for resident #29, revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and review of the facility Immunization report revealed no evidence that the resident had been offered or received the Influenza or Pneumococcal vaccines. 5. Review of the clinical record for resident #30, revealed an undated facility consent form that indicated refusal of the Influenza and Pneumococcal vaccines per resident wishes. Review of the facility Immunization record revealed that the resident received the Influenza vaccine on 12/30/09 and the Pneumococcal vaccine on 1/08/10. Continued review of the clinical record revealed no evidence that a consent form had been signed for administration of these vaccines. 6. Review of the clinical record for resident #31, revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and review of the facility Immunization report revealed that the resident received the Influenza vaccine on 10/28/09 and the Pneumonia vaccine on 1/04/10. Further review of the clinical record revealed no evidence that a consent form had been signed for administration of these vaccines. 7. Review of the clinical record for resident #38, revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and review of the facility Immunization report revealed that the resident received the Influenza vaccine on 11/09/09. Further review of the clinical record revealed no evidence that a consent form had been signed for administration of this vaccine. Interview on 4/06/10 at 3:40 p.m., with the East Wing Unit Manager revealed that consents are only good for one year. A new consent must be signed yearly for administration of the Influenza vaccine. Review of the facility ""Immunization Program Policy"", revealed that residents are offered Influenza and Pneumococcal vaccination. Annual vaccination requires a physician's orders [REDACTED]. 8. Review of the clinical record for resident #8, revealed a consent form dated 1/5/10, for the resident to receive the Influenza vaccination, but there was no evidence that the resident had ever had the pneumococcal vaccination or that it had been offered and/or refused. Interview on 4/6/10 at 1:40 p.m., the Director of Nursing (DON), confirmed that there was no evidence of the pneumococcal vaccine and indicated that each unit manager handles there own immunizations on the units, but they have no overall coordinator for the program. 9. Review of the clinical record for resident #3, revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and review of the facility Immunization report revealed no evidence that a consent had been obtained and no evidence the resident received the Influenza vaccination in 2009. 10. Review of the clinical record for resident #14, revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and review of the facility Immunization report revealed that the resident had received the Pneumococcal vaccination on 10/24/07, with no evidence of consent. Continued review of the Immunization report revealed that the resident once again received the Pneumococcal vaccination in 2009, even though the vaccination is only recommended to be completed every five (5) years. Continued review revealed that a consent had been obtained for the Influenza vaccination for the year of 2009, with no evidence that the resident had received the vaccine. 11. Review of the clinical record for resident #4 revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and review of the facility Immunization report revealed no evidence that the resident had been offered or received the Influenza vaccine. 12. Review of the clinical record for resident #19, revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and review of the facility Immunization report revealed no evidence that the resident had been offered or received the Influenza vaccine for 2009-10. 13. Review of the clinical record for resident #22, revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and review of the facility Immunization report revealed no evidence that the resident had been offered or received the Influenza vaccine or Pneumococcal vaccine.",2015-03-01
9988,RIVERDALE CENTER,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2010-04-07,441,F,0,1,I0Y711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to implement appropriate Infection Control practices during an outbreak of a potential infectious process, failed to wash hands and/or change gloves appropriately and failed to provide [DIAGNOSES REDACTED] assessments for four (4) residents (#6. #7, #11, and #19 ) of the thirty-eight (38) sampled residents. Findings include: During entrance interview on 4/5/10 at 8:45 a.m., the Director of Nursing (DON), revealed that the facility had a Gastrointestinal (GI) Outbreak that had begun on 4/3/10 on the North Wing Unit and had spread to three (3) residents on the Northeast Unit. Continued interview revealed that the Public Health Department had been notified of the outbreak and that a representative of the Health Department had visited the facility and cultures had been completed. The affected residents were being treated with medication for nausea, vomiting, diarrhea and receiving a clear liquid diet. The kitchen was using disposable utensil when serving these residents. 1. Observation on 4/6/10 of the facility's implementation of Infection Control Program related to GI Outbreak at facility during the survey revealed the following: Staff had no knowledge of the precautions and/or preventative methods to use with the residents who were experiencing signs and symptoms of GI Outbreak including nausea, vomiting, diarrhea to prevent the likelihood of contaminating other residents, visitors and staff. There were no signs posted to identify the Infection Control Precautions that should be used, only a sign posted for visitors to check with nursing before entering the unit. Observation on 4/6/10 at 7:20 a.m. revealed that Licensed Practical Nurse (LPN) ""BB"", the staff nurse on the North unit, appeared to be unaware of the precautions necessary during a GI outbreak, including that shoe covers should be worn. The LPN was not wearing shoe covers. Interview on 4/6/10 at 7:30 a.m. the DON, revealed that the LPN who was observed without the shoe covers had been called to come to work because of an illness of another employee. Continued interview revealed that the LPN was unaware of the GI Outbreak. Interview on 4/6/10 at 7:35 a.m. with LPN, ""BB"" indicated that she had been off for a few days and had not been informed of the GI Outbreak.. Observation on 4/06/10 at 7:40 a.m., revealed a staff ""OO"", entered the unit prior to applying foot covering. Observation on 4/06/10 at 7:44 a.m., revealed a Certified Nursing Assistant (CNA) ""PP"", walking on unit down the hall without shoe coverings. Observation on 4/06/10 at 8:02 a.m., the Northeast Unit Manager entered the unit without shoe coverings and picked up a shoe covering from the dirty stack to apply to her shoes. Observation on 4/06/10 at 8:03 a.m. the Regional Registered Nurse (RN), entered the unit without wearing shoe coverings. Interview at the time of the observation with the Regional RN revealed that she was only going to the nurses station. Observation on 4/6/10 at 9:45 a.m., revealed an LPN coming out of the therapy room into the North Unit nursing station. The LPN walked around without putting on any shoe coverings and then went back through the therapy room out the door to the Northeast Unit. Observation on 4/6/10 at 10:20 a.m., revealed a dietary staff, delivering new menus to residents, on the North Unit without applying the shoe coverings. Observation on 4/6/10 at 11:00 a.m. revealed facility staff, the State Fire Marshall and a State Surveyor standing at the North Unit door waiting to be let in; however, no shoe coverings were available. Observation on 4/06/10 at 11:43 a.m. the North Unit was without shoe coverings being available for staff to wear per their protocol of prevention of spread Review of the facility Steps to take when symptoms of Nausea, Vomiting and Diarrhea are reported, revealed staff are to wear shoe covers on the nursing units and that hand sanitizer will be given to each staff member with specific instructions. Continued review revealed that that linen and the trash will be double bagged. Interview on 4/6/10 at 10:50 a.m. with Laundry Aide ""HH"", revealed that she became aware of the GI Outbreak on 4/5/10 but was unaware of the precautions related to laundering the resident's linen. Continued interview revealed that all residents personal clothing is washed together and all the linen, sheets, towels, and washcloths are all washed together. Laundry Aide ""HH"" stated no precautions had been taken in laundry. Interview on 4/6/10 at 10:52 a.m. with Laundry Aide ""II"" , revealed that the Assistant Director of Nursing (ADON) completed one-to-one (1:1) teaching on 4/6/10 about wearing the proper footwear (shoe coverings), gloves and mask when having direct resident contact. but indicated that nothing had come to the laundry double bagged. Interview on 4/6/10 at 11:15 a.m., with Staff Development Coordinator, revealed that staff who have direct contact with residents should wear shoe coverings; however just to be on the unit, no shoe coverings have to be worn. Continued interview at 12:00 p.m. revealed that resident laundry does not have to be done separately because the hot water will kill the virus, as will the heat from the dryer. Interview on 4/6/10 at 11:34 a.m. with Infection Control Coordinator (ICC), revealed that the Infection Control Plan/Policy is accessible on the computer but that the information is disseminated to the managers by her and then it is given to the staff by the unit. Continued interview revealed that the managers have access to the computers. Interview on 4/6/10 at 12:50 p.m. with the ICC, revealed that because the organism had not been isolated yet, Contact Isolation Precautions should be practiced. Continued interview revealed that Contact Isolation Precautions include wearing a gown during direct care of a resident that has exhibited GI symptoms. Continued interview revealed that the ADON is staff member responsible for the education of the CNAs. Interview with ADON on 4/6/10 at 1:15 p.m., indicated that she instructed the CNA's to glove, use good handwashing technique, especially in between residents and to wear gowns if the resident is one who has been targeted as having Gastroenteritis when providing care. 2. Review of the clinical record for resident #19, revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and review of the facility Immunization report revealed no evidence that the resident had been offered or received the PPD (Mantoux) for [DIAGNOSES REDACTED] (TB) testing since 11/01/08. Review of the physician orders [REDACTED]. 3. Review of the clinical record for resident #11, revealed that the resident was admitted to the facility on [DATE]. Continued review of the clinical record and review of the facility Immunization report revealed no evidence that the resident had been offered or received the PPD (Mantoux) for TB testing since 11/01/08. Review of the physician orders [REDACTED]. 4. Record review for resident #6, it was determined that the resident's [MEDICATION NAME] skin test for 2009 was placed but not read. Interview on 4/7/10 at 1:00 p.m., the Director of Nursing (DON), acknowledged that the resident's [MEDICATION NAME] skin test had not been read. 5. Observation on 4/6/10 at 11:45 a.m. of incontinent care for resident #7, performed by CNA, ""DD"" revealed that after completing care, the CNA left the room to obtain an incontinent brief for the resident. Upon re-entering the room CNA, ""DD"" did not wash his hands, obtained a pair of gloves out of his pockets, applied the incontinent brief and dressed the resident. During the care CNA, ""DD"" also placed all of the soiled items (diapers, wet wipes, gloves) into an unlined trash can. In addition, CNA ""DD"", failed to use a gown to protect his clothes from potential contamination, and the resident was on the unit identified with the GI Outbreak. Interview on 4/7/10 at 12:24 p.m., with the Staff Development Coordinator (SDC), indicated that the CNAs are instructed to wash hands upon re-entering the room prior to beginning and/or resuming care. They also should not place soiled items in an unlined trash can.",2015-03-01
9989,RIVERDALE CENTER,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2010-04-07,253,C,0,1,I0Y711,"Based on observation and staff interview, the facility failed to ensure that housekeeping and maintenance services maintained a sanitary, orderly and comfortable environment on four (4) of four (4) Units. Findings include: Observations on 4/5/10 at 8:45 a.m., on 4/6/10 beginning at 8:40 a.m. and on 4/7/10 at 12:50 p.m., revealed the following: 1. On the North Hall: in room N-20, to the right side of the wall, there was a patched, unpainted square section; in room N-21, the bathroom floor tile was loose to the right of the commode, the baseboard behind the commode on the left side was chipped, the caulk around the commode was brown in color and the sheetrock behind the commode was cracked; in room N-23, the bathroom floor was gray in color with a sticky/tacky feel and the bathroom door was marred; in room N-25, the air conditioner knob was missing; in room N-27, the wall to the left of the air conditioner was patched with plaster and unpainted, the wall had areas that were bubbled, with cracked sheetrock at the air conditioner unit; in room N-28, the backboard under the air conditioner unit was loose, lying on the floor, and the sheetrock was cracked; in rooms N-23 and N-25, the wallpaper was peeling off the wall; in room N-12, an area of wallpaper, approximately two (2) feet, was missing from the baseboard area. 2. On the Northeast Hall: in room NE-11, there were two (2) ceiling tiles that had tan color stains, with peeling covering; in front of room NE-1 and the emergency exit door the air conditioner unit return vent had a accumulation of black dust particles; to the left of room NE-7, in the hallway the wallpaper was torn; and to the left of the locked unit doors the wallpaper was peeling. 3. On the West Hall: in room W-5, the caulk around the bathroom sink was cracked; the ceiling tile outside room P-6 was cracked with a one-half (1/2 inch) gap exposed without covering. 4. On the East Hall: in front of room E-1, the vent had a moderate accumulation of black colored lint. Interview on 4/7/10 at 10:25 a.m., with the Administrator and Maintenance Director, revealed that the issues that the facility were currently focusing in on were the touchup painting and that they were in the process of replacing the sheetrock and baseboards, starting in the hallway. Repairs were to include: touch up painting, and bathroom issues, such as: clean, patch and repair of bad seals. The Maintenance Director indicated he completes a audit during the first week of the month, which then will determine what needs to be done and that goal date. If the goal date is not met then it is moved until completed. Interview on 4/7/10 at 11:00 a.m. with the Housekeeping Supervisor revealed that monthly, each resident room is deep cleaned including washing the walls, bed frame, and bed mattress. The Housekeeping Supervisor confirmed that the vents, in the hallways and bath/bedrooms, should be cleaned on a daily basis.",2015-03-01
9990,RIVERDALE CENTER,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2010-04-07,221,D,0,1,I0Y711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to assess the need for the physical restraint and failed to obtain a physician's orders [REDACTED]. Findings include: Observations on 4/05/10 revealed the following: at 10:00 a.m., 10:30 a.m. and 11:00 a.m., resident #10 was sitting in a reclining gerichair with a tray table attached, the resident had her/his head laying on the tray table; at 2:50 p.m. and 3:50 p.m. resident #10, remained in the gerichair with the tray table attached leaning to the right side. Review of the clinical record for resident #10, revealed [DIAGNOSES REDACTED]. Continued review revealed a Minimum Data Assessment, dated 2/22/10, that assessed the resident as cognitively impaired, ambulatory with assistance of one (1) person, extensive assistance needed to transfer from the bed to the chair, and unable to propel the chair, requiring staff to transport from one area to another in the facility. Review of physician's orders [REDACTED]. Review of the clinical record revealed that resident #10, sustained a pathological [MEDICAL CONDITION] on 7/29/09 and received Physical Therapy that was discontinued on 9/1/09. Continued review of the clinical record revealed a second Physical Therapy evaluation dated 3/24/10, that assessed the resident as unable to ambulate. Interview on 4/07/10 at 10:30 a.m., with the Licensed Practical Nurse (LPN) Unit Manager of the West Wing, revealed that the resident had been transferred from the North Unit with the gerichair and tray table, because the resident was no longer ambulatory. Interview on 4/07/10 at 10:40 a.m., with the Physical Therapist (PT) and the Occupational Therapist (OT), revealed that they had no knowledge of the purpose or use of the gerichair with the tray table for resident #10. Interview on 4/07/10 at 10:50 a.m. with the Regional Registered Nurse (RN), revealed that upon transfer from unit to unit, the nursing staff was expected to review all the needs of the resident.",2015-03-01
9991,"STEVENS PARK HEALTH AND REHABILITATION CENTER, LLC",115294,820 STEVENS CREEK ROAD,AUGUSTA,GA,30907,2011-02-03,314,D,0,1,LK4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and staff interviews, the facility failed to ensure that two (2) residents (#5, and 37) on a sample of nineteen (19 ) residents received necessary treatments according to the physician's orders to treat pressure sores. Findings include: 1. Review of the admission Minimal Data Set assessment dated [DATE] assessed resident #37 as having two unstageable pressure sores with suspected deep tissue injury. Review of the admission physician's orders dated 12/17/10 revealed the resident was to have wet to dry gauze dressings to the right heel daily. This treatment order continued until 1/26/11. Review of treatment record for December 2010 thru January 25, 2010 revealed the wet to dry dressings were discontinued and to observe the right heel blister, however there was no physician's order in the record to discontinue the wet to dry dressing or to just observe the blister to the right heel. Review of the nursing assessment dated [DATE] revealed that the resident had a blister to the right heel with serous drainage on the dressing when removed and this blister had a small opening. An achilles blister was intact. Review of the Treatment Record-Wound assessment dated [DATE] revealed the right heel measured 7 x 11.3 x 0 and was an unstageable deep tissue injury with light drainage. The last measurement on the right heel done 1/26/10 and measured 3.7 x 4.3 x 0 centimeters in size and was unstageable with no drainage. Observation of the wound care treatment done on 2/2/11 at 8:15 am revealed that the right heel had black eschar. Interview with the Registered Nurse Consultant on 2/1/11 at 9:20 am revealed that the area on the resident's heel was a closed blister and the facility follows their wound protocol for a blister, which was to just observe the blister, until it opens. She further indicated that the admission nurse forgot to write the physician's order to discontinue the wet to dry dressing and just observe the blister. 2. Record review for resident #5 revealed the resident was admitted to the facility on [DATE] after a fall and surgical repair of the left hip. The Foot and Skin Assessment sections of the Nursing Admission assessment dated [DATE] noted a 7.0 centimeter (cm) long by 0.8 cm wide area on top side of left foot, and a 3.5 cm by 1.0 cm area on the outer aspect of the left foot. The area across the left foot was described as having an open yellow base with non-approximated edges. Review of physician's orders from 12/16/10 thru 01/26/11 revealed the dressing for the left foot was to be changed every three days and as needed. Review of the resident's Treatment Records revealed that there was no evidence that the dressing to the left foot was changed between 12/19/10 and 12/24/10; between 12/27/10 and12/31/10; between 12/31/10 and 01/05/11; between 01/12/11 and 01/17/11 and between 01/22/11and 01/26/11. Additionally, there was a notation on the Treatment Record of 'OTA' on 01/14/11 when the dressing was due to be changed. Interview conducted 02/03/11 at 8:30 a.m.with the Wound Care Coordinator Licensed Practical Nurse (LPN) 'AA' revealed that the facility believed the wound on the resident's left foot was caused from compression hose or a protective boot that was too tight when she was in the hospital. ""AA"" further revealed that the facility nurse assigned to the resident did the ordered dressing changes, as well as weekly skin assessments. She indicated that she observed all the wounds weekly on Wednesdays to measure and assess if the wound was healing, and/or if the wound care consultant needed to be contacted for suggestions. LPN 'AA' revealed that she saw resident #5's foot for the first time on 01/05/11, and verified that the description of the wound on the Admission Assessment was that of an open wound with a yellow base, but stated when she first saw it in January it looked like a line surrounding the entire foot that was purplish,and red in color. She felt like it was deep tissue injury (DTI). She verified there was no evidence that the dressing was changed as ordered on [DATE]; between 01/01/11-01/05/11; and when due on 01/25/11, and she did not know why the dressing was not changed. She thought the abbreviation 'OTA' on the Treatment Record meant the resident was not in the building, but could find no documentation in the nurse's notes to support this. During interview on 02/03/11 at 10:45 a.m. with the Director of Nurses (DON), she indicated that 'OTA' generally meant the resident was out to an appointment, but that the dressing on the left foot should have been changed when the resident returned to the facility.",2015-03-01
9992,"STEVENS PARK HEALTH AND REHABILITATION CENTER, LLC",115294,820 STEVENS CREEK ROAD,AUGUSTA,GA,30907,2011-02-03,322,D,0,1,LK4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to administer the amount of enteral nutrition according to the physician's orders [REDACTED].#175), on a sample of nineteen (19) residents. Findings include: Observation conducted 02/02/11 at 8:25 a.m., revealed Licensed Practical Nurse (LPN) 'AA' administered the morning medications to resident #175 via the resident's gastrostomy tube. ""AA"" also gave one 8-ounce/237 milliliters (ml) can of Glucerna 1.2, which was scheduled to be given at that time. Review of resident #175's clinical record revealed a physician order [REDACTED]. of Glucerna 1.2 every 4 hours. During interview on 02/02/11 at 10:15 a.m., LPN 'AA' acknowledge that the label on a can of Glucerna indicated that the 8 ounces was equal to 237 mL. She verified that the physician's orders [REDACTED].",2015-03-01
9993,GOLDEN LIVINGCENTER - BRIARWOOD,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2010-08-03,281,D,0,1,H72N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and staff interviews, the facility failed to develop an initial careplan for one (1) resident (#212) of twenty-four (24) sampled residents. Findings include: Observation on 7/28/2010 at 2:00 p.m. of resident #212 revealed an indwelling catheter to bedside drainage Record review for resident #212 revealed that the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Continued review revealed that although the resident was assessed as having an indwelling catheter during the admission nursing assessment, there was no evidence that an initial careplan for the indwelling catheter had been done. Interview on 7/28/10 2010 at 2:18 p.m. with the facility Minimum Data Set (MDS) coordinator revealed that the comprehensive care plan had not been completed yet but that nursing should have initiated a careplan for the indwelling catheter. Interview on 7/28/2010 at 2:25 p.m. with facility supervisory staff revealed that an indwelling catheter careplan should have been written and individualized for the resident on admission.",2015-03-01
9994,PRUITTHEALTH - WASHINGTON,115325,112 HOSPITAL DRIVE,WASHINGTON,GA,30673,2010-08-19,332,E,0,1,1QKI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations conducted during the medication pass , record review, and staff interview, the facility failed to ensure it was free of a medication error rate of five (5) percent or greater. Findings include: Observations conducted on 8/17/10 at 4:12 p.m. and on 8/18/10 at 8:25 a.m. and 8:36 a.m. revealed two (2) of four (4) nurses on one (1) of three (3) halls administering medications. Four (4) medication errors were observed out of fifty-four (54) opportunities. This resulted in a medication error rate of 7.14%. 1. Observation on 08/17/10 at 4:12 p.m. revealed Licensed Practical Nurse (LPN) ""BB"" administering 5:00 p.m. medications to resident #7. Included in the medications given to the resident was [MEDICATION NAME], used for high blood pressure. Review of the physician's orders [REDACTED]. Interview on 08/18/10 at 11:15 a.m. with the Registered Nurse (RN) Administrator revealed that if a drug was scheduled on the physician's orders [REDACTED]. 2. Observation on 08/18/10 at 8:36 a.m .revealed LPN ""AA"" administering 9:00 a.m. medications to resident #16. Review of the physician's orders [REDACTED]. Interview on 8/18/10 at 10:30 a.m. with LPN ""AA"" revealed that the medication was not given. 3. Observation on 08/18/10 at 8:25 a.m. revealed LPN ""AA"" administering 9:00 a.m. medications to resident #64. Review of the physician's orders [REDACTED]. These medications were not given during the medication pass. Interview on 08/18/10 at 10:30 a.m. with, LPN ""AA""' revealed that she did not give the multivitamin, as it had been discontinued off the MAR indicated [REDACTED]. Interview on 8/18/10 at 10:54 a.m. with the Administrator revealed that the physician's orders [REDACTED].",2015-03-01
9995,PRUITTHEALTH - WASHINGTON,115325,112 HOSPITAL DRIVE,WASHINGTON,GA,30673,2010-08-19,309,D,0,1,1QKI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to administer give (1) medication and discontinue one (1) medication as ordered for one (1) resident (#64) from a sample size of twenty-nine (29) residents. Findings include: Observation on 08/18/10 at 8:25 a.m., during medication pass with Licensed Practical Nurse (LPN) ""AA"" revealed mediations being administered to resident #64. Review of the physician's orders [REDACTED]. Interview on 8/18/10 at 10:30 a.m. with LPN ""AA"" revealed that she thought the [MEDICATION NAME] had been discontinued and replaced with [MEDICATION NAME]. The nurse was unable to find the order to do this. During continued interview, the nurse called the facility's dispensing pharmacy, and was told by the Pharmacist that an order for [REDACTED]. She stated this supply was left over from what the resident received prior to their hospitalization on [DATE] and acknowledged that there was no [MEDICATION NAME] packaged for the resident in the medication cart. Interview on 8/18/10 at 10:54 a.m. with the Registered Nurse (RN) Administrator and the Corporate Consultant ""CC"" revealed that when resident #64 returned from the hospital on [DATE], [MEDICATION NAME] 30 mg daily was ordered and the [MEDICATION NAME] 40 mg, which the resident received twice a day prior to the hospitalization , had been discontinued. The Corporate Consultant indicated that it appeared as though the 'L' in [MEDICATION NAME] had been written over on the Medication Administration Record [REDACTED]. Interview on 8/18/10 at 11:15 a.m. with LPN ""AA"" revealed that the resident's doctor instructed her to discontinue the [MEDICATION NAME], and give [MEDICATION NAME] 30 mg daily.",2015-03-01
9996,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2011-11-17,309,E,1,0,NS1X11,"Based on medical record review, facility record review, and staff interview, the facility failed to assess the neurological status of four (4) residents (#1, #2, #3 and #11) after having sustained a head injury, as directed by the facility's Clinical Protocol for Neurological Checks, in a survey sample of eleven (11) residents. Findings include: Review of the facility's Clinical Protocol for Neurological Checks revealed that neurological checks were to be conducted following any head injury and/or trauma. The assessment schedule was as follows: every fifteen (15) minutes for the first hour; every thirty (30) minutes for the second hour; every hour for the next two (2) hours; every two hours for four (4) times; and then every four (4) hours for the remaining twenty-four (24) hour period following the head injury or trauma. Interview with the Director of Nursing on 10/17/2011 at 3:30 p.m. confirmed that this was the facility's policy for assessment of residents who sustained head injuries or trauma. 1. Record review for Resident #1 revealed a Nurse's Notes dated 08/11/2011 which documented that during incontinence care, the resident was turned to the left side and hit her head on the side rail resulting in a one (1) centimeter laceration of the forehead with minimal bleeding. However, further record review, to include review of the Nurse's Notes, revealed no evidence to indicate that neurological checks were done as directed by the Protocol for Neurological Checks after the injury. During an interview with the Director of Nursing (DON) on 10/17/2011 at 4:45 p.m., the DON acknowledged that no neurological assessment was done on the resident after the head trauma. 2. Record review for Resident #2 revealed a Nurse's Note for 09/03/2011 at 12:32 p.m. documenting that the resident was observed on the floor in front of the wheelchair lying on the left side with a laceration to the left forehead and left side of the head above the ear. The vital signs were assessed and the resident was sent to the emergency room for assessment. Review of the record of the meal consumption for 09/03/2011 revealed that the resident was back in the facility at dinner which was served between 5:00 p.m. and 6:00 p.m. However, further record, to include review of the Nurse's Notes and Neurological Assessment Flowsheet, revealed evidence indicating that the only neurological assessments that were completed on the resident were done on 09/05/2011 at 7:00 am, 12:00 p.m. and 6:00 p.m.. During a 10/17/2011, 2:35 p.m. interview with Nurse ""AA"", the nurse who did the neurological assessment for Resident #2 on Monday, 09/05/2011, this nurse stated that when she reported for work on that Monday, she noted that the resident had fallen over the weekend (Saturday, 09/03/2011), but that a neurological assessment had not been done as directed by the protocol, so therefore, neurological checks were initiated at that time. During an interview with the DON on 10/17/2011 at 3:30 p.m., the DON stated that if a resident came back from the hospital after a head injury, neurological checks were to be continued for twenty fours (24) hours after the incident had occurred. 3. Record review for Resident #3 revealed a Nurse's Note of 10/04/2011 at 8:20 p.m. documenting that the resident fell from the wheelchair, bumping the head and causing a gash on the left forehead. It was further documented that neurological checks were begun and then the resident was sent to the hospital for evaluation. A Nurse's Note of 10/04/2011 at 11:05 p.m. documented that the resident had returned to the facility from the hospital with Steri Strips to the left forehead. Review of the Neurological Assessment Flowsheet revealed that neurological checks were initiated upon the resident's arrival back in the facility on 10/04/2011 at 11:05 p.m., and continued hourly, with the last assessment documented as being done on 10/05/2011 at 7:00 a.m. However, further record review, to include review of this Neurological Assessment Flowsheet, revealed no evidence to indicate that neurological checks were completed for full the twenty-four (24) hours post the fall, as specified by the facility's protocol. During an interview with the DON on 10/18/2011 at 4:00 p.m., the DON acknowledged that the neurological assessment should have been continued until 8:30 p.m. on 10/05/2011, for the full twenty-four (24) hours after the fall. 4. Record review for Resident #11 revealed a Nurse's Notes entry of 09/11/2011 at 7:00 a.m. which documented that the resident was observed on his buttocks on the floor with a scant amount of blood and a lump to the back of the head. It was also documented that neurological checks were begun. A Nurse's Notes entry of 09/11/2011 at 11:00 a.m. documented that neurological checks were continued. However, further record review, to include review of Nurse's Notes and Neurological Assessment Flow Sheet, revealed no evidence to indicate that any neurological assessments were done after 11:00 a.m. on 09/11/2011. Therefore, there was no evidence to indicate that neurological checks were completed, per the facility protocol, for twenty-four (24) hours after the resident's fall with head trauma. During an interview with the DON on 10/17/2011 at 5:00 p.m., the DON acknowledged that there was no evidence of neurological assessment done after 11:00 a.m. on 9/11/2011.",2015-03-01
9997,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2011-11-17,323,D,1,0,NS1X11,"Based on record review and staff interview, it was determined that the facility failed to provide adequate supervision to prevent an accident for one (1) resident (#1) in a survey sample of eleven (11) residents. Findings include: Record review for Resident #1 revealed a Nurse's Note dated 08/11/2011 at 2:00 p.m. which documented that during incontinence care, the resident was turned to the left side using a draw sheet and hit her forehead on the side rail, resulting in a one (1) centimeter laceration of the forehead with minimal bleeding. During an interview with Certified Nursing Assistant ""BB"" conducted on 10/18/2011 at 12:30 p.m. regarding this incident referenced above, this CNA stated that she had pulled the draw sheet too fast and caused Resident #1 to hit her head on the upper part of the side rail, resulting in the laceration to the head.",2015-03-01
9998,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2010-04-14,241,D,0,1,RQ0O11,"Based on observations, it was determined that the facility failed to promote a dignified dining experience in one (1) of (3) three dining rooms and failed to promote an environment that enhanced the dignity of one (1) resident (""A""). Findings include: 1. Observation on 4/12/10 from 12:35 p.m. to 12:55 p.m., of lunch served in the chapel dining room, revealed Certified Nursing Assistants (CNAs) ""AA"" and ""GG"" sitting at a table with four (4) residents while assisting them to eat. The CNAs were talking with each other about personal issues instead of interacting with the residents while they were assisting them. Continued observation revealed Licensed Practical Nurse ""BB"" entered the dining room and began speaking to a CNA in a loud, disruptive, angry tone. 2. During an interview on 4/14/10 at 8:45 a.m. with resident ""A"", CNA ""AA"" knocked on the door to the resident's room and after receiving permission to enter the room, CNA ""AA"" opened the door but continued to talk loudly to another person in the hall. The CNA entered the resident's room, looked behind the curtain, indicated that he had been looking for someone and left the room without acknowledging the resident's presence in the room. 3. Random observation on 4/13/10 at 12:20 p.m., of lunch served in the chapel dining room, revealed a resident, who was sitting in a merry walker being assisted by staff to a table. The resident was positioned, while remaining in the merry walker, along the side of the table with his/her left side closest to the table. When the resident's tray was served, the resident had to reach over the arm of the merry walker making it difficult to reach the food. Continued observation revealed that at 12:40 p.m., another staff member pulled a chair in front of the merry walker and began feeding the resident.",2015-03-01
9999,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2010-04-14,368,E,0,1,RQ0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on three (3) of four (4) residents in group interview and staff interviews, the facility failed to offer a bedtime snack to all residents. The facility has a census of 117 residents that have the potential to be effected by this failure. Findings include: During the Group Interview on 4/13/10 at 11:00 a.m., three (3) of the four (4) residents in attendance indicated that the staff did not consistently offer bedtime snacks. Resident ""B"" revealed that bedtimes snacks were only offered an average of three (3) times per week. Resident ""C"" revealed that bedtime snacks were only offered one (1) to two (2) times per week. Resident ""D"" indicated that he/she was never offered a bedtime snack. Interview on 4/13/10 at 4:30 p.m., Certified Nursing Assistant (CNA) ""CC"", who worked on the 400 hall, revealed that residents who had a [DIAGNOSES REDACTED]. Interview on 4/13/10 at 4:40 p.m. with CNA ""DD"", who worked on the 500 hall, revealed that only two (2) residents on her assignment received bedtime snacks. Continued interview revealed that the CNA was not aware of how it was determined which residents received bedtime snacks. Interview on 4/13/10 at 4:50 p.m. with CNA ""FF"" s revealed that snacks were sent from the kitchen and were labeled with residents' names. Continued interview revealed that if there are extra snacks or if residents asked for a snack, then the staff would provide them with a snack.",2015-03-01
10000,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2010-04-14,369,D,0,1,RQ0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interviews, it was determined that the facility failed to provide correct adaptive drinking devices for two (2) residents (#12 and #17) of the sampled twenty-four (24) residents. Findings include: 1. Review of the clinical record for resident #12, revealed a Functional Feeding Program which included a self-feeding assessment completed by the Occupational Therapist (OT), dated 2/2/10. The OT assessed the resident to need a cup with a lid for all meals. Observation on 4/12/10 at 12:20 p.m., revealed resident #12 in the chapel dining room. A staff member poured tea from a plastic tumbler into a sippy cup (without handles) and a sip lid. The resident as observed drinking from the sippy cup. Observation on 4/13/10 at 7:50 a.m., revealed resident #12, in the solarium being fed by a staff member. The staff member gave the resident liquids from a sippy cup with two (2)handles. However, the lid of the cup was on the table and not attached to the cup. Review of the diet card revealed that the resident was to use a two (2) handled cup without the lid. At that time, the staff member stated that after reading the diet card, he/she had removed the lid. Observation on 4/13/10 at 12:20 p.m., revealed resident #12, in the chapel dining room, drinking tea from a regular plastic tumbler. A sippy cup was located on the table next to the plate of food. However, staff did not pour the tea into the cup. Interview on 4/14/10 at 10:15 a.m. with the Dietary Manager (DM) revealed that information about adaptive devices is sent through a communication slip from the therapy department. Review of the resident's diet card with the DM, revealed that the resident was to be served liquids in a two (2) handled cup with no lid. At that time, the DM, indicated that there was a mistake on the diet card and corrected it. Observation 4/14/10 at 11:00 a.m., with the DM, revealed the original communication slip from the therapy department which was dated 10/6/09, indicating that the resident should receive a cup with a lid. Interview on 4/14/10 at 11:00 a.m. with the DM revealed that she did not know where the information about the resident needing a two (2) handled cup had come from and that further investigation was indicated. 2. Review of the clinical record for resident #17, revealed a physician's orders [REDACTED]. Continued review of the clinical record revealed a plan of care to include a sippy cup with a straw. Observation on 4/14/10 at 8:00 a.m., revealed resident #17 in the solarium being assisted by staff to eat breakfast. The resident had juice in a sippy cup with a straw, but there was no lid on the cup. Interview on 4/14/10 at 10:15 a.m., the DM revealed that the resident's family had requested that the resident use a sippy cup with a straw. Continued interview revealed that the cup had a lid for a straw and that the lid should have been on the cup when the resident was being served.",2015-03-01
10001,OCONEE HEALTH AND REHABILITATION,115357,107 RIDGEVIEW DR,OCONEE,GA,31067,2010-12-16,309,D,0,1,4YOU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow the physician's order for the administration of a medication for one resident (#49) from a sample of 15 residents. Findings include Review of the medical record for resident #49 revealed [DIAGNOSES REDACTED]. end stage [DIAGNOSES REDACTED], recurrent [MEDICAL CONDITION], history of abnormal weight loss, vitamin deficiency, history of protein caloric malnutrition, history of [MEDICAL CONDITION], interstitial lung disease, [MEDICAL CONDITION], dementia, [MEDICAL CONDITION], and a history of [MEDICAL CONDITION] Infarction (MI). Review of the current physician orders for resident #49 revealed an order dated 10/9/10 for [MEDICATION NAME], a medication given to stabilize the heart after MI, 100 milligrams (mgs) one (1) tablet two (2) times a day via feeding tube. Hold the medication if the pulse rate is less than 54 and call the physician for orders. Review of the Medication Administration Records (MARs) revealed that although the pulse had been recorded before each dose of medication and circled, indicating it was held for a pulse rate of less than 54, there was no evidence that the physician was notified as ordered. Continued review revealed that the medication was held October 11, 19, 21, and 29, 2010; November 1, 3, 8, 9, 12, 16, 17, 18, 19, 20, 22, 24, 26, and 30, 2010 and December 1,6,7,9, and 13, 2010 for a total of twenty three (23) times since ordered on [DATE]. During an interview with the Education Coordinator Registered Nurse,""JJ""on 12/15/10 at 11 a.m. she indicated that that there was no evidence to indicate that the nurses had contacted the physician when the medication was held.",2015-03-01
10002,OCONEE HEALTH AND REHABILITATION,115357,107 RIDGEVIEW DR,OCONEE,GA,31067,2010-12-16,323,D,0,1,4YOU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the facility policy for Medication Administration and staff interview, the facility failed to ensure that medications and sharps items were secured in the medication cart on one (1) of two (2) halls (200 Hall).. Findings include: 1. Observation during medication administration with Licensed Practical Nurse (LPN) ""AA"", on 12/14/10 at 11:30 a.m., revealed that the nurse left the medication cart unattended in the hallway with lancets and Insulin syringes on a tray on top of the cart. . 2. Observation on 12/14/10 at 8:41 a.m., during medication pass, with LPN ""AA"" revealed that the nurse left five (5) blister packs of medication including, an antidepressant, three (3) antihypertensives, a medication for the treatment of [REDACTED]. Interview with the Acting Director of Nursing (DON) on 12/15/10 at 10:05 a.m.,revealed that sharp items and/or oral medication should never be left unattended on top of the medication cart, they should always be locked up before leaving the cart. Continued interview revealed that there was one (1) resident who liked to wander throughout the building and their room was on the 200 hall. Review of the facility Medication Administration General Guidelines, reviewed and updated January, 2009, revealed that no medications are to be kept on top of the medication cart.",2015-03-01
10003,OCONEE HEALTH AND REHABILITATION,115357,107 RIDGEVIEW DR,OCONEE,GA,31067,2010-12-16,431,D,0,1,4YOU11,"Based on observation, review of the facility policy for Medication Administration and staff interview, the facility failed to ensure that the medication cart was in direct observation of the person administering the medications on one (1) of two (2) halls (200 Hall).. Findings include: 1. Observation during medication administration on 12/14/10 at 8:41 a.m. with Licensed Practical Nurse (LPN) ""AA"", revealed that the nurse was called away from the medication cart by another staff member,to assist with a resident. Continued observation revealed that the the LPN had removed five (5) blister packages of medication and one (1) bottle of aspirin from the cart and placed these medications into a medication cup to be administered. The LPN left the medication cart unattended and out of direct observation, with these medications on the top of the cart, for approximately two (2) minutes later. 2. Observation during medication administration with Licensed Practical Nurse (LPN) ""AA"", on 12/14/10 at 11:30 a.m., revealed that the nurse left the medication cart unattended and out of direct observation, with lancets and Insulin syringes on a tray on top of the cart, while she administered medication to another resident. Interview with the Acting Director of Nursing (DON) on 12/15/10 at 10:05 a.m., she indicated that at no time should any medication be left out unattended on top of the medication cart, stating that all medication should be locked up. Also, indicated that there was one (1) resident in the facility that likes to wander the halls and this residents room is on the 200 hall. Review of the Medication Administration-General Guidelines, reviewed and updated January 20, 2009, revealed that the medication cart is to be clearly visible to the personnel administering medications.",2015-03-01
10004,OCONEE HEALTH AND REHABILITATION,115357,107 RIDGEVIEW DR,OCONEE,GA,31067,2010-12-16,441,D,0,1,4YOU11,"Based on observation and staff interview, the facility failed to ensure that appropriate infection control practices were followed related to handwashing for one (1) randomly observed resident during medication pass. Findings include: Observation during medication administration with Licensed Practical Nurse (LPN) ""AA"" on 12/14/10 between 8:40 a.m. and 8:50 a.m. revealed that the LPN prepared, administered and documented medications for one (1) resident and then prepared and administered medication to a second resident without washing her hands between residents. Continued observation at 11:30 a.m. revealed that LPN ""AA"" prepared the glucometer for blood glucose testing, entered the residents room washed her hands and put on a pair of gloves; however, she then realized she did not have a strip for the glucometer and removed the gloves, opened the bedroom door, obtained a strip, put on another pair of gloves and checked the resident's blood glucose. The LPN did not wash her hands upon returning to the resident's room. Interview with the Acting Director of Nursing (DON) on 12/15/10 at 10:05 a.m. revealed that handwashing should occur if hands are visibly soiled, but sanitizing gel should be used before preparing meds and after giving medication. During continued interview, she indicated that the nurse should have washed and/or used the gel after re-entering the residents room before performing the blood glucose testing.",2015-03-01
10005,LUMBER CITY NURSING & REHABILITATION CENTER,115404,93 HIGHWAY 19,LUMBER CITY,GA,31549,2010-05-27,387,D,0,1,NSXF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the attending physician alternated visits with the nurse practitioner for two residents (#2 and #11), and visited one resident (#12) every 30 days for the first 90 days after admission in a total sample of 16 residents. Findings include: 1. Resident #2 was admitted on [DATE]. On 8/26/09, 9/23/09, 10/23/09, 11/11/09 and 12/16/09, the resident was visited by the nurse practitioner. Although the physician co-signed the nurse practitioner's progress notes, there was no indication that the physician alternated visits with the nurse practitioner. 2. Residents #11 was admitted on [DATE]. On 9/23/09, 10/23/09, 11/11/09, and 12/16/09, the resident was visited by the nurse practitioner. Although the physician co-signed the nurse practitioner's progress notes, there was no indication that the physician alternated visits with the nurse practitioner. 3. Resident #12 was admitted on [DATE]. On 3/17/10, the resident was seen by the physician. However, on 4/21/10 and 5/19/10, the resident was seen by the nurse practitioner. the attending physician did not visit the resident once every 30 days for the first 90 days after his/her admission to the facility. In an interview on 5/26/10 at 2:30 p.m., the Director of Nursing said that the physician and nurse practitioner came to the facility together, and that the nurse practitioner saw some residents while the physician saw other residents. The physician signed his notes and co-signed the nurse practitioner's notes.",2015-03-01
10006,LUMBER CITY NURSING & REHABILITATION CENTER,115404,93 HIGHWAY 19,LUMBER CITY,GA,31549,2010-05-27,309,D,0,1,NSXF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to remove a [MEDICATION NAME] as ordered by the physician for one random resident during the mediation pass. Findings include: During the medication pass observation on 5/26/10 at 8:20 a.m., the licensed nurse removed a [MEDICATION NAME] from a resident's chest before applying the new medicated patch. However, review of the resident's clinical record revealed a 2/13/10 physician's orders [REDACTED].",2015-03-01
10007,LUMBER CITY NURSING & REHABILITATION CENTER,115404,93 HIGHWAY 19,LUMBER CITY,GA,31549,2010-05-27,323,D,0,1,NSXF11,"Based on observation, it was determined that the facility failed to maintain safe hot water temperatures on one (A Hall) of three halls. Findings include: During the General Observations Tour of the facility on 5/27/10 at 11:20 a.m., the hot water temperature in the A Hall Shower Room sink was 127.7 degrees Farenheit (F.) and in room 109, the water temperature was 124.8 degrees F. Observation of the hot water heater on 5/27/10 at 1:00 p.m. revealed that the thermostat was set at 110 degrees F. During an interview at that time, the Maintenance Supervisor stated that the thermostat in that hot water heater, which only served those two rooms, was malfunctioning and would be replaced. On 5/27/10 at 1:00 p.m., the water temperatures in the Shower room and room 109 were 100.5 F.",2015-03-01
10008,LUMBER CITY NURSING & REHABILITATION CENTER,115404,93 HIGHWAY 19,LUMBER CITY,GA,31549,2010-05-27,157,D,0,1,NSXF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, it was determined that the facility failed to consult with the attending physician about significant changes in the urine and urinary output and, episodes of vomiting for one resident (#4) from a total sample of 16 residents. Findings include: The Springhouse Corporation's Nurse Review ""Clinical Update System for [MEDICAL CONDITION] Problems"" documented ""because [MEDICAL CONDITION] causes urinary obstruction,"" a patient with that disorder might have the following complication: urinary stasis, infection or [MEDICATION NAME]. [MEDICAL CONDITION] could also cause [MEDICAL CONDITION] obstruction. Signs and symptoms of a prostatic problem included decreasing urinary stream and hematuria. However, licensed nursing staff failed to consult with resident #4's attending physician, oncologist or urologist when they had observed significant changes in his/her urine and the presence of an odor in the urine. Resident #4 had a [DIAGNOSES REDACTED]. The interdisciplinary care plan team had not revised the 9/9/09 care plan that addressed the indwelling urinary catheter related to the resident's [DIAGNOSES REDACTED]. There were not any interventions for nursing staff to address monitoring of potential complications, and signs and symptoms that would warrant consultation with a physician for possible intervention. Although licensed nursing staff documented significant changes in the resident's urine five times between 3/1/10 and 4/30/10, there was no evidence that they consulted the resident's physician about those changes. a. The nurse's notes on 3/1/10 at 10:30 p.m. described the resident's urine in his/her bedside drainage bag as dark amber in color and having a ""very strange odor."" The licensed nurse documented that the information was reported to the oncoming nurse and requested a follow up be completed on 3/2/10. However, there was no evidence that a follow up had been completed or that the physician had been consulted. b. The 4/7/10 nurse's notes at 7:00 p.m. documented that the resident complained of not being able to void. The licensed nurse documented that the resident had 200 cubic centimeters (cc) of urine in his/her bedside drainage bag. At 9:20 p.m., the licensed nurse wrote that the resident continued to have only 200 cc of urine in his/her bedside drainage bag. The nurse documented that she had attempted to flush the resident's catheter with 30 cc of sterile water without success. She wrote that she replaced the resident's indwelling catheter and that there was an immediate return of urine that was thick, yellow, and cloudy with a large amount of sediment. However, there was no evidence that the physician was consulted. c. The nurse's note dated 4/15/10 at 2:30 a.m. described the resident's urine as foul smelling and dark yellow in his/her catheter bag. However, there was no evidence that the physician was consulted. d. The nurse's note dated 4/17/10 at 4:30 a.m. documented that the resident had 60 cc of urine in his/her bedside urinary drainage bag with bright blood in the catheter tubing. However, there was no evidence that the physician was consulted. e. The nurse's note on 4/30/10 at 2:25 a.m. described the urine in the resident's bedside drainage bag as dark yellow and foul smelling. However, there was no evidence that the physician was consulted. The nurse's note on 5/23/10 at 4:50 a.m. documented that the resident had vomit covering his/her chest and torso area. At 7:30 a.m. on that day, the licensed nurse documented that the resident had an episode of nausea and vomiting and was cleaned up by the certified nursing assistant. However, there was no evidence that the physician had been consulted about the resident's vomiting. During an interview on 5/27/10 at 8:45 a.m., the Registered Nurse (RN) supervisor stated that she would have expected the nurses to notify the physician about any change in the resident's urine. She said that she would be more concerned about the foul smelling urine than the blood in the urine because of the resident's [DIAGNOSES REDACTED]. She was unable to locate any information about it in the resident's medical record. She stated that she was not aware that the resident had had episodes of vomiting but, would have expected the nurses to notify the physician.",2015-03-01
10009,LUMBER CITY NURSING & REHABILITATION CENTER,115404,93 HIGHWAY 19,LUMBER CITY,GA,31549,2010-05-27,280,D,0,1,NSXF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, it was determined that the facility failed to revise the plan of care for one resident (#4) with a [DIAGNOSES REDACTED]. Findings include: Resident #4 had a [DIAGNOSES REDACTED]. He was routinely seen by an oncologist, and had seen a urologist, in addition to visits by his attending physician. There was a care plan since 9/9/09 to address the resident's use of an indwelling urinary catheter related to his [DIAGNOSES REDACTED]. However, the only interventions were for nursing staff to change the catheter and bag every month and as needed, to monitor for changes in the resident's output, to provide catheter care every shift and as needed, to monitor laboratory studies as ordered, and to notify the physician as needed. There was no evidence that those interventions had been evaluated or revised since 9/9/09 to include any monitoring for potential complications, and signs and symptoms that would warrant consultation with a physician for possible interventions. See F157 for additional information regarding resident #4.",2015-03-01
10010,CEDAR VALLEY NSG & REHAB CTR,115436,225 PHILPOT STREET,CEDARTOWN,GA,30125,2010-05-12,309,D,0,1,T2SO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of physician's orders, and staff interview, the facility failed to ensure physician's orders were followed for one (1) resident (#2) from a sample of sixteen (16) residents. Findings include: Observation made during a skin assessment on 5/11/10 at 1:30pm, conducted with a Certified Nursing Assistant (CNA) ""CC"" revealed an [MEDICATION NAME] to the right lower abdomen dated 5/4/10, a second [MEDICATION NAME] patch to the left lower abdomen dated 5/8/10, and a Nitro Dur patch on the right chest dated 5/10/10. Review of the physician's orders dated 1/7/10 indicated a Nitro Dur Patch 0.8 milligrams (mg) was to be applied at bedtime and removed every morning. The physician's order was for [MEDICATION NAME] Patch 3.9 mg one (1) patch, two (2) times weekly. Interview with the Licensed Practical Nurse (LPN) ""AA"" conducted 5/11/10 at 1:50pm revealed the Nitro Dur patch should have been removed this morning and that the [MEDICATION NAME] Patch dated 5/4/10 should have been removed on 5/8/10 when the new Patch was applied.",2015-03-01
10011,CEDAR VALLEY NSG & REHAB CTR,115436,225 PHILPOT STREET,CEDARTOWN,GA,30125,2010-05-12,502,D,0,1,T2SO11,"Based on review of the medical records, physician's orders, and staff interviews, the facility failed to ensure laboratory tests were completed in a timely manor for two (2) residents ( #2 and #12) from a sample of sixteen (16) residents. Findings include: 1. Record review for resident #2 revealed an physician's order dated 1/7/10 for a Complete Blood Count (CBC) every month. No March 2010 CBC results was not found in the medical record. Interview with a Licensed Practical Nurse (LPN) ""BB"" conducted 5/10/10 at 2:00pm revealed, that after consulting with the Laboratory, no CBC was done for March 2010. 2. Record review for resident #12 revealed a physician's order dated 2/1/10 for Liver Function Tests (LFT) every three (3) months. There were no laboratory results for a LFT found for February 2010. There was a LFT results for April 20 and May 6, 2010. Interview with a LPN ""BB"" conducted 5/12/10 at 9:45am revealed that the only order found on the chart for LFT was 2/1/10, and there was no laboratory test done at that time. ""BB"" confirmed with the Laboratory that there was no LFT completed prior to 4/20/10. ""BB"" concluded that the original order for 2/1/10 was missed, and was not completed until 4/20/10.",2015-03-01
10012,CEDAR VALLEY NSG & REHAB CTR,115436,225 PHILPOT STREET,CEDARTOWN,GA,30125,2010-05-12,504,D,0,1,T2SO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to obtain physician's orders for laboratory tests completed for one (1) resident (#12) from a sample of sixteen (16) residents. Findings include: Record review revealed a physician's order dated 3/6/09 for Lipids yearly. Further record review for laboratory results revealed Lipids completed 1/7/10 and 3/9/10. Interview with a Licensed Practical Nurse ""BB"" on 5/12/10 at 9:45am revealed ""BB"" was not sure why the Lipids were completed two (2) months apart, Lipids had been done 3/1/09 prior to admission to the facility on [DATE], therefore would be due again March 2010 according to the order. There was no order found in the medical record for the Lipids completed 1/7/10.",2015-03-01
10013,HERITAGE INN OF BARNESVILLE HEALTH AND REHAB,115447,946 VETERANS PARKWAY,BARNESVILLE,GA,30204,2010-05-26,314,D,0,1,DSM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to perform a pressure sore treatment per the physicians's order for one (1) resident (#4) of the twenty-four (24) sampled residents. Findings included: Review of the clinical record for resident #4, revealed the resident had a stage 4 pressure sore on the coccyx. Review of a physician order [REDACTED]. Observation on 05/24/10 at 1:25 p.m. of the pressure sore treatment for [REDACTED]. Interview on 05/24/10 at 2:05 p.m. with LPN ""AA"" revealed she thought the Calcium Alginate went onto the wound first then the [MEDICATION NAME]. Interview on 05/24/10 at 2:07 p.m. with the Director of Nursing (DON), confirmed that the physician ordered the [MEDICATION NAME] to be applied directly to the wound bed and then pack the wound with Calcium Alginate.",2015-03-01
10014,HERITAGE INN OF BARNESVILLE HEALTH AND REHAB,115447,946 VETERANS PARKWAY,BARNESVILLE,GA,30204,2010-05-26,441,D,0,1,DSM311,"Based on observation and staff interview, the facility failed to ensure that staff wash their hands after removing contaminated gloves during wound care treatment for two (2) residents (#4 and #8) of the sampled twenty-four (24) residents. Findings included: 1. Observation on 05/24/10 at 1:40 p.m. of a pressure sore treatment for resident #4, performed by Licensed Practical Nurse (LPN) ""AA"" revealed that after dressing the pressure sore, the nurse removed the contaminated gloves, left the room, proceeded down the hall and took a dressing out of the treatment cart. The nurse failed to wash hands or use hand sanitizer after removing the contaminated gloves, before opening the treatment cart and obtaining a clean dressing. Interview on 05/24/10 at 2:05 p.m. with LPN ""AA"", revealed that the hands should have been washed or the hand sanitizer used after removing the contaminated gloves. 2. Observation on 05/25/10 at 12:07 p.m. of a pressure sore treatment for resident #8, performed by LPN ""BB"", revealed after dressing the pressure sore, the nurse removed the contaminated gloves, took the bagged contaminated dressings, discarded them in a receptacle on the side of the treatment cart, then went into the treatment cart to get a bottle of alcohol to clean off a tray. The nurse failed to wash her hands or use a hand sanitizer after removing the contaminated gloves, before opening the treatment cart and obtaining the bottle of alcohol. Interview on 05/25/10 at 12:17 p.m. with LPN ""BB"", revealed that she did not wash her hands or use the hand sanitizer after removing the contaminated gloves.",2015-03-01
10015,CRESTVIEW HEALTH & REHAB CTR,115525,2800 SPRINGDALE ROAD,ATLANTA,GA,30315,2010-04-20,253,B,0,1,2X7O11,"Based on observations, the facility failed to maintain a clean and orderly interior on three (3) of five (5) units (A-1, A-2 and C-2) . Findings include: Observations conducted 4/20/10 at 11:50 a.m., during environmental tour with the Interim Maintenance Director ""EE"" and Superintendent ""XX"" revealed problems in the following units. A-2: The microwave in the pantry contained dried food spatters on the sides, top and bottom. The common shower, tub #1, had a ceiling light fixture which was not functioning. C-2: The microwave in the pantry had dried food spatters on one side, and the top. A-1: The pantry microwave had dried food spatters on three sides, and the top. The common shower room had a shower stretcher which had hair and black moldy stains under the pad. Also there were two (2), four (4) by four (4), missing tiles on the side wall and one (1), four (4) by four (4), tile missing from the wall at tub #1.",2015-03-01
10016,CRESTVIEW HEALTH & REHAB CTR,115525,2800 SPRINGDALE ROAD,ATLANTA,GA,30315,2010-04-20,502,D,0,1,2X7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, and staff interview the facility failed to ensure physician's orders for laboratory services were obtained in a timely manner for one (1) residents ( #13) from a sample of thirty (30) residents Findings include: Review of the medical record for resident #13 revealed a physician's order dated 1/5/10 for a Pre-[MEDICATION NAME] level, Complete Blood Count (CBC) and Basic Metabolic Panel (BMP). Further review of the medical record for resident #13 revealed that these laboratory results were not found in the medical record. Interview with the Registered Nurse Unit Manager ""CC"" on 4/19/10 at 1:30pm revealed these laboratory were not done and he/she instructed the nurse on the unit to notify the physician and get a clarification for the 1/5/10 order.",2015-03-01
10017,CRESTVIEW HEALTH & REHAB CTR,115525,2800 SPRINGDALE ROAD,ATLANTA,GA,30315,2010-04-20,323,E,0,1,2X7O11,"Based on observations during the Environmental tour, review of the facility temperature logs for the past thirty days and staff interview, the facility failed to ensure that the resident's environment was free of hazards related to hot water temperatures greater than 120 degres Fahrenit on two (2) of six (6) halls and the Beauty Shop. Findings include: Observation of water temperatures during the general environmental tour conducted with the Senior Maintenance Technician ""BB""on 4/20/10 starting at 12:00pm revealed hot water temperatures exceeding 120 degrees F. in the following area: B 2 Common shower had a water temperature of 127 degrees F. in the sink. The facility reported that eleven (11) residents had access to the showers and sinks in this area. Community rest room had a water temperature of 130 degrees F. in the sink. The facility reported that six (6) residents had access to the sinks in this area. Resident room B-211 had a water temperature of 128 degrees F. in the sink. The facility reported that one (1) resident had access to the sink in this room. Resident room B-218 had a water temperature of 126 degrees F. in the sink. The facility reported that four (4) residents had access to the sink in this room. B 1 Common shower had a water temperature of 126 degrees F. in the sink. The facility reported that six (6) residents had access to the showers and sinks in this area. Community rest room had a water temperature of 126 degrees F. in the sink. The facility reported that no residents had access to the sinks in this area. Resident room B-105 had a water temperature of 127 degrees F. in the sink. The facility reported that two (2) residents had access to the sink in this room. Resident room B-120 had a water temperature of 121 degrees F. in the sink. The facility reported that three (3) residents had access to the sink in this room. Beauty Shop Beauty Shop had a water temperature of 124 degrees F. in sink. Review of the beauty shop service revealed eight resident received shampoos on 4/15 and 4/16/10 Interview with ""BB"" on 4/20/10 revealed that random daily temperature are taken and when the temperature is above 113 degrees F. immediate adjustments are made and temperature is rechecked. Review of the facility's ramdon water temperature logs for the past thirty (30) days revealed the following: A-1 hall one room reached 122.7 degrees F. on 3/22/10 B-2 hall one room reached 121.6 degrees on 3/29/10",2015-03-01
10018,CRESTVIEW HEALTH & REHAB CTR,115525,2800 SPRINGDALE ROAD,ATLANTA,GA,30315,2010-04-20,309,D,0,1,2X7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Physician's orders, Medication Administration Records (MARs), Insulin Administration Logs and staff interviews, the facility failed to follow physician's orders for two (2) residents (#8 and #10) from a sample of thirty (30) residents. Findings include: 1. Resident #8 had a physician's order dated 4/19/09 for an Accucheck one (1) time per week, with sliding scale coverage. A physician's order dated 2/24/10 clarified the sliding scale coverage for insulin to be administered for blood glucose as follows: 201-250 give four (4) units regular Insulin 251-300 give six (6) units regular Insulin 301-350 give eight (8) units regular Insulin 351-400 give ten (10) units regular Insulin Review of the February 2010 Insulin Administration Log indicated on 2/8/10 the blood sugar level was 242, and the resident should have received four (4) units of regular Insulin but none was administered. On 2/15/10 the blood sugar was 228. The resident should have received four (4) units of regular Insulin but no insulin was given. Review of the March 2010 Insulin Administration Log indicated on 3/15/10 that the blood sugar level was 201. The resident should have received four (4) units of regular Insulin, but none was given. On 3/29/10 the blood sugar was 275. The resident should have received six units of regular Insulin and received none. Interview with the Registered Nurse Manager ""DD"" on 4/20/10 at 1:30pm revealed that after review of the Insulin logs, the resident had not received the correct Insulin coverage as ordered on [DATE], 2/15/10, 3/15/10, and 3/29/10. 2. Resident #10 had a physicians order dated 4/15/10 to decrease [MEDICATION NAME] to 150 milligrams (mg) daily. Review of the April 2010 MAR indicated [REDACTED]. Interview with the Nurse Manager ""DD"" on 4/20/10 at 4:10pm revealed that the resident should have received [MEDICATION NAME] 150mg one (1) time per day from 4/15/10, but had continued to receive the medication two (2) times per day.",2015-03-01
10019,CRESTVIEW HEALTH & REHAB CTR,115525,2800 SPRINGDALE ROAD,ATLANTA,GA,30315,2010-04-20,367,D,0,1,2X7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on meal observations, review of physicians orders, Registered Dietician (RD) progress notes, and staff interviews, the facility failed to follow physician's orders [REDACTED].#10 and #11) from a sample of thirty (30) residents. Findings include: 1. Observation of the meal tray for Resident #10 on 4/18/10 at 12:45pm revealed the resident had nectar thickened water and tea on the tray. The resident also had one (1) carton of chocolate milk and one (1) container of pineapple juice which were not thickened. The resident consumed the carton of chocolate milk, and the pineapple juice. The resident did not consume any of the nectar thickened water or tea. The resident was assisted with the meal by a Certified Nursing Assistant (CNA). Review of the diet card revealed the resident was to receive nectar thickened liquids. Further observation of breakfast on 4/19/10 at 8:15am revealed there was fat free milk and apple juice on the tray that was not thickened. The resident consumed one half of each. Review of the diet card revealed nectar thickened liquids was crossed off. Record review revealed that the current physician's orders [REDACTED]. Further record review revealed that nectar thickened liquids was originally ordered on [DATE]. A nutrition note dated 3/1/10 indicated the resident was to continue a mechanical soft diet, with nectar thickened liquids. Interview with the RD ""FF"" on 4/18/10 at 2:40pm revealed the resident should be receive nectar thickened liquids. Interview with the Speech Therapist ""GG"" on 4/19/10 at 8:30am revealed the facility had requested a reassessment for fluid recommendations for the resident. ""GG"" reassessed the resident on 4/19/10 and the resident was to continued with nectar thickened fluids pending further observations. 2. Observation of the lunch meal for Resident #11 on 4/18/10 at 1:00pm revealed the resident received a regular diet which matched the diet card. On 4/19/10 at 7:55am the resident also received a regular diet for breakfast. Record review revealed a physician's orders [REDACTED]. Further record review revealed RD notes dated 1/19/10 and 2/3/10 which indicated the resident was on a Mechanical Soft diet with double portions. Interview with a Licensed Practical Nurse (LPN) ""HH""on 4/19/10 at 1:15pm revealed that the resident should be on a Mechanical Soft Diet, and was not sure why a regular diet was served for the past two (2) days.",2015-03-01
10020,CRESTVIEW HEALTH & REHAB CTR,115525,2800 SPRINGDALE ROAD,ATLANTA,GA,30315,2010-04-20,314,D,0,1,2X7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the physician's orders, treatment records, and staff interviews, the facility failed to preform wound care according to physician's orders for one (1) resident (#9) from a sample of thirty (30) residents. Findings include: Observation of wound care for Resident #9 on 4/19/10 at 2:20pm revealed an old dressing was removed which was dated 4/14/10. The dressing was saturated with brownish, foul smelling drainage. A small piece of the [MEDICATION NAME] dressing was stuck to the wound and had to be soaked with normal saline before it could be removed. The treatment nurse ""PP"" revealed the dressing should have been changed 4/16/10. Review of the physician's orders revealed an order dated 3/11/10 to cleanse the right heel with Normal Saline, apply [MEDICATION NAME] AG, and seal with appropriate dressing Monday, Wednesday, Friday, and whenever necessary (PRN). Review of the April 2010 Treatment Record indicated the dressing was due to be changed 4/2/10, 4/5/10, 4/7/10, 4/9/10, 4/12/10, 4/14/10, 4/16/10, and 4/19/10. This record had no evidence that the dressing was changed on 4/5/10, 4/12/10, and 4/16/10. Interview with Nurse Manager ""DD"" on 4/20/10 at 6:15pm revealed that if the Treatment Nurse was unable to complete the treatment as ordered because the resident was unavailable, the treatment should be assigned to the nurse on the next shift. There was no excuse for an ordered wound treatment not to be done unless the resident was admitted to the hospital.",2015-03-01
10021,LAKE CITY NURSING AND REHABILITATION CENTER LLC,115535,2055 REX ROAD,LAKE CITY,GA,30260,2011-11-28,502,D,1,0,0T4G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain ordered laboratory tests in a timely manner for (1) resident (#1) of four (4) sampled residents. Findings include: Medical record review for Resident #1 revealed a 09/15/2011, 12:29 p.m. Departmental Notes entry which documented that the resident was admitted to the facility. A 09/16/2011 physician's orders [REDACTED]. to pureed with large portions and nectar thickened liquids, and specified that Complete Blood Count (CBC) and a Comprehensive Metabolic Panel (CMP) laboratory tests be completed times one. However, a laboratory report documented that a CBC and a CMP were collected on 09/29/2011, thirteen (13) days after the 09/16/2011 physician's orders [REDACTED]. During an interview on 11/28/2011 at 3:45 p.m., Administrative Nurse ""BB"" stated that a laboratory technician was at the facility daily, except on weekends, and that normally a written laboratory order was to be completed on the next day. This nurse stated she was not certain why there had been a 13 day delay between the date the order was written on 09/16/2011 and the date the blood was drawn on 9/29/2011 for the completion of these laboratory tests. During an interview conducted on 11/28/2011 at 2:30 p.m., the Registered Dietician stated she recommended these laboratory tests be drawn for Resident #1 so she could have a nutritional baseline for the resident.",2015-03-01
10022,LAKE CITY NURSING AND REHABILITATION CENTER LLC,115535,2055 REX ROAD,LAKE CITY,GA,30260,2011-11-28,504,D,1,0,0T4G11,"Based on medical record review, staff interview, and facility document review, the facility failed to obtain laboratory tests only when ordered by the attending physician of (1) resident (#1) of four (4) sampled residents. Findings include: Medical record review for Resident #1 revealed a Departmental Notes entry of 10/13/2011 at 1:37 p.m. which documented bruises to the bilateral hands of Resident #1. This entry specifically documented bruising to the back of the right hand and a reddened area to the left hand, both having puncture wounds. A laboratory report documented that specimens for a Complete Blood Count (CBC) and a Comprehensive Metabolic Panel (CMP) had been collected from Resident #1 on 10/13/2011. However, further record review revealed no evidence of a physician's order for these 10/13/2011 laboratory tests. During an 11/28/2011, 3:45 p.m. interview with Administrative Nurse ""BB"", this nurse was unable to produce a physician's order for the laboratory tests which were drawn for Resident #1 on 10/13/2011. Additionally, a Departmental Notes entry of 11/14/2011 at 12:38 p.m. documented that the laboratory staff had again drawn laboratory specimens, and documented that the resident was noted with bruises to both hands secondary to needle sticks. However, further record review revealed no physician's order for the resident to have laboratory testing on 11/14/2011. During an interview conducted on 11/28/2011 at 11:15 a.m., Nurse ""CC"" stated that 11/14/2011, the laboratory technician was supposed to draw specimens for laboratory tests for the roommate of Resident #1, but mistakenly drew specimens from Resident #1. A facility Incident Report dated 11/18/2011 documented that on 11/14/2011, the laboratory technician had obtained laboratory specimens from Resident #1 without a physician's order, and that the laboratory specimens should have actually been drawn from Resident #2.",2015-03-01
10023,TWIN VIEW HEALTH AND REHAB,115540,211 MATHIS AVENUE,TWIN CITY,GA,30471,2010-06-26,371,E,0,1,CKH411,"Based upon observation, record review and staff interview the facility failed to maintain for one (1) of one (1) pantry refrigerator at or below forty one (41) degrees Farenheit. Findings include: Observation of the Station 2 pantry on 6/24/2010 at 12:00 p.m. revealed a small refrigerator with three (3) cartons of milk, two (2) sandwiches labeled with resident's names. The sandwiches and milk cartons felt warm. Further observation revealed there was no thermometer in the refrigerator. At that time, Licensed Practical Nurse (LPN) ""EE"" confirmed the refrigerator was for resident use only. The temperature of the milk was checked at that time, with LPN ""EE"" present and recorded at 57.4 degrees Farenheit (F). LPN ""EE"" revealed that the temperature was supposed to be checked on the night shift and recorded on the calendar above the refrigerator. She had no idea what was used to check the temperature. She agreed the milk is too warm to be served safely. Record Review of the temperature record for June 2010 revealed that the refrigerator temperature was recorded as exactly 38 degrees F. everyday from 6/01/2010 through 6/24/2010. An interview with the Maintenance Director on 6/24/2010 at 12:20 p.m. revealed he was not aware there was no thermometer in the refrigerator and had no idea how the night shift was measuring a temperature of the refrigerator.",2015-03-01
10024,TWIN VIEW HEALTH AND REHAB,115540,211 MATHIS AVENUE,TWIN CITY,GA,30471,2010-06-26,469,E,0,1,CKH411,"Based upon observation, staff, family pest control service representative interviews the facility failed to ensure that the facility was free of flies throughout the facility. Flies were observed in the dining room and on the hallway near the smoking porch. Findings include: Observation on 6/21/2010 between 1:00 p.m. to 5:00 p.m. revealed flies throughout the facility and in the outside smoking area. Flies were observed to land on randomly observed residents and their drinking glasses in the dinning room during the lunch meal. Observation of resident #28 on 6/23/2010 at 12:40 p.m. in the dinning room, revealed flies were landing on the resident as well as on other randomly residents and their water glasses. Observation of resident #28 at 1:00 p.m., during a smoke break on the back smoking porch, four (4) flies were observed on the resident's lower body. Observation of the hallway nearest the smoking area revealed multiple flies. During observation of resident # 28 on 6/24/2010 at 1:00 p.m. in the dinning room at lunch, a fly was noted to land on the resident and the resident's tea glass. Observation of resident #111 on 6/24/2010 at 5:10 p.m. revealed the resident was drinking water while waiting for the trays to be served. A fly was noted crawling around on the table where he was sitting. On 6/24/2010 at 12:45 p.m. a representative of the facility pest control company arrived for a monthly visit. Interview with the representative revealed that the facility has ""misters"" throughout the facility to address the flies. An interview with a family member on 6/22/2010 at 11:00 p.m. revealed they visit frequently and that over the last two (2) weeks there had been an increased problem with flies in the facility. An interview with the Maintenance Director on 6/23/2010 at 4:30 p.m. reveals that ""misters"" are located around the building and he does not know why there are more flies in the building.",2015-03-01
10025,TWIN VIEW HEALTH AND REHAB,115540,211 MATHIS AVENUE,TWIN CITY,GA,30471,2010-06-26,279,D,0,1,CKH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to develop a care plan related to the loss of range of motion (ROM) with interventions to improve or prevent further reduction in loss for one (1) resident ('S') on a sample of twenty-six (26) residents. Findings include: On 06/25/2010 at 10:10 a.m. and 2:30 p.m., and 06/26/2010 at 8:45 a.m., 11:00 a.m., and 1:10 p.m., resident 'S' was noted in a wheelchair with their right hand clenched, and no splint device in place. On 06/25/2010 at 2:30 p.m., the resident stated they used to have a splint, but didn't know where it was. Additionally, the resident stated that at one time he/she was given a rubber ball to squeeze, but that they hadn't done that for a long time now. Review of resident 'S's annual Minimum Data Set ((MDS) dated [DATE] noted ROM limitation on one side, with full loss of voluntary movement. A Potential for Falls care plan dated 02/23/2010 noted the resident had weakness and was receiving Restorative. None of the resident's care plans addressed the loss of ROM, nor interventions to improve or prevent further decline. Review of the physician's progress notes dated 3/12/2010 and 4/16/2010 noted resident 'S' had [DIAGNOSES REDACTED]. On 06/26/2010 at 10:45 a.m., Occupational Therapist (OT) 'GG' stated she discharged the resident to Restorative services in March, and remembered educating the Restorative Aide about what needed to be done, including ROM and splint application. On 06/26/2010 at 11:30 a.m., Licensed Practical Nurse (LPN) MDS Coordinator 'BB' stated she was not aware of the referral made by therapy for Restorative services in March.",2015-03-01
10026,TWIN VIEW HEALTH AND REHAB,115540,211 MATHIS AVENUE,TWIN CITY,GA,30471,2010-06-26,323,K,1,1,CKH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility's policy and procedure: Wandering Resident Monitoring, review of facility's Accident/Incident Report, record review and staff and responsible party interviews, the facility failed to provide adequate supervision to residents that had been identified as being at risk for elopement; failed to implement effective interventions by securing a fenced area; and failed to develop effective safety measures to prevent residents from eloping for four (4) residents (#114, 85, 81 and ""E"") from twenty-six (26) sampled residents and one (1) randomly observed resident. It was determined that the facility's failure to prevent resident elopement, and a lack of a working WanderGuard system, which they relied almost exclusively on to prevent elopement, resulted in a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident existed from June 3, 2010 until June 26, 2010 when the facility submitted an acceptable plan of correction. Findings include: 1) Record review for resident #114 revealed the resident was admitted to the facility on [DATE] with an admission [DIAGNOSES REDACTED]. An admission Minimum Data Set, dated dated [DATE] assessed the resident as having short and long term memory problems, moderately impaired cognitive skills and was exhibiting periods of altered perception or awareness of surroundings. The resident was also assessed as exhibiting verbal, physical abusive behaviors, as being socially inappropriate and resistive to care. Review of a Nurses Note dated 6/03/2010 revealed that at 10:50 p.m., the resident received medication for an increase in agitation and stated that she was going to sleep outside on the bench (in the back yard). When staff went to check on the resident 20 minutes later, at 11:10 p.m., 911 was called when the resident was not found on the porch. The resident was located at a nearby business and returned to the facility by the police. A Nurses Note dated 6/11/2010 at 12:00 a.m. indicated that the resident walked out on the porch, was staying out there and would not come back in the building. When the nurse checked on her at 12:05 a.m., the resident was not on the porch. The resident was located down the road near the police station and was returned to the facility. On 6/19/2010, another Nurses Note revealed that the resident escaped over the back fence. Police had called the facility to inform them that they had picked up a lady (resident #114) walking down the road. A care plan developed 4/19/2010 identified the resident as having the potential for elopement due to threats of leaving the facility unescorted. Initial interventions that were initiated included adding a WanderGuard bracelet to the resident, check the placement of the bracelet every shift, conduct a WanderGuard system check every morning and to encourage the resident to ventilate her feelings of placement into the nursing home. Additional interventions added to the care plan after the first elopement, 6/03/2010, was to monitor the resident for an increase in agitation and medicate if appropriate. After the second elopement, 6/11/2010, interventions were added to redirect the resident when agitated, provide visual checks and monitor the resident when she was out on the porch. When the resident eloped the third time, 6/19/2010, interventions were added to encourage the resident to talk to the doctor about her placement in the nursing home, refer the resident for psychological services and encourage medication compliance. A review of the Weekly Checklist for WanderGuard Monitoring completed by the Maintenance Supervisor revealed that he was checking the system on a weekly basis and not daily. Review of the PAR (Patients at Risk) Tracking Form detailed the elopement of the resident from the facility on 6/04/2010. Documentation of the action that was taken by the PAR team was to inservice staff on the WanderGuard alarm system, the resident would be redirected when agitated, visual checks would be conducted every 30 minutes and the resident would be supervised when on the back porch. For the 6/11/2010 elopement, the response written on the PAR note was to continue with visual checks every 30 minutes, have staff 1:1 with resident when she is on the porch. On 6/19/2010 after describing the third elopement for the resident, the interventions that were added to the PAR note were to interview the resident, staff and nurses to determine the resident's behavior prior to elopement, interview the resident to discover how she eloped and to administer medications for agitation. Observation of the resident on 6/22/2010 at 3:10 p.m. revealed that the resident was outside on the smoking porch (same area where resident has eloped three previous times) unsupervised by staff. The Assistant Director of Nursing was at the Nurses Station at the time of the observation but left the area with another resident. As the resident entered the building from the porch, the WanderGuard alarm sounded. Without any visible staff in the area, the resident was observed to reach under the alarm sensor on the side of the door and turn it off. An interview with the Director of Nursing on 6/26/2010 at 11:30 a.m. revealed that a resident is placed in the monitoring program if they attempt to/or leave the facility. The frequency of monitoring is determined based on if the resident is displaying a pattern of behaviors, has made multiple attempts to leave the facility or has a history of elopement and would stay on this schedule for the next quarter if we suspect they might attempt to elope again. The residents should be reassessed to determine if the frequency (of monitoring) needed to be changed if there were any changes or additional attempts to elope. The Elopement/Wandering Risk Assessment was completed on this resident on 6/04/2010 and again on 6/23/2010, twelve (12) days after the second elopement of 6/11/2010 . An assessment after the elopement on 6/11/2010 had not been completed per the facility policy and interview with the Director of Nursing. Included in the facility's Policy and Procedure for Wandering Resident Monitoring: The PAR Committee will review the resident's wandering behavior and determine if the resident requires visual monitoring and establish a monitoring schedule based on the resident's behavior pattern. Residents requiring monitoring will be reviewed weekly. An interview with the Medical Director on 6/25/2010 at 12:00 p.m. revealed that it is difficult to get a psychological evaluation done on the residents and he thought that PASSR was no longer available. He also stated that the criteria that has to be met before a resident is sent out for evaluation has become more involved. Review of the clinical record for resident #114 revealed PASSR Level I and Level II Screenings had been conducted. An interview with the Administrator on 6/23/2010 at 8:30 a.m., revealed that the facility had put interventions in place to monitor the resident but they had not been consistently carried out. There was a pattern that the resident usually attempted to leave at change of shift (from evening to night shift). No evaluations or changes were made to the areas of the fence where the resident was believed to have eloped. The staff relied heavily on hearing the door alarm to let them know if someone is leaving the facility. 2) Record review for resident # 85 revealed an admission date of [DATE] with an admission [DIAGNOSES REDACTED]. The resident was assessed on the 6/07/2010 Minimum Data Set as having long and short term memory problems and moderately impaired cognitive skills for daily decision making. The resident was also identified with being verbally abusive, exhibiting socially inappropriate and disruptive behaviors as well as resisting care. A care plan developed on 3/19/2009, identified the resident as having the potential for elopement related to a history of leaving the facility unescorted and a history of climbing the (back yard) fence. Updates added to the care plan on 9/08/2009 revealed the resident had left the facility by jumping over the fence and the intervention added to address this behavior was to discuss the dangers of jumping over the fence with the resident. According to the care plan on 02/27/2010, the resident left the facility and was found across the street from the facility property. A Nurses Note dated the same day indicated that the resident had again left the facility. It was documented that he opened the front door by leaning on the handle until it opened. An intervention added to the care plan in response to this elopement was to assist the resident to the DRPH (day room program) room, monitor the resident while in the program and allow the resident time to express his feelings. Review of an Accident/Incident Report dated 10/07/2009 at 1:30 p.m. revealed the resident was noted climbing the gate at the back fence and refused to come down. He ran to the dollar store across the street. Staff escorted the resident back to the facility. The facility disposition for this incident was to counsel the resident 1:1 and continue with the WanderGuard and visual checks (no frequency specified). Review of the facility's policy and procedure for Wandering or a Missing Resident revealed the following: Wandering exhibited by residents who are cognitively impaired can put the resident at risk for harm. Whenever a resident leaves facility property, unaccompanied by staff or without notifying staff, an elopement has occurred. The potential for harm to the resident who wanders or elopes increases with the extent of cognitive impairment. If a resident repeatedly wanders off the unit, the Resident Care Plan should reflect a monitoring schedule to ensure resident safety. Included in the facility's Policy and Procedure for Wandering Resident Monitoring: The PAR Committee will review the resident's wandering behavior and determine if the resident requires monitoring and establish a monitoring schedule based on the resident's behavior pattern. Residents requiring monitoring will be reviewed weekly Review of the Wandering Resident Monitor form revealed that the resident was being monitored every hour with documentation of his location at the time of the observation before and after the days of elopement that was entered on the care plan; however, adding the intervention to conduct visual checks on the resident had not been added to the care plan on 3/19/2009 and on 3/09/2010. And based on the facility's policy, the resident was not assessed for more frequent monitoring following the most recent elopements from the facility. In an interview with the Care Plan Coordinator on 6/26/2010 at 9:30 a.m. revealed that visual monitoring had been done on this resident but had not been added to the care plan as an intervention. An interview with the Director of Nursing on 6/26/2010 at 11:30 a.m. revealed that a resident is placed on the monitoring program if they attempt to/or leave the facility. The frequency of monitoring is determined based on if the resident is displaying a pattern of behaviors, has made multiple attempts to leave the facility or has a history of elopement. A random observation of the back door leading to the fenced area on 6/22/2010 at 4:05 p.m. revealed that the WanderGuard system did not alarm as another resident wearing a WanderGuard bracelet walked out of the door accompanied by staff. Facility staff checked the door alarm by having another resident wearing a WanderGuard bracelet approach the door. It was determined that the alarm was not functioning properly. 3. Record review for resident #81 revealed an annual MDS, dated [DATE] assessed the resident as having short and long term memory problems, persistent anger with self and others, repetitive movements, verbally abusive and resists care. [DIAGNOSES REDACTED]. He was assessed on the Elopement/Wandering Risk Assessment as being ambulatory, wandering with a pre-determined destination and as being confused. Review of the incident/accident form dated 6/09/2009 revealed that resident #81 had removed his WanderGuard bracelet and after a smoke break at 11:45 p.m. on the back porch, he climbed the fence and left the facility. He was seen by a passerby and the police were notified. The passerby directed the police to where the resident was on the road. Resident #81 told the police he had just gotten off the bus and he was returned to the facility. The nursing staff had not seen him since giving him medication at 9:45 p.m. and at the time he was returned by the police were not aware that resident #81 was not in the building. Review of the Nurses' Notes dated 2/28/2010 at 5:30 p.m. revealed that the resident could not be found for the supper meal. The resident was found on Highway 80 trying to thumb a ride to the Interstate. The police returned resident to the facility. The resident had again removed the WanderGuard bracelet and gone out the back porch and on this occasion, under the fence. Interview with LPN ""DD"" on 6/24/2010 at 1:00 p.m. revealed that they just try to watch the residents the best they can and redirect them to activities. There were no interventions developed to prevent this resident from leaving the building again. 4. Resident ""E"" was admitted to facility on 8/03/2009 from another facility and had a history of [REDACTED]. The resident had severe speech limitations (only one (1) or two (2) words) and was assessed as rarely understands what is being said. The resident was observed to be ambulatory with an unsteady gait. Resident ""E"" had a current physician order [REDACTED]. The resident was assessed as having the potential for elopement due to past history and a WanderGuard was place on the resident on Admission to the facility. Resident ""E""s care plan was updated on 4/20/2010 to include visual checks, WanderGuard and potential for elopement due to attempts to climb the (back yard) fence. The resident was assessed as resisting care on 1/18/2010 and 4/20/2010 on the Minimum Data Sets (MDS). Record review of the Social Worker notes dated 10/01/2009 revealed the resident was frequently going out the smoke room door, going thru other resident's rooms, climbed through other resident's windows. SW Notes included behaviors of hiding in closets, wandering into other's rooms and getting into their beds. The resident was to wear a WanderGuard bracelet. An interview with the resident's responsible party on 6/24/2010 at 11:00 a.m. revealed that he/she had been notified by the facility that the resident had climbed out of a window to the outside and was attempting to get under the (back yard) fence. The responsible party could not remember exactly when this occurred. An interview with the Administrator on 6/24/2010 at 10:30 a.m. revealed she was not aware of the resident climbing through windows. An interview with the Social Worker on 6/24/2010 at 12:55 p.m. revealed that she thought the note was an error and should have documented that the resident had not climbed through a window to the outside, but rather would attempt to enter the building from outside windows. She agreed that the documentation indicated something different. 5. An observation on 6/22/2010 at 8:30 a.m. revealed a male resident was sitting in the area, at the Nurses Station, near the door to the smoking porch when a resident wearing a WanderGuard exited to the smoking porch setting off the door alarm. No staff were in the area, and the male resident yelled to staff at the end of the hall, ""I'll get it"", then walked over to the WanderGuard system at the door, reached under the box and turned off the alarm. The situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to have been removed on June 26, 2010 but, the associated noncompliance continues in order to ensure the following are maintained by the facility: all residents identified as having wandering and elopement behaviors have an effective plan of care that ensures ongoing safety; that all direct care staff are inserviced on revised policy and procedures related to resident elopement; new staff position of Safety Tech is filled and implemented; all WanderGuard systems are functional and monitored on a daily basis and back yard fencing and gate repairs are conducted. Therefore, the scope and severity of the deficiency was reduced from a ""K"" level to an ""E"" level when the facility implemented the following plan of correction: 1. All residents identified as having wandering and elopement behaviors were reassessed and care plans were revised to include individualized interventions based on the assessment. All remaining residents were assessed to ensure accuracy of previous determinations. Completion date: June 23, 2010 2. A development of an Elopement Alert Notice book with resident photographs was placed at each nursing station. Completion Date: June 24, 2010 3. Repair of the malfunctioning WanderGuard system on Station II. Completed: June 23, 2010. 4. All residents wearing WanderGuard had them tested to be sure they were working consistently. Completed: June 22, 2010. 5. Daily monitoring of the doors for WanderGuard and key pad functioning to be conducted by the Maintenance or Housekeeping Supervisors. A tool was developed to document the results of the monitoring. Completed: June 23, 2010. 6. 24 hour monitor (staff person) in place until permanent repairs to areas of back yard fence, gate, and resident windows. (Authorization of repairs was obtained with a completion date of 7/15/2010) Completed date for monitor position hire: June 23, 2010. 7. Revision to policy: Elopement Prevention Interventions for Residents Deemed at Risk. An inservice was conducted that included risk factors, elopement behaviors, monitoring of residents, new tool for documenting monitoring and the revised policy. Five inservices were conducted from June 22-25, 2010. The remaining 21 staff not available for inservice will have training on new policy prior to returning to work. 8. A Quality Assurance meeting was held with the Administrator, all department heads and the facility's Medical Director to develop long term interventions, review policy changes and new documentation tools. Completed: June 25, 2010.",2015-03-01
10027,TWIN VIEW HEALTH AND REHAB,115540,211 MATHIS AVENUE,TWIN CITY,GA,30471,2010-06-26,280,K,1,1,CKH411,"Based on record review and staff interview, the facility failed to revise the care plan to include the determination of the frequency the resident should be monitored and to designate the staff person that would be responsible for the monitoring of three (3) residents (# 114, 81 and 85) from twenty-six (26) sampled residents. A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to exist from June 3, 2010 until June 26, 2010 when the facility submitted an acceptable plan of correction. Findings include: 1. Record review for resident # 114 revealed that a care plan had been developed on 4/19/2010 which identified the resident as having elopement behaviors. As identified in the care plan, the resident had the potential for elopement due to frequent threats to leave the facility unescorted. Interventions were added at this time for placing and checking the WanderGuard bracelet and encourage the resident to ventilate her feelings regarding placement in the Facility. On 6/4/2010, 6/11/2010 and on 6/19/2010, the care plan was updated after the resident had eloped from the facility over the back fence on these dates. Two additional interventions that were added after these dates were to perform visual checks of the resident and to monitor the resident when she was on the back porch, but failed to include the frequency of monitoring and to designate the staff person responsible for conducting the monitoring. 2. Record review for resident # 85 revealed a care plan dated 3/19/2009 and on 3/09/2010 had identified the resident as having the potential for elopement due to a history of leaving the facility unescorted and having a history of climbing the fence. This care plan had also been updated on 9/08/2009 and 02/27/2010 after the resident eloped from the facility. An intervention to monitor the resident and a determination of the frequency and assignment of staff to conduct the monitoring was not added as an intervention of the plan even after the two elopements. In an interview with the Care Plan Coordinator on 6/26/2010 at 9:30 a.m. she stated that visual monitoring had been done on this resident but had not been added to the care plan as an intervention and should have been. 3. Record review revealed resident #81 had eloped from the facility on 6/09/2009 and 2/28/2010. Review of the care plan dated 6/10/2010 for the potential for elopement revealed that the staff were to encourage resident #81 to let staff know when he wanted to go outside, to explain the dangers of leaving the facility unattended, to attempt to determine where the resident wanted to go, monitor for increased pacing and check the WanderGuard bracelet every shift. Resident #81 was assessed a being confused and independent with ambulation. There were no interventions that address threat the resident removed their WanderGuard bracelet, or that the resident elopes under and over the back yard fence. Interview with Licensed Practical Nurse (LPN ""BB"") and Licensed Practical Nurse (LPN ""DD"") on 6/24/2010 at 2:30 p.m. revealed that resident #81 was assessed for wandering but the interventions were not relevant to his wandering behavior or mental status. The situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to have been removed on June 26, 2010 but, the associated noncompliance continues in order to ensure the following are maintained by the facility: all residents identified as having wandering and elopement behaviors have an effective plan of care that ensures ongoing safety; that all direct care staff are inserviced on revised policy and procedures related to resident elopement; new staff position of Safety Tech is filled and implemented; all WanderGuard systems are functional and monitored on a daily basis and back yard fencing and gate repairs are conducted. Therefore, the scope and severity of the deficiency was reduced from a ""K"" level to an ""E"" level when the facility implemented the following plan of correction: 1. All residents identified as having wandering and elopement behaviors were reassessed and care plans were revised to include individualized interventions based on the assessment. All remaining residents were assessed to ensure accuracy of previous determinations. Completion date: June 23, 2010 2. A development of an Elopement Alert Notice book with resident photographs was placed at each nursing station. Completion Date: June 24, 2010 3. Repair of the malfunctioning WanderGuard system on Station II. Completed: June 23, 2010. 4. All residents wearing WanderGuard had them tested to be sure they were working consistently. Completed: June 22, 2010. 5. Daily monitoring of the doors for WanderGuard and key pad functioning to be conducted by the Maintenance or Housekeeping Supervisors. A tool was developed to document the results of the monitoring. Completed: June 23, 2010. 6. 24 hour monitor (staff person) in place until permanent repairs to areas of back yard fence, gate, and resident windows. (Authorization of repairs was obtained with a completion date of 7/15/2010) Completed date for monitor position hire: June 23, 2010. 7. Revision to policy: Elopement Prevention Interventions for Residents Deemed at Risk. An inservice was conducted that included risk factors, elopement behaviors, monitoring of residents, new tool for documenting monitoring and the revised policy. Five inservices were conducted from June 22-25, 2010. The remaining 21 staff not available for inservice will have training on new policy prior to returning to work. 8. A Quality Assurance meeting was held with the Administrator, all department heads and the facility's Medical Director to develop long term interventions, review policy changes and new documentation tools. Completed: June 25, 2010. Cross refer to F323",2015-03-01
10028,TWIN VIEW HEALTH AND REHAB,115540,211 MATHIS AVENUE,TWIN CITY,GA,30471,2010-06-26,520,K,1,1,CKH411,"Based on record review and staff interview the facility failed to have an effective Quality Assurance process that identified elopement as an issue for residents needing supervision and or monitoring to ensure their safety, that developed effective interventions and determined the effectiveness of any interventions that were developed. The facility failed to identified a significant number of residents with wandering behaviors or to identify commonalities in how residents were leaving the facility with staff awareness. This effected seventeen (17) residents currently residing in the facility with elopement behaviors. A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to exist from June 3, 2010 until June 26, 2010 when the facility submitted an acceptable plan of correction. Findings include: An interview on 6/25/2010 at 2:15 p.m. with the Administrator revealed she did not remember if elopement was addressed in the most recent Quality Assurance (QA) meeting that took place on 6/16/2010. Interview at that time revealed she was not aware of the number of, or the frequency of residents leaving the facility without staff being aware. She further commented that when you look back at the year, there had been more elopements than she realized. Record review of the summary documentation of the QA meetings conducted in the past year revealed wandering or elopement was listed as a topic twice but no trending, new interventions or factors contributing to elopement from the facility were discussed. Although the back yard fence was a frequent source of elopement by residents, no solutions were developed. A lack of sufficient outside sources for psychiatric referrals was listed but no solutions developed. The Administrator was aware that the back yard fence, gate and roof sections have been problematic with residents going over and under the fence and that the fence needed repairs. Interview with the Medical Director on 6/25/2010 at 2:30 p.m. revealed he attended the QA meetings. The situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to have been removed on June 26, 2010 but, the associated noncompliance continues in order to ensure the following are maintained by the facility: all residents identifies as having wandering and elopement behaviors have an effective plan of care that ensures ongoing safety; that all direct care staff are inserviced on the revised policy and procedures related to resident elopement; new staff position of Safety Tech is filled and implemented; all WanderGuard systems are functional and monitored on a daily basis and back yard fencing and gate repairs are conducted. Therefore, the scope and severity of the deficiency was reduced from a ""K"" level to an ""E"" level when the facility implemented the following plan of correction: 1. All residents identified as having wandering and elopement behaviors were reassessed and care plans were revised to include individualized interventions based on the assessment. All remaining residents were assessed to ensure accuracy of previous determinations. Completion date: June 23, 2010. 2. A development of an Elopement Alert Notice book with resident photographs was placed at each nursing station. Completion date: June 24, 2010 3. Repair of the malfunctioning WanderGuard system on Station II. Completed: June 23, 2010. 4. All residents wearing WanderGuard had them tested to be sure they were working consistently. Completed: June 22, 2010. 5. Daily monitoring of the doors for WanderGuard and key pad functioning to be conducted by the Maintenance or Housekeeping Supervisors. A tool was developed to document the results of the monitoring. Completed: June 23, 2010. 6. 24 hour monitor (staff person) in place until permanent repairs to areas of back yard fence, gate, and resident windows. (Authorization of repairs was obtained with a completion date of 7/15/2010) Completed date for monitor position hire: June 23, 2010. 7. Revision to policy: Elopement Prevention Interventions for Residents Deemed at Risk. An inservice was conducted that included risk factors, elopement behaviors, monitoring of residents, new tool for documenting monitoring and the revised policy. Five inservices were conducted from June 22-25, 2010. The remaining 21 staff not available for inservice will have training on new policy prior to returning to work. 8. A Quality Assurance meeting was held with Administrator, all department heads and the facility's Medical Director to develop long term interventions, review policy changes and new documentation tools. Completed: June 25, 2010. Cross refer to F323.",2015-03-01
10029,TWIN VIEW HEALTH AND REHAB,115540,211 MATHIS AVENUE,TWIN CITY,GA,30471,2010-06-26,318,D,0,1,CKH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to provide services to improve or prevent a potential decline in range of motion for one (1) resident ('S'). The sample size was twenty-six (26) residents. Findings include: On 6/25/2010 at 10:10 a.m., resident 'S' was noted to be holding a carton of milk with their left hand. The resident's right hand was clinched shut in a fist, and when asked, the resident was unable to extend the fingers of this hand. No splint device was in use, and the resident stated they were currently not receiving any therapy. On subsequent observations on 6/25/2010 at 2:30 p.m., and 6/26/2010 at 8:45 a.m., 11:00 a.m., and 1:10 p.m., the resident was noted in a wheelchair with their right hand clenched, and no splint device in place. On 6/25/2010 at 2:20 p.m., Restorative Certified Nursing Assistant (CNA) stated that she had not received a referral from the therapist, nor provided any Restorative services for resident 'S' in past 4 months or more. She added that at one time the resident was being seen for a splint to their hand, but that the splint had been missing for probably 7 months now. On 6/25/2010 at 2:30 p.m., resident 'S' stated they used to have a splint, but didn't know where it was, and that they hadn't worn it for over 6 months. They added that the splint seemed to help, and that they would like to have it back. Additionally, the resident stated that at one time he/she was given a rubber ball to squeeze, but that they hadn't done that for a long time now. On 6/26/2010 at 10:45 a.m., Occupational Therapist (OT) 'GG' stated she discharged the resident to Restorative services in March, and remembered educating the Restorative Aide about what needed to be done, including range of motion (ROM) and splint application. On 6/26/2010 at 11:30 a.m., Licensed Practical Nurse (LPN) stated she was not aware of the referral made by therapy for Restorative services in March. She provided a ""Nursing Rehab/Restorative"" flow sheet for the resident for service dates of 2/8/2010 to 3/31/2010, with approaches to encourage participation in passive ROM to the right hand and elbow. Review of the physician's progress notes dated 3/12/2010 and 4/16/2010 noted resident 'S' had [DIAGNOSES REDACTED]. Review of Physical Therapy (PT) progress notes with service dates of 3/09/2010 through 3/16/2010 noted the resident had met goals of transferring to/from the wheelchair, and that caregiver education was initiated with the CNA's focusing on transfer safety. There was no mention of therapy services to the right hand, and interventions did not include a splint device. LPN 'GG' verified that there was no documentation of the resident receiving services after 3/31/2010. A Rehabilitation and Restorative Nursing Program dated 02/06/2009 contained goals of performing gentle ROM exercises to the right upper extremity, and implementing a right hand/wrist orthosis daily as tolerated.",2015-03-01
10030,TWIN VIEW HEALTH AND REHAB,115540,211 MATHIS AVENUE,TWIN CITY,GA,30471,2010-06-26,490,K,1,1,CKH411,"Based on observation, record review and staff interview the facility failed to be administered in a manner that ensured the safety of residents with wandering and elopement behaviors. The failure to implement effective interventions to address residents leaving the facility with staff being aware and to maintain a safe environment, specifically, the back yard fenced area effected seventeen (17) residents identified by the facility as having a high risk for their safety based on elopement behaviors. Therefore, a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to exist from June 3, 2010 until June 26, 2010 when the facility submitted an acceptable plan of correction. Findings include: During interview with the Administrator on 6/25/2010 at 10:00 a.m. revealed she was aware of problems with elopement and that this had been an on-going problem. The residents in this facility were described as unique and do not have the same issues as in other facilities. ""If these residents decide to leave you can not prevent it"". Interventions that were put into place for (named) resident (#114) were not consistently followed. The resident was difficult to keep track of. She indicated that they placed one-to-one supervision on the resident after the second elopement but they stopped after a couple of days and the supervision should have been on going. Interview with the DON and the Administrator on 6/25/2010 at 2:00 p.m. and 4:00 p.m. revealed neither was aware that residents knew how to and were turning off the WanderGuard system when an alarm would sound. Nor were they aware that staff were in visual site of the area when this was occurring. An interview on 6/25/2010 at 2:15 p.m. with the Administrator revealed that when they looked back at the whole year of occurrences, the number of elopements was more than they realized. The situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to have been removed on June 25, 2010 but, the associated noncompliance continues in order to ensure the following are maintained by the facility: all residents identified as having wandering and elopement behaviors have an effective plan of care that ensures ongoing safety; that all direct care staff are inserviced on revised policy and procedures related to resident elopement; new staff position of Safety Tech is filled and implemented; all WanderGuard systems are functional and monitored on a daily basis and back yard fencing and gate repairs are conducted. Therefore, the scope and severity of the deficiency was reduced from a ""K"" level to an ""E"" level when the facility implemented the following plan of correction: 1. All residents identified as having wandering and elopement behaviors were reassessed and care plans were revised to include individualized interventions based on the assessment. All remaining residents were assessed to ensure accuracy of previous determinations. Completion date: June 23, 2010 2. A development of an Elopement Alert Notice book with resident photographs was placed at each nursing station. Completion Date: June 24, 2010 3. Repair of the malfunctioning WanderGuard system on Station II. Completed: June 23, 2010. 4. All residents wearing WanderGuards had them tested to be sure they were working consistently. Completed: June 22, 2010. 5. Daily monitoring of the doors for WanderGuard and key pad functioning to be conducted by the Maintenance or Housekeeping Supervisors. A tool was developed to document the results of the monitoring. Completed: June 23, 2010. 6. 24 hour monitor (staff person) in place until permanent repairs to areas of back yard fence, gate, and resident windows. (Authorization of repairs was obtained with a completion date of 7/15/2010) Completed date for monitor position: June 23, 2010. 7. Revision to policy: Elopement Prevention Interventions for Residents Deemed at Risk. An inservice was conducted that included risk factors, elopement behaviors, monitoring of residents, new tool for documenting monitoring and the revised policy. Five inservice were conducted from June 22-25, 2010. The remaining 21 staff not available for inservice will have training on new policy prior to returning to work. 8. A Quality Assurance meeting was held with Administrator, all department heads and the facility's Medical Director to develop long term interventions, review policy changes and new documentation tools. Completed: June 25, 2010. Cross refer to F323",2015-03-01
10031,PEACHBELT HEALTH & REHAB CTR,115552,801 ELBERTA RD,WARNER ROBINS,GA,31093,2015-01-15,468,E,0,1,5KY411,"Based on observation and staff interview the facility failed to ensure that four (4) of thirty one (31) resident bathrooms and in one (1) of two (2) shower room grab bars were securely attached to the wall. Findings include: During the initial tour of the facility on 1/12/2015 at 11:30 a.m. the bathrooms in room 206 and room 207 were observed to have loose grab bars next to the toilet and were not securely attached to the wall. During the initial tour of the facility on 1/12/2015 at 11:30 a.m. in resident room 225 and the main shower room on the 200 hall, revealed the grab bars next to the toilet were loose and not secured to the wall. On 1/13/2015 at 9:40 a.m. observation of the bathroom in room 222 revealed the grab bar next to the toilet was observed to be loose and not securely attached to the wall. Review of weekly Assist Bar Rounds for October 2014 through January 2015, provided by the facility, revealed documentation of weekly checks of assist bars in rooms 206, 207, 222, 225 and the 200 hall shower room as well as all resident rooms and the two shower rooms. During interview with the Maintenance Director on 1/15/2015 at 3:30 p.m. he stated the last time prior to 1/12/2015 that he checked the grab bars in the bathrooms in 206, 207, 222, 225 and the 200 hall shower room was on January 5th or 6th. He further stated he checks the bars in all the bathrooms and shower rooms every Monday or Tuesday. The Maintenance Director stated the bars in rooms 206, 207, 222, 225 and the 200 shower room were not loose when he checked them last week on January 5th or January 6th .",2015-03-01
10032,GATEWAY HEALTH AND REHAB,115560,3201 WESTMORELAND ROAD,CLEVELAND,GA,30528,2011-11-03,328,D,1,0,EL2111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Emergency Medical Services document review, and family interview, the facility failed to clarify the respiratory care needs, related to oxygen administration, for one (1) resident (""A""), who was a new admission to the facility, from a survey sample of four (4) residents. Findings include: Record review for Resident ""A"" revealed a Skilled Nursing Progress Note of 08/12/2011 at 4:30 p.m. which documented the resident's admission to the facility, having been transported via ambulance. This Note documented that at the time of admission, the resident's oxygen saturation level was ninety-two (92) percent. The resident's admission physician's orders [REDACTED]. The admission orders [REDACTED]. Review of the admission Skilled Nursing Note of 08/12/2011 at 4:30 p.m. documented the respiratory concern that the resident needed oxygen per cannula as-needed. However, as indicated above, there was no admission order for oxygen administration, and there was no evidence to indicate that nursing staff made an attempt to clarify if the resident needed oxygen on an as-needed basis or on a continuous basis. A Skilled Nursing Progress Notes entry of 08/12/2011 at 6:30 p.m., two hours after the resident's admission to the facility, documented that a family member of Resident ""A"" came to the facility and informed facility staff that the resident had been on oxygen for the past five years, and documented that oxygen was started at that time at the family's request. This Note also documented that the family member called Emergency Medical Services (EMS) at that time. A Telephone Orders sheet of 08/12/2011 at 6:45 p.m. specified a physician's orders [REDACTED]. The Emergency Medical Services Prehospital Care Report dated 08/12/2011 documented that upon arrival at the nursing facility, at 18:35 p.m. the resident's oxygen saturation was documented at eighty (80) percent and that the resident was placed on oxygen at 3 liters per minute, and then increased to four (4) Liters per minute at that time. The resident was transferred back to the hospital at that time. During an interview with the family member of Resident ""A"" conducted on 11/03/2011 at 9:30 a.m., this family member stated that the resident had been on continuous home oxygen for years due to [MEDICAL CONDITION] and [MEDICAL CONDITION].",2015-03-01
10033,GATEWAY HEALTH AND REHAB,115560,3201 WESTMORELAND ROAD,CLEVELAND,GA,30528,2010-10-20,309,D,0,1,ZHH511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that physician's orders for medication administration were followed for three residents (#1, #3 and #12) from a total sample of 14 residents. Findings include: 1. According to a 10/13/10 laboratory test results form, resident #12 had an abnormally low sodium level of 129 on 10/13/10 (normal range was between 135 and 148). On 10/15/10, the physician ordered licensed nursing staff to administer one gram of sodium chloride to the resident every day. However, review of the resident's 10/2010 Medication Administration Record (MAR) revealed that licensed nursing staff failed to transcribe the medication order to the October, 2010 MAR. Therefore, licensed nursing staff failed to administer the sodium chloride to the resident as ordered from 10/15/10 to 10/20/10. On 10/20/10 at 12:25 p.m., the Director of Nursing stated that the medication was available in the medication cart but, licensed nursing staff had failed to administer the medication to the resident as ordered until 9:00 a.m. on 10/20/10. Resident #12 had a [DIAGNOSES REDACTED]. rate was less than 55 beats per minute and/or the resident's systolic blood pressure was less than 110. However, a review of the resident's Medication Administration Records (MARs) for 8/2010, 9/2010 and 10/2010, revealed that licensed nursing staff had not held [MEDICATION NAME] when the resident's systolic blood pressures readings were less than 110. .On 8/9/10 at 5:00 p.m., the resident's systolic blood pressure was 106; on 8/23/10 at 5:00 p.m., the resident's systolic blood pressure was 103; and on 8/29/10 at 5:00 p.m., the resident's systolic blood pressure was 94. On 9/1/10 at 9:00 a.m., the resident's systolic blood pressure was 108. On 9/1/10 at 5:00 p.m., the resident's systolic blood pressure was 108; on 9/16/10 at 5:00 p.m., the resident's systolic blood pressure was 83; on 9/19/10 at 5:00 p.m., the resident's systolic blood pressure was 100; on 9/24/10 at 5:00 p.m., the resident's systolic blood pressure was 90; on 9/26/10 at 5:00 p.m., the resident's systolic blood pressure was 98; and on 9/29/10 at 5:00 p.m., the resident's systolic blood pressure was 92. On 10/6/10 at 5:00 p.m., the resident's systolic blood pressure was 100; on 10/7/10 at 5:00 p.m., the resident's systolic blood pressure was 76; on 10/8/10 at 5:00 p.m., the resident's systolic blood pressure was 100; and on 10/11/10 at 5:00 p.m., the resident's systolic blood pressure was 96. 2. Resident #1 was admitted with [DIAGNOSES REDACTED]. The 10/15/10 nurse's notes documented that medications were held for 3:00 p.m. (nutritional supplement), 5:00 p.m. [MEDICATION NAME] (for hypertension), and 9:00 p.m. [MEDICATION NAME] (appetite stimulant) and, [MEDICATION NAME] (sleep enhancer) because the resident was asleep. That documentation was substantiated by the licensed nurse's documentation on the resident's MAR for 10/15/10. However, there was not a physician's order to hold the resident's medication. There was no evidence that nursing staff had notified the physician that those medications had not been given as ordered. In an interview on 10/20/10 at 1:00 p.m., the Director of Nursing stated that she would have expected the physician to be notified if a medication was held. 3. Resident #3 was admitted with [DIAGNOSES REDACTED]. The resident had a 10/12/10 physician's order for licensed nursing staff to administer 0.1 milligrams of [MEDICATION NAME] if the resident's systolic blood pressure was over 180. Licensed nursing staff documented on the MAR on 10/17/10 at 11:00 a.m. that the resident's systolic blood pressure was 188. However, there was no evidence that the [MEDICATION NAME] had been administered as ordered. During an interview on 10/19/10 at 9:50 a.m., licensed nurse ""AA"" confirmed that nursing staff had failed to administer the medication as ordered.",2015-03-01
10034,MEADOWBROOK HEALTH AND REHAB,115561,4608 LAWRENCEVILLE HIGHWAY,TUCKER,GA,30084,2011-11-15,311,D,1,0,21V711,"Based on medical record review, resident interview, staff interview, and Complaint/Grievance Report review, the facility failed to ensure that one (1) resident (""B""), who had been assessed by the facility as being totally dependent on staff for toilet use, on the total survey sample of five (5) residents, received the appropriate services to maintain or improve his ability to toilet. Findings included: Review of the medical record for Resident ""B"" revealed the September 2011 Minimum Data Set assessment indicated that the resident was totally dependent on staff for toilet use, requiring the physical assistance of one (1) person for toileting. During an interview conducted on 11/15/2011 at 3:45 p.m., Resident ""B"" stated that most of the time, when he utilized the call light to request assistance, staff would initially respond, turn off the call light, and state they would be back in a few minutes, but then he would end up having to wait one (1) to two (2) hours before getting help. He specifically stated that he had experienced a delay of two (2) hours after requesting help to go to the bathroom. He stated that he preferred to go to the bathroom for toileting, but had to utilize the bedpan and to clean himself due to the delay in obtaining assistance. He further stated that the facility had made an effort to resolve the issue, but that the problem had not been solved. Review of the Complaint/Grievance Report revealed an October 2011 entry indicating that Resident ""B"" had complained about staff not answering the call light. During an interview conducted on 11/15/2011 at 4:45 p.m., the Administrator acknowledged that there had been resident grievances about staff call light response and that the facility was in the process of surveying residents regarding this issue.",2015-03-01
10035,CRISP REGIONAL NSG & REHAB CTR,115568,902 BLACKSHEAR ROAD,CORDELE,GA,31015,2010-05-27,246,D,0,1,VSOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to equip the wheelchair to accommodate the positioning needs for one resident (#13) from a total sample of 24 residents. Findings include: Resident #13 had [DIAGNOSES REDACTED]. Licensed nursing staff documented on the 5/5/10 Nurse's Monthly Progress Note sheet, which covered the resident's status from 4/5/10 to 5/5/10, that the resident was totally dependent on staff for transfers and locomotion. The resident was observed seated in a wheelchair without any foot rest supports on 5/25/10 during the initial tour, and 12:15 p.m., 2:20 p.m. and 4:35 p.m., and on 5/26/10 at 7:00 a.m. On 5/26/10 at 12:55 p.m., the resident was seated in a wheelchair with foot rest supports attached. However, the foot rests were too long and did not support the resident's feet. During all of the observations, both of the resident's feet were dangling down. His/Her feet were not touching the floor. In an interview on 5/26/10 at 9:00 a.m., rehabilitation aide ""CC"" said that the resident did not propel the wheelchair with his/her feet.",2015-03-01
10036,CRISP REGIONAL NSG & REHAB CTR,115568,902 BLACKSHEAR ROAD,CORDELE,GA,31015,2010-05-27,502,D,0,1,VSOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to obtain laboratory tests as ordered by the attending physician for two residents (#11 and #14) from a total sample of twenty four residents. Findings include: 1. Resident #14 had a 7/3/09 physician's orders [REDACTED]. However, there was no evidence that it had been done every three months. The most recent test had been done on 1/5/10. Licensed nursing staff failed to obtain a HgbA1c in April 2010. During an interview on 5/27/10 at 1:15 p.m., the Director of Nursing confirmed that licensed nursing staff had failed to obtain the laboratory test until 5/26/10, after surveyor inquiry. 2. Resident #11 had a 4/28/10 physician's orders [REDACTED]. However, licensed nursing staff failed to obtain the CBC as ordered. During an interview on 5/28/10 at 2:15 p.m.,. the unit manager confirmed that the CBC laboratory test had not been done.",2015-03-01
10037,CRISP REGIONAL NSG & REHAB CTR,115568,902 BLACKSHEAR ROAD,CORDELE,GA,31015,2010-05-27,282,D,0,1,VSOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to implement the plan of care to apply an alarm when up in wheelchair for one resident(#13) at risk for falls from a total sample of 24 residents. Findings include: Resident #13 had a history of [REDACTED]. On 4/8/10, the licensed nursing staff added a care plan intervention to apply an alarm when the resident was up in the wheelchair. However, during observations on 5/25/10 at 12:15 p.m., 2:20 p.m. and 4:35 p.m., on 5/26/10 at 7:00 a.m., and 12:05 p.m., and on 5/27/10 at 7:25 a.m., the resident was up in a wheelchair but, there was not an alarm in place. During an interview on 5/27/10 at 12:15 p.m., the Director of Nursing said that she was unaware of the plan for the resident to have had an alarm in place when he/she was up in the wheelchair. See F323 for additional information regarding resident #13.",2015-03-01
10038,CRISP REGIONAL NSG & REHAB CTR,115568,902 BLACKSHEAR ROAD,CORDELE,GA,31015,2010-05-27,323,D,0,1,VSOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to implement the plan of care to apply an alarm when up in a wheel chair for one resident (#13) with a risk for falls from a total sample of twenty four residents. Findings include: Resident #13 had a history of [REDACTED]. The resident was identified on the care plan since at least 07/14/09 as being a high risk for falls due to impulsiveness and fidgeting to rise from the wheelchair. On 4/8/10, the licensed nursing staff added a care plan intervention to apply a chair alarm when the resident was in the wheelchair. However, it was observed on 5/25/10 at 12:15 p.m., 2:20 p.m. and 4:35 p.m., on 5/26/10 at 7:00 a.m. and 12:05 p.m., and on 5/27/10 at 7:25 a.m., that staff had not applied the chair alarm when the resident was in a wheelchair. During an interview on 5/27/10 at 12:15 p.m., the Director of Nursing said that she was unaware that the resident was supposed to have had a chair alarm in place when he/she was up in the wheelchair.",2015-03-01
10039,CRISP REGIONAL NSG & REHAB CTR,115568,902 BLACKSHEAR ROAD,CORDELE,GA,31015,2010-05-27,157,D,0,1,VSOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and physician interview, it was determined that the facility failed to ensure that the physician was consulted about a significant change in the physical condition of one resident (#3) from a total sample of 24 residents. Findings include: Resident #3 had [DIAGNOSES REDACTED]. The resident was tube fed and was given Milk of Magnesia daily. The treatment nurse had documented on the 2/8/10 at 1:26 p.m. nurses note that resident #3's gastrostomy tube had become dislodged. The treatment nurse inserted a new catheter tube into the gastrostomy site and verified placement by auscultation and checking for gastric residual. The treatment nurse documented that she had observed the resident's stomach to be large at that time and had notified the resident's nurse who might want to measure and monitor it. However, there was no evidence that the resident's physician was consulted about the reported increase in size of the resident's stomach. Licensed nursing staff had documented on the 2/27/10 at 7:30 p.m. nurses notes that the resident was shaking, sweating, and had a swollen stomach. Licensed nursing staff documented that placement of the resident's gastrostomy tube could not be verified at that time. The resident's physician was consulted and sent the resident to the emergency room . The resident was admitted to the hospital with [REDACTED]. Although licensed nursing staff had documented that the resident was monitored for complications related to his/her gastrostomy tube before and after 2/8/10, i.e., bowel movements monitored every shift, gastric residual checks every four hours and gastrostomy tube placement verifications every shift, there was no evidence that nursing staff had consulted the resident's physician about the increase in size of his/her stomach on 2/8/10 or of any monitoring of its size prior to 2/27/10. On 5/27/10 at 3:10 p.m., the resident's physician stated that licensed nursing staff's failure to consult him about the increase in size of the resident's stomach on 2/8/10 did not result in the resident's 2/27/10 admission to the hospital or subsequent [MEDICAL CONDITION]. However, the physician stated that he did expect licensed nursing staff to consult him about any increase in size of the resident's stomach and any other changes in the resident's condition.",2015-03-01
10040,CRISP REGIONAL NSG & REHAB CTR,115568,902 BLACKSHEAR ROAD,CORDELE,GA,31015,2010-05-27,280,D,0,1,VSOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to revise the plan of care to include interventions to prevent future fecal impactions for one resident (#1) of 24 sampled residents. Findings include: Resident #1 was at risk for constipation due to immobility. He/She had a physician's orders [REDACTED]. On 3/22/10, a KUB was done on the resident that showed that the resident had a fecal impaction in his/her rectal vault. Licensed nursing staff administered an enema to the resident on 3/23/10 as ordered by his/her physician and had good results. Nursing staff had documented that the resident had bowel movements every day prior to the fecal impaction except on 3/6/10, 3/7/10 and 3/19/10. Nursing staff continued to monitor the resident's bowel movements every shift as ordered by the physician since 7/17/09. However, licensed nursing staff failed to revise the resident's care plan to address the prevention of future fecal impactions.",2015-03-01
10041,CRISP REGIONAL NSG & REHAB CTR,115568,902 BLACKSHEAR ROAD,CORDELE,GA,31015,2010-05-27,314,D,0,1,VSOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's policy and procedure for wound staging, and interview with the treatment nurse, it was determined that the facility failed to ensure that the treatment nurse accurately staged pressure sores for two (#2 and #8) of eight residents with pressure sores from a total sample of 24 residents. Findings include: The U.S. Department of Health and Human Service's Clinical Practice Guideline for ""Pressure Ulcers in Adults"" noted that, when eschar was present, accurate staging of a pressure sore was not possible until the eschar had sloughed or the wound had been debrided. The facility's Policy and Procedure for Wound Staging identifies a Stage II Pressure Sore as a partial-thickness skin loss involving epidermis and/or dermis which is superficial, red/pink wound bed without slough or eschar, and does not include tunneling or undermining. A Stage III pressure sore included full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to underlying fascia, yellow-pink wound bed, may exhibit slough, and may involve tunneling or undermining. A Stage IV pressure sore included full-thickness skin loss, tissue necrosis or damage to muscle, bone or supporting structures, may have tunneling or undermining, and with necrotic tissue (slough or eschar) present which does not allow adequate visualization of the wound bed. 1. Resident #2 had a pressure sore that was unavoidable due to his/her immobility, weight loss and medical [DIAGNOSES REDACTED]. Licensed nursing staff had noted that there was an intact pressure sore on the resident's left heel on 4/16/10. They had obtained a physician's orders [REDACTED]. The treatment nurse documented on the 5/2/10 Wound Evaluation Flow Sheet that the resident had a 1.2 centimeter Stage II open area on his/her left heel that was 10% red and 90% tan in color. Weekly assessments of the pressure sore were done with the last assessment having been done on 5/24/10. On 5/24/10, the treatment nurse documented it as a 1.1 centimeter (cm) by 0.4 cm. Stage II pressure sore that was 10% red and 90% tan in color . On 5/26/10 at 2:05 p.m., during observation of pressure sore treatment, the pressure sore had an approximately 2 cm. by 3 cm. elongated area of eschar on the resident's left heel that extended medially around the heel. The treatment nurse inaccurately stated at that time that the pressure sore was a Stage II. 2. Resident #8 was admitted to the facility on [DATE] with an existing pressure sore on his/her sacrum. On the 11/11/09, 11/16/09, 11/23/09 and 11/30/09 facility's ""Wound Evaluation Flow Sheet"", the treatment nurse assessed the area as a stage II pressure sore on the resident's sacrum with 100% tan colored tissue in the wound bed. On 12/7/09, the treatment nurse continued to document that the pressure sore was a stage II, with 50% red tissue and 50% white tissue in the wound bed and yellow drainage. On 12/14/09, the pressure sore was described as a stage II, 100% white tissue in the wound bed and milk colored drainage. On 1/5/10 and 1/10/10, the treatment nurse described the pressure sore as a stage II with tan and red colored tissue in the wound bed, milk colored drainage, and 0.5 cm of either undermining or tunneling around the wound circumference. On 5/26/10 at 10:10 a.m. the treatment nurse stated that the tan colored tissue in the wound bed was slough. However, according to the facility's policy for wound staging, the presence of slough in the wound should have caused nursing staff to stage the pressure sore as a III not a II.",2015-03-01
10042,CRISP REGIONAL NSG & REHAB CTR,115568,902 BLACKSHEAR ROAD,CORDELE,GA,31015,2010-05-27,363,E,0,1,VSOI11,"Based on observations, review of the approved planned menus and staff interview, it was determined that the facility failed to follow the planned menu at one lunch served to 91 residents in a sample of three lunch meals observed from 5/25/10 through 5/27/10. Findings include: The facility's approved menu for lunch on 5/25/10 planned for cranberry glazed ham or Swiss steak with gravy were to be served to the residents. However, only the 19 residents on a mechanical soft diet were served ham. Dietary staff failed to follow the approved menu for the other 73 residents who were served pork loin instead of ham. The dietary manager said on 5/25/10 at 3:40 p.m. that the hospital kitchen supplied and prepared the meat served to all of the residents. She said that the hospital kitchen did not have enough glazed ham to serve all of the residents, so the hospital substituted pork loin for the ham. She said that she was not notified in advance about that change in the planned menu. The facility's planned menu for 5/25/10 included serving residents on a pureed diet 2/12 to 3 ounces of a baked sweet potato as a main side dish. Carrots were listed on the planned menus as an alternate. However, none of the seventeen residents on a pureed diet were served any sweet potato as planned but were served carrots, the substitute.",2015-03-01
10043,CRISP REGIONAL NSG & REHAB CTR,115568,902 BLACKSHEAR ROAD,CORDELE,GA,31015,2010-05-27,281,D,0,1,VSOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide information from the clinical record requested by the attending physician regarding current the medication regimen for one resident (#11), from a total sample of 24 residents. Findings include: Resident #11 had an elevated [MEDICAL CONDITION] stimulating hormone (TSH) level of 7.54 on 3/29/10. Upon review of the results of the laboratory test (presumably on 3/29/10), the physician requested that the facility fax the resident's medication sheet to his office. However, there was no evidence that the facility sent the resident's medication sheet to his/her physician as requested for review or followed up with the physician about the abnormal laboratory test results. The consultant pharmacist's 4/22/10 drug regime review identified the resident's elevated TSH level. On 5/11/10, in response to the consultant pharmacist's report, the physician ordered a new medication to address that elevated level of TSH. On 5/28/10 at 2:15 p.m., the unit manager stated that there was not any follow up communication about the elevated TSH with the physician after 3/29/10 until his 5/11/10 response to the pharmacist's 4/22/10 recommendation.",2015-03-01
10044,CRISP REGIONAL NSG & REHAB CTR,115568,902 BLACKSHEAR ROAD,CORDELE,GA,31015,2010-05-27,325,D,0,1,VSOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review, it was determined that the facility failed to ensure that the registered dietician's (RD) recommendation was communicated to the physician for one resident experiencing weight loss (#15), and failed to serve Ensure with meals as ordered for one resident (#8) at risk for weight loss, of 11 residents reviewed with weight loss, from a total sample of 24 residents. Findings include: 1. Resident #8 had [DIAGNOSES REDACTED]. According to his/her 12/1/09 care plan, licensed nursing staff had identified the resident as being at risk for weight loss. There was a 5/21/10 physician's orders [REDACTED]. However, it was observed at lunch meals on 5/25/10 at 1:05 p.m., 5/26/10 at 12:30 p.m. and 5/27/10 at 1:40 p.m., that staff failed to serve the Ensure to the resident as ordered. Staff had documented on the resident's diet card that Ensure was to be served with meals. On 5/27/10 at 1:40 p.m., licensed nurse ""BB"" and dietary staff ""AA"" stated that they did not know why Ensure was not served to the resident at lunch. 2. Resident #15 had [DIAGNOSES REDACTED]. On 4/28/10, the Registered Dietician (RD) documented that the resident had experienced a gradual weight loss over a six month period. The registered dietician recommended increasing the Med Pass (nutritional supplement) to 240 cubic centimeters (cc) three times daily. However, a review of the May 2010 Medication Administration Record [REDACTED]. The 5/13/10 nurse's notes revealed that the resident had a very poor appetite. There was no evidence that the physician had been consulted about the recommendation to increase the Med Pass. During an interview on 5/27/10 at 12:45 p.m., the unit manager stated that the RD would fax her recommendations to the physician, and then provide a copy of the recommendations to the unit manager. However, the unit manager stated that she was not aware of the RD's 4/28/10 recommendation to increase the amount of Med Pass.",2015-03-01
10045,CARTERSVILLE HEIGHTS,115571,78 OPAL STREET,CARTERSVILLE,GA,30120,2011-11-21,314,D,1,0,Q0ZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide the necessary treatment for [REDACTED].#4), of six (6) sampled residents having pressure sores, on a total survey sample of seven (7) residents. Findings include: Record review for Resident #4 revealed a Care Plan entry of 08/25/2011 which identified the resident to have the potential for skin breakdown related to immobility and incontinence. An Interdisciplinary Progress Notes' entry of 11/03/2011 documented that a fluid-filled blister had been noted on the resident's right heel, and that a treatment order had been obtained. The physician's orders [REDACTED]. were to be floated as needed. An updated entry on the resident's Care Plan referenced above documented this new 11/03/2011 physician's orders [REDACTED]. when possible. However, observation of Resident #4 with the treatment nurse in attendance on 11/21/2011 at 12:25 p.m. revealed the resident to be in bed and both heels on the bed, with no means of pressure relief for the heels. During interview with the treatment nurse conducted on 11/21/2011 at 12:25 p.m., the treatment nurse stated that the resident's feet needed to be elevated off the bed and went to get a pillow. During an observation conducted on 11/21/2011 at 12:45 p.m., the nurse was observed placing the pillow under the calves of the resident's legs, however, after placement of the pillow, both heels were observed to be pressing into the mattress. Additional observation of the resident's feet on 11/21/2011 at 2:00 p.m. revealed that the resident's heels were still pressing into the mattress and the pillow was providing no pressure relief. During observation of the resident with the Administrator in attendance on 11/21/2011 at 4:30 p.m., the Administrator acknowledged that the resident's heels were on the mattress and no pressure relief was being provided.",2015-03-01
10046,PRUITTHEALTH - FRANKLIN,115616,360 SOUTH RIVER ROAD,FRANKLIN,GA,30217,2011-11-16,157,D,1,0,29OT11,"Based on record review and staff interview, the facility failed to immediately consult with the physician regarding a significant change in status, as indicated by abnormal laboratory results of a blood test, which also indicated the potential need to change the existing form of treatment for one (1) resident (# 1) from a survey sample of eight (8) residents. Findings include: Review of medical record for Resident # 1 revealed a physician's written order dated 10/21/2011 from the wound center physician that specified to please draw a Complete Blood count (CBC) with diff., a Complete Metabolic Profile (CMP) and a Sedimentation rate. A review of a laboratory report revealed that the blood specimen was collected on 10/25/2011 at 3:10 p.m. and the results were received back from the laboratory on 10/25/2011 at 16:23:10. The laboratory results documented on the report revealed the Blood Urea Nitrogen (BUN) level was high at 82 (normal range, 7-25), Creatinine was high at 4.1 (normal, 0.5-1.6), and the Sedimentation rate was also high at 28 (normal 0-20). Review of previous laboratory results for this resident revealed the BUN level had been 16 on 8/25/2011 and 29 on 9/22/2011. However, further record review revealed no evidence to indicated that the physician was immediately consulted on 10/25/2011, upon the facility's receipt of these significantly abnormal BUN, Creatinine and Sedimentation rate results as documented on the 10/21/2011 laboratory report. Review of the Skilled Daily Nurses Note dated 10/26/2011 at 8:00 a.m. revealed the a licensed staff nurse entered the resident's room and found the resident to be lethargic with slight confusion and not eating breakfast, was aroused by tactile stimuli, and had been noted to have had a low blood pressure on the previous shift. The resident's family member arrived at the facility, the nurse discussed the resident's condition with the family member, and the family member felt the resident needed to go the the hospital. A subsequent Nurse's Note timed at 8:30 a.m. on 10/26/2011 documented the facility called the Emergency Medical Service (EMS) to transfer the resident to the hospital at the request of the family, and documented that EMS arrived and transferred the resident to the hospital. However, further review of the 10/25/2011, 16:23:10 laboratory report referenced above revealed a hand written note by a licensed nurse who signed that the results of this report had been sent to physician via facsimile at 2:30 p.m. on 10/26/2011. A facsimilie verification notice recorded the report was sent at 14:31 on 10/26/2011. Thus, this resulted in an approximate twenty-two (22) hour delay in physician notification after receipt of these laboratory results by the facility, and also indicated that the physician was not notified until after the resident had become lethargic, experienced confusion, and a low blood pressure. During an interview on 11/16/2011 at 2:00 p.m. with Licensed Staff Nurse ""A"", the nurse who had signed the laboratory report, this nurse said that the laboratory results usually came in on the rear unit facsimile machine. This staff nurse, who stated she worked the day shift, was not on duty when the laboratory report arrived in the facility on 10/25/2011 at 4:30 p.m. The nurse further said she sent the resident out the next day almost as soon as she got to work on 10/26/2011. As far as this staff nurse was aware no one else had sent the laboratory results to the physician prior to the time indicated on the verification form, nor had the physician been consulted regarding the resident's abnormal laboratory work.",2015-03-01
10047,PRUITTHEALTH - FRANKLIN,115616,360 SOUTH RIVER ROAD,FRANKLIN,GA,30217,2011-11-16,502,D,1,0,29OT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to obtain the correct ordered laboratory services, but rather ordered the wrong laboratory test, for one (1) resident (#1) from a survey sample of eight (8) residents. Findings include: Record review for Resident #1 revealed a physician telephone orders sheet dated 10/23/2011 which specified an order to draw a [MEDICATION NAME] Trough before the third dose, and a peak after the third dose, of intravenous [MEDICATION NAME]. However, review of the laboratory results revealed that a [MEDICATION NAME] Peak, rather than a [MEDICATION NAME] Troughs, was obtained on 10/21/2011, and that a [MEDICATION NAME] Peak, rather than a [MEDICATION NAME] Peak, was done 10/24/2011.",2015-03-01
10048,PRUITTHEALTH - FRANKLIN,115616,360 SOUTH RIVER ROAD,FRANKLIN,GA,30217,2011-11-16,505,D,1,0,29OT11,"Based on record review and staff interview, the facility failed to promptly notify the attending physician of laboratory results for one (1) resident (# 1) from a survey sample of eight (8) residents. Findings include: Cross refer to F157 for more information regarding Resident #1 Review of medical record for Resident # 1 revealed a physician's written order dated 10/21/2011 from the wound center physician that specified to please draw a Complete Blood count (CBC) with diff., a Complete Metabolic Profile (CMP) and a Sedimentation rate. A review of a laboratory report documented the blood specimen was collected on 10/25/2011 at 3:10 p.m. and the results were received back from the laboratory on 10/25/2011 at 16:23:10. However, further record review revealed no evidence to indicate that the physician was notified on 10/25/2011, upon the facility's receipt of these laboratory results. Further review of the 10/25/2011, 16:23:10 laboratory report referenced above revealed a hand written note by a licensed nurse who signed that the results of this report had been sent to physician via facsimile at 2:30 p.m. on 10/26/2011. A facsimilie verification notice recorded the report was sent at 14:31 on 10/26/2011. Thus, this resulted in an approximate twenty-two (22) hour delay in physician notification after receipt of these laboratory results by the facility. During an interview on 11/16/2011 at 2:00 p.m. with Licensed Staff Nurse ""A"", this staff nurse stated that as far as she was aware, no one else had sent the laboratory results to the physician prior to the time indicated on the verification form.",2015-03-01
10049,GLENVUE HEALTH AND REHABILITATION,115619,721 NORTH VETERANS BLVD,GLENNVILLE,GA,30427,2010-07-01,248,E,0,1,OYQW11,"Based on staff interviews, review of the activity calendar, the comments of 2 of 5 residents in the group interview, it was determined that the facility failed to provide residents with activities of interest on Saturdays and Sundays. Findings include: During the Group Interview (meeting) on 6/30/10 at 10:30 a.m., two (2) of five (5) residents in attendance said that activities scheduled on Saturday and Sunday were not provided. The other residents nodded in agreement with their comment. Both residents said that a variety of activities was not offered during the week. They said that bingo was played too frequently. According to the posted June activity calendar, bingo was scheduled 10 times in 30 days. . Resident ""R"" stated during the Group Interview that the activity staff was not available on the weekends. He/She said that if the group, who was scheduled to conduct an activity during the weekend, were to cancel then there were not any other other weekend activities offered. He/She said that the activity office was locked on the weekends so, residents did not access to activity supplies and could not even get out a checkerboard and play. Activities scheduled on weekends did not occur as scheduled . Only one activity was scheduled each day on the weekends. These activities were supposed to have been provided by volunteer groups from the community. According to the April, June and July activity calendars, the only activities scheduled on Saturdays and Sundays were a church service each day. However, the religious based activities posted on the calendar for Saturdays 6/5 /10 and 6/19/10 had been removed, because the community groups had cancelled. There was not any activity posted on the calendar for Sunday 6/20/10 (Father's Day) but only a sign of ""No Services"". According to the calendar, there were not any activities scheduled for those three days. There were not any activities during the weekend on June 19 and 20, 2010. There were not any activities scheduled on Mother's Day (Sunday, May 9), April 3 (Saturday) and April 4, 2010 (Easter Sunday). In an interview on 7/1/10 at 10:00 a.m., the Administrator stated that the Activity Department staff consisted of the Director and two assistants. He said that the two assistants rotated their work schedules so that someone was present for activities scheduled for later in the day. However, he did not know about that department's weekend coverage. During an interview on 7/1/10 at 10:15 a.m., the Activity Director confirmed the church services scheduled for 6/5/10 and 6/19/10 had been cancelled and no other activities had been provided for the residents on those dates. She stated that the activity staff rotated their work schedule to accommodate weekends if an activity was planned. The Activity Director said that none of the activity department staff was in the facility on the weekend unless an activity was planned. She confirmed that none of the activity staff came to the nursing home when an outside group cancelled their scheduled weekend service and no other activity was offered to the residents.",2015-03-01
10050,GLENVUE HEALTH AND REHABILITATION,115619,721 NORTH VETERANS BLVD,GLENNVILLE,GA,30427,2010-07-01,309,D,0,1,OYQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record reviews, it was determined that the facility failed to administer medications as ordered for one resident (#7) and failed to thoroughly assess a non-pressure wound to evaluate and monitor the effectiveness of treatments for one resident (#1) from a total sample of 22 residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 5/21/10 physical therapy evaluation revealed that the resident had a 2.3 centimeter (cm) by 1.2 cm ""ruptured blister - friction rub"" on his/her left medial foot. The physical therapist described the wound as having a pink and yellow wound bed with ""some"" slough and ""some"" yellow-green drainage. A review of the June 2010 Treatment Record revealed that licensed nursing staff had provided treatment on that wound every seven days as ordered. However, after 5/21/10, there was no evidence that the licensed nursing staff or physical therapist thoroughly assessed the wound to evaluate and monitor the effectiveness of treatments. Observation of the wound on 7/1/10 at 10:40 a.m. revealed an approximately 1/2 inch opened area with red tissue in the wound bed with black discoloration around the lower portion of the wound. 2. Resident #7 had [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. The facility had scheduled it to be put on at 9:00 a.m. and taken off at 9:00 p.m. However, during an observation of medication administration on 6/30/10 at 9:15 a.m., a [MEDICATION NAME] dated 6/29/10 was observed on the resident's left knee. Licensed nursing staff had not removed the [MEDICATION NAME] as scheduled at 9:00 p.m. on 6/29/10. Resident #7 was at risk for constipation because of his/her impaired mobility and frequent use of pain medications. The resident had a physician's orders [REDACTED]. However, during medication administration on 6/30/10 at 9:15 a.m., licensed nursing staff administered 30 cc of [MEDICATION NAME] (a stool softener) to the resident. Licensed nursing staff failed to administer the [MEDICATION NAME] as ordered.",2015-03-01
10051,GLENVUE HEALTH AND REHABILITATION,115619,721 NORTH VETERANS BLVD,GLENNVILLE,GA,30427,2010-07-01,253,B,0,1,OYQW11,"Based on observation and staff interview, it was determined that the facility failed to properly cover exposed pipes behind a bath tube, to cover a hole in the wall in one of five common shower rooms and to maintain the cleanliness of one ice maker. Findings include: Observations of the facility were made on 6/29/10 at 2:30 p.m. C Hall common shower room 1. There was a hole in the wall and plumbing pipes were exposed. 2. There was a hole in the floor. During an interview on 7/1/10 at 9:15 a.m., the Maintenance Supervisor stated that a new bath tub had been installed several weeks ago. He said that he had not completed work to cover those pipes. He said that old plumbing was removed that left the hole in the floor. F Hall The inside of the metal ice machine was rusty.",2015-03-01
10052,GLENVUE HEALTH AND REHABILITATION,115619,721 NORTH VETERANS BLVD,GLENNVILLE,GA,30427,2010-07-01,314,D,0,1,OYQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to consistently monitor the status of two residents' pressure sores (#1 and #20) from a sample of 11 residents with pressure sores of a total sample of 22 residents. Findings include: The U.S. Department of Health and Human Services Clinical Practice Guideline, Number 15: treatment of [REDACTED]. 23). Pressure sores should be reassessed at least weekly in order to monitor the progress or deterioration of the pressure sores. The weekly assessment should include an accurate measurement of the length, width, depth of the ulcer, a description of sinus tracts, tunneling, undermining, necrotic tissue, or exudate and the presence or absence of granulation and [MEDICATION NAME]. The facility's policy and procedure for Pressure Ulcer Prevention and Wound Care documented that, during dressing changes, the ""RN/LPN"" was supposed to assess and document the location, size, color, temperature, [MEDICAL CONDITION], odor, moisture and appearance of skin around the ulcer, stage of the wound, exudate and drainage and pain. However, licensed nursing staff failed to consistently and thoroughly assess the pressure sores on residents #1 and #20. During an interview on 7/1/10 at 12:30 p.m., the Director of Nursing stated that the physical therapy department was responsible for assessing pressure sores when they were treating them. During an interview on 7/1/10 at 11:30 a.m., the physical therapist stated that the nursing staff provided dressing changes alternating with debridement by the therapy department, and that the nursing staff should have been assessing and monitoring the pressure sores. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the 5/19/10, licensed nursing staff identified the resident as having a high risk for developing pressure sores. The 5/21/10 physical therapy evaluation identified a pressure sore on the resident's left lateral foot. During treatment of [REDACTED]."", it was observed that the area was covered with a 1/4 to 1/2 inch dark scab. Although the pressure sore area was identified on 5/21/10 and nursing staff and the physical therapist continued to provide treatment for [REDACTED]. The 5/21/10 physical therapy evaluation identified a 8.0 cm by 1.7 cm by 0.9 cm pressure sore on the resident's right gluteal fold. The physical therapist provided debridement of that pressure sore on the right gluteal fold through 6/14/10. A review of the June 2010 Treatment Record revealed documentation that licensed nursing staff had continued to provide treatment to the pressure sore on the right gluteal fold. However, licensed nursing staff failed to thoroughly assess the pressure sore to include measurements, description of the wound bed and presence or absence of drainage or odor after 6/14/10 until 6/25/10. It was observed on 7/1/10 at 10:40 a.m. that there was less than a 1/4 of an inch open area on the resident's right gluteal fold. The 5/21/10 physical therapy evaluation identified a 1.5 cm by 2.0 cm pressure sore with yellow-green drainage on the resident's left lateral ankle. The physical therapist documented that the depth of the wound was unmeasurable because of the presence of necrotic tissue but, he/she incorrectly staged the pressure sore as a stage III. According to the facility's Pressure Ulcer Prevention and Wound Care policy, if the wound bed could not be visualized because of yellow slough or black necrotic tissue, then the pressure sore could not be staged. On 7/1/10 at 11:30 a.m., the physical therapist stated that the wound bed could not be visualized during the initial evaluation of the resident's left lateral malleolus because of the necrotic tissue in the center and would have been unstageable. According to the physical therapist's progress notes, she debrided the pressure sore on the resident's left lateral ankle on 5/26, 5/28, 5/31, and 6/4/10. A review of documentation on the May 2010 Treatment Record revealed that licensed nursing staff provided treatment on that pressure sore as ordered. However, there was no evidence that licensed nursing staff or physical therapist had consistently and thoroughly assessed the pressure sore to include measurements, a description the wound bed and the presence or absence of drainage and odor after 6/4/10 until 6/25/10. It was observed on 7/1/10 at 10:40 a.m. that there was a 1/4 inch to 1/2 inch scabbed area over the wound on the resident's left lateral ankle. During an interview on 7/1/10 at 11:30 a.m., the physical therapist confirmed that she debrided the pressure sores on the resident's right gluteal fold and left lateral ankle. The physical therapist stated that after her initial evaluation, she only documented about the two pressure sores that she was [MEDICATION NAME]. 2. Licensed nursing staff documented on the 12/21/09 Admission Assessment that resident #20 was admitted to the facility on that date with a 0.5 cm by 0.5 cm abrasion on his/her left buttock. Nursing staff's documentation on the 12/21/09 Treatment Record identified the area as a stage II pressure sore with a pink wound bed. Although the Treatment Records revealed documentation that pressure sore treatment on the resident's left buttock area was provided as ordered until his/her discharge from the facility on 1/20/10, licensed nursing staff failed to thoroughly assess that pressure sore after 12/21/10.",2015-03-01
10053,GLENVUE HEALTH AND REHABILITATION,115619,721 NORTH VETERANS BLVD,GLENNVILLE,GA,30427,2010-07-01,371,F,0,1,OYQW11,"Based on observations and staff interviews, it was determined that the facility failed to ensure the correct amount of sanitizer was used in the dishwasher to effectively sanitize dishware; to ensure that dietary staff knew the correct method to check the amount of sanitizer in the water; and to ensure that the hot water temperature in the dishwasher was monitored to ensure proper cleaning of contaminated equipment. Findings include: During the initial tour of the kitchen on 6/29/10 between 1:30 p.m. and 2:30 p.m., the kitchen supervisor stated that the facility's dishwasher was a low temperature machine but, she did not know the recommended hot water temperature to effectively wash, rinse and sanitize dishware. Another dietary staff member, who was washing dishes, also did not know the recommended hot water temperature of 140 degrees Fahrenheit (F.) for washing and 150 degrees F. for rinsing. At that time, when the dietary staff person, who was washing dishes, checked for the amount of sanitizer in the dishwasher's rinse water, the chemical test strip did not change colors to indicate that any amount of sanitizer was in use. On 6/30/10 at 8:50 a.m., the Director of Nutritional Services said that the serviceman for the dishwasher manufacturer was at the facility. She explained that the serviceman had told her that the problem with dispensing the chemical sanitizer had been an air bubble in the tubing of the sanitizer dispenser which was corrected. However, dietary staff were not able to demonstrate knowledge of how to obtain sanitizer solution for the rinse cycle. During an observation on 6/30/10 at 11:40 a.m., a dietary staff person pushed the rinse agent button on the machine three separate times but, the chemical test strip did not change colors to indicate that any sanitizer had been dispensed. Another dietary staff member, who was operating the dishwasher at that time, pressed a different button on the machine. However, when he checked for the amount of sanitizer in the rinse water, the chemical test strip did not change colors to indicate the presence of any sanitizer solution in the water. He then stopped the rinse cycle and pushed another button on the machine. At that time, it was determined that the correct concentration of chemical sanitizer was in the water.",2015-03-01
10054,GLENVUE HEALTH AND REHABILITATION,115619,721 NORTH VETERANS BLVD,GLENNVILLE,GA,30427,2010-07-01,282,D,0,1,OYQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to ensure that care plan interventions were implemented for two residents (#7 and #18) from a sample of 22 residents. Findings include: 1. Resident #7 had [DIAGNOSES REDACTED]. There was a care plan intervention since 2/22/10 for licensed nursing staff to administer routine medication as ordered by the physician. There was a physician's orders [REDACTED]. The facility had scheduled for it to be put on at 9:00 a.m. and taken off at 9:00 p.m. However, on 6/30/10 at 9:15 a.m., a [MEDICATION NAME] dated 6/29/10 was observed on the resident's left knee. Licensed nursing staff had not removed the patch as ordered. See F309 for additional information regarding resident #7. Resident #7 was at risk for constipation because of his/her impaired mobility and frequent use of pain medications. He/She had a care plan intervention since 2/22/10 for licensed nursing staff to administer medications as ordered. The resident had a physician's orders [REDACTED]. However, during medication administration on 6/30/10 at 9:15 a.m., it was observed that licensed nursing staff administered 30 cc. of [MEDICATION NAME] (a stool softener) to the resident. See F309 for additional information regarding resident #7. Resident #7 had a gastrostomy tube. There was a care plan intervention since 2/22/10 for licensed nursing staff to administer flushes as ordered by his/her physician. There was a physician's orders [REDACTED]. However, on 6/30/10 at 9:15 a.m., licensed nursing staff did not flush the resident's gastrostomy tube prior to administering the medications through the tube. See F322 for additional information regarding resident #7. 2. Resident #18 had a gastrostomy tube. He/She had a care plan intervention since 6/12/10 for licensed nursing staff to assess the resident's gastrostomy tube for gastric residual volume prior to administering the formula feeding. There was a physician's orders [REDACTED]. However, during formula administration on 6/30/10 at 9:50 a.m., licensed nursing staff did not check the resident's gastric residual amount prior to administering 240 cc of Resource 2.0 through his/her gastrostomy tube. See F322 for additional information regarding resident #18.",2015-03-01
10055,GLENVUE HEALTH AND REHABILITATION,115619,721 NORTH VETERANS BLVD,GLENNVILLE,GA,30427,2010-07-01,322,D,0,1,OYQW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that two residents (#7 and #18) of five residents with gastrostomy tubes received the appropriate treatment to prevent complications from a total sample of 22 residents. Findings include: According to the facility's policy, Reference 15: Pertinent Techniques for Medication Administration, nursing staff were supposed to flush a resident's gastrostomy tube with 30 cubic centimeters (cc) of water prior to medication administration unless otherwise ordered by the physician to ensure that the patency of the tube was maintained. According to the facility's General Nursing Care Considerations and Principles regarding the care of a resident's gastrostomy tube, nursing staff were supposed to check the amount of gastric residual before administering tube feedings to ensure that the resident's stomach was not overfull which might cause the feeding solution to be regurgitated and place the resident at risk for aspiration. However, licensed nursing staff failed to flush the gastrostomy tube as ordered prior to administering medications for resident #7 and failed to check the amount of gastric residual prior to administering the tube feeding for resident #18. 1. Resident #7 had a gastrostomy tube and a care plan intervention since 2/22/10 for licensed nursing staff to administer flushes as ordered. There was a physician's orders [REDACTED]. However, on 6/30/10 at 9:15 a.m., licensed nurse ""CC"" failed to flush the resident's gastrostomy tube with 30 cc of water prior to administering the medications through the tube. On 7/1/10 at 11:35 a.m., licensed nurse ""CC"" stated that he/she only flushed a resident's gastrostomy tube with water after administering medications and/or feedings. ""CC"" stated that he/she did not flush a resident's gastrostomy tube prior to medication administration. 2. Resident #18 had a gastrostomy tube and a physician's orders [REDACTED]. There was a physician's orders [REDACTED]. However, during observation of medication and formula administration on 6/30/10 at 9:50 a.m., licensed nurse ""CC"" failed to flush the resident's gastrostomy tube with water prior to administering the resident's medications through his/her gastrostomy tube. ""CC"" failed to check the amount of gastric residual prior to administering 240 cc of Resource 2.0 formula through the resident's gastrostomy tube. On 7/1/10 at 11:35 a.m., licensed nurse ""CC"" stated that he/she did not flush a resident's gastrostomy tube with water prior to administering medications through the tube. ""CC stated that she/he only flushed gastrostomy tubes with water after medication administration. ""CC"" stated that he/she should have checked the amount of the resident's gastric residual prior to administering the formula through the resident's gastrostomy tube.",2015-03-01
10056,OCONEE REG MC SKILLED NSG UNIT,115649,821 NORTH COBB ST,MILLEDGEVILLE,GA,31061,2011-10-26,325,D,0,1,UCMI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that the dietary recommendation by the Registered Dietician was implemented for one (1) resident (#102) from a sample of fourteen (14) residents. Findings include: Review of the medical record for resident #102 revealed that the Registered Dietician made a recommendation during the Skilled Nursing Unit Team Meeting on 9/22/11 to increase the resident's tube feeding from 70 milliliters (ml) to 80 ml per hour. The dietician assessed the resident as at severe nutritional risk. Continued review revealed that the resident was admitted on [DATE] weighing 208 pounds (lbs) and on 09/19/11 the resident weighed 204 lbs. Review of the Skilled Nursing Unit Team Meeting dated 09/29/11 revealed that the Registered Dietician indicated that the tube feeding remained at 70 ml with no explanation as to why it had not been increased to the 80 ml as per her recommendations. There was no evidence to indicate that the physician was aware of the recommendation. Review of the facility weight record for this resident revealed that on 9/29/11 the resident weighed 195 lbs and on 10/03/11, the resident weighed 188 lbs. Interview with the Registered Dietician (RD) ""AA"" on 10/26/11 at 10:34 a.m. revealed that each resident is rated to determine their nutritional risk. This resident was rated as a severe nutritional risk according because the resident was receiving enteral nutrition, had unintentional weight loss, a low [MEDICATION NAME] and had a stroke. The resident's score was fourteen (14) which caused him/her to be followed up by the RD every four (4) days. Continued interview revealed that she documents her assessment in the Electronic Medical Record (EMR) and that any recommendation that she made would be in these notes and the team meeting notes which she places it in front of the residents medical record. Because resident #102 was not the Medical Director's patient, she placed the recommendation in the EMR, in the front of his chart, in the team meeting notes and alerted nursing. However, she could not be certain that the physician received the recommendation. Interview with the Administrator on 10/26/11 at 10:44 a.m. revealed that she could not be certain that the physician received the recommendation to increase the tube feeding from 70 ml to 80 ml because there is no evidence in the medical record to suggest that the physician saw the recommendation and agreed and/or disagreed with it. No one followed up.",2015-03-01
10057,OCONEE REG MC SKILLED NSG UNIT,115649,821 NORTH COBB ST,MILLEDGEVILLE,GA,31061,2011-10-26,371,F,0,1,UCMI11,"Based on observation and staff interview the facility failed to maintain sufficient sanitizer in the three (3) compartment sink. Findings include: Observation on 10/24/11 at 11:00 a.m. of the three (3) compartment sink revealed that the sanitizer, checked by the Dietary Manager, measured a zero parts per million (ppm) concentration. Continued observation revealed that the container of the sanitizer solution was almost empty. Observation on 10/25/11 at 11:30 a.m. of the three compartment sink revealed that the sanitizer solution, checked by the Dietary Manager, measured between a zero (0) and one hundred (100) ppm concentration. The dietary manager obtained a new test strip package and retested the sanitizer again with the same result. Continued observation revealed that the dietary manager removed the sanitizer solution from the dispensing tubing under the sink and poured four ounces (4 oz) of the sanitizer solution into the sink water. The sanitizing solution was rechecked and measured two hundred (200) ppm as recommended. She then called her dietary porter over to the sink and instructed him to rewash all the dishes that were drying on the rack to the right of the sink. Interview with the Dietary Manager on 10/25/11 at 11:34 a.m. revealed that the Ecolab equipment automatically dispenses the correct amount of the sanitizer solution into the sink and her staff tests the strips daily after breakfast, lunch and dinner. Continued interview revealed that the dietary manager indicated that she would have to retrain her staff on how to read the strips correctly.",2015-03-01
10058,OCONEE REG MC SKILLED NSG UNIT,115649,821 NORTH COBB ST,MILLEDGEVILLE,GA,31061,2011-10-26,372,C,0,1,UCMI11,"Based on observation and staff interviews the facility failed to ensure that the dumpster/garbage compactor was free of leaks. Findings include: Observation of the garbage disposal area on 10/25/11 at 11:40 a.m. revealed a large automatic garbage compactor in a gated padlocked area. Inside this padlocked area, there was a coffee colored, foul smelling liquid on the ground, continuously draining from underneath the garbage compactor and running by gravity about fifteen (15) feet down into the storm drain. There were flies all around the area. Interview with the Dietary Manager on 10/25/11 at 11:44 am revealed that the responsibility of the garbage compactor is shared by both herself and the Environmental Services Manager. Interview with the Environmental Service Manager on 10/25/11 at 11:45 am revealed that the garbage compactor might be leaking hydraulic fluid because they had some trouble with that in the past. Continued interview revealed that the garbage compactor is monitored daily and is cleaned at the end of the week. Observation on 10/25/11 at 11:46 a.m. with the Dietary Manager and the Environmental Service Manager of the garbage compactor revealed that it was not hydraulic fluid leaking and running into the storm drain. Interview with the Environmental Service Manager on 10/25/11 at 12:10 p.m. revealed that she did not have any record that the trash compactor was monitored daily. Interview with the Environmental Service Manager on 10/26/11 at 8:30 a.m. revealed that Advanced Disposal replaced the dumpster/garbage compactor 10/25/11 at 2:30 p.m. after acknowledging that the old garbage compactor was leaking from underneath.",2015-03-01
10059,OCONEE REG MC SKILLED NSG UNIT,115649,821 NORTH COBB ST,MILLEDGEVILLE,GA,31061,2011-10-26,431,D,0,1,UCMI11,Based on observation and staff interview the facility failed to ensure that the medication storage refrigerator was free of expired medications. Findings include: Observation of the Medication Storage room on 10/24/11 at 1:40 p.m. revealed five (5) expired medications. Promethazine Hcl 25 milligram (mg) suppositories in a plastic bag in the refrigerator with the following expiration dates 05/2010 (2 suppositories) and 06/2010(3 suppositories). Interview with the Administrator on 10/25/11 at 12:25 p.m. revealed that it is the responsibility of all the nurses that pass medications to check for expired medication as well as the pharmacy. She further revealed that the pharmacy staff had just been there.,2015-03-01
10060,LIFE CARE CENTER,115654,176 LINCOLN AVE,FITZGERALD,GA,31750,2010-06-10,253,C,0,1,7UBW11,"Based on observation it was determined that the facility failed to maintain an environment free of dust, dirt, rust, chipped and/or missing floor tile, cracked light covers, stained tiles, unsecured vent covers,loose caulk, cobwebs, dead bugs, on three of three resident halls (South, West and East). Findings include: Observations were made during the initial tour on 6/8/10 between 10:20 a.m. and 11 a.m. and on 6/9/10 at 11:30 a.m., and during the General Observations of the Facility tour on 6/9/10 at 3:00 p.m. East Hall 1. There was a hole in the bathroom ceiling tile in room E28. 2. There were dead bugs and cobwebs between the screen and window in the women's bath near N20. 3. The screen (inside of the window) was not secured in the men's bath near N20. 4. There was dust on the vent in the corridor near N9. 5. There was a build up of paper debris, dust and dirt behind the vending machines in the acitivities area. There were dead bugs and cobwebs on the window sills. 6. There was a cracked ceiling light cover near room E4. West Hall 1. There was a rusty frame on the overbed table in room W25. 2. There were chipped and bulging floor tiles under the sink in room W4. 3. There was dust on the ceiling vent in the corridor near room W27. 4. There was paper trash and a dead roach on the floor in the Clean Linen room. 5. There was dust on the ceiling vent in the corridor outside of the Clean Linen room. 6. There was dust on the exhaust vent in the shower room across from room W17. 7. There were orange stains and rust on the frame and wheels of the shower chair in the shower room. 8. There was a hole in the ceiling tile in the corridor outside of room W14. 9. The light cover in the corridor outside of room W11 was cracked and had a piece of the plastic missing. There were cracked light covers in the corridor outside of rooms W1 and W3. 10. There was dust and dirt behind the double doors leading into the dining room at the end of the corridor near W1. 11. There were brown stains on nine ceiling tiles in the dining room near W1. 12. There was dust on the ceiling vent outside of the pantry. 13. There were dead bugs in the light cover in the pantry above the refrigerator and ice chest. 14. There was a brown/black substance along the hinge of the ice chest in the pantry. 15. There was dust on the return air vent in the dining room door near the nursing station. 16. There were dust, dead bugs and cobwebs on the window sills and ledges of the six windows in the dining area near the nursing station. 17. There was a cracked light cover in the corridor near the nurse's station. 18. A window blind slat was bent in room W18. There was a large dark stain on the bathroom floor next to the commode. 19. The bottom drawer of the chest of drawers was coming apart from the frame in room W8. The caulk around the back of the sink had pulled away from the wall. 20. The bathroom exhaust fan cover had pulled away from the ceiling in room W11. There was a dark stain on the floor next to the commode. There were dust and dirt on the window frames and blinds. 21. There were cobwebs and dust on the window frames and blinds in room W9. 22. There was a brownish-red stain on the bathroom floor around the commode in room W16. South Hall 1. There was a heavy build up of dust on two curtain rods in room S3. 2. There were 19 (1 inch by 1 inch) bathroom floor tiles missing in room S1. 3. There were dead bugs and dust in the air conditioning unit in the common area. There was a gap between the top of the air conditioning unit and the wall in the common area. 4. There were dead bugs in the cabinet of the soiled linen room across from room S14. 5. There was dust on the ceiling vent in front of the nurse's station. 6. There was dust on the ceiling vent in the pantry. 7. There were dead bugs and dust on the window sills in the dining room. 8. Three light covers in the corridor were cracked. Parts of the light covers were hanging down. 9. The commode tank cover did not fit properly in the whirlpool bath room. The ceiling vents were not secured to the ceiling. 10. There were two ceiling tiles with brown stains in room S25.",2015-03-01
10061,LIFE CARE CENTER,115654,176 LINCOLN AVE,FITZGERALD,GA,31750,2010-06-10,241,D,0,1,7UBW11,"Based on observations, it was determined that the facility failed to promote a dignified dining experience for seven residents (#19, #20, and 5 randomly observed residents) from a total sample of 21 residents. Findings include: 1. During an observation of the breakfast meal on 6/10/10 at 8:30 a.m. in the East Hall dining room, staff had tied bed sheets around the necks of residents #19 and #20 and two other residents as clothing protectors. 2. During lunch on 6/9/10 at 1:25 p.m. in the East Hall dining room, three randomly observed residents had bed sheets tied around their necks as clothing protectors.",2015-03-01
10062,LIFE CARE CENTER,115654,176 LINCOLN AVE,FITZGERALD,GA,31750,2010-06-10,514,D,0,1,7UBW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to have accurate documentation about restorative nursing services provided to one resident (#15) from a total sample of 21 residents. Findings include: Resident #15 had a physician's orders [REDACTED]. Restorative nursing staff had not initialed the resident's May 2010 Nursing Rehab/Restorative form to indicate that the staff had provided services from 5/22/10 to 5/31/10. A review of the Restorative notebook on 6/9/10 at 4:30 p.m. revealed that there was not a Nursing Rehab/Restorative form in the notebook for the resident for May or June. During an interview on 6/9/10 at 9:10 a.m., the Restorative Certified Nursing Assistant (RCNA) stated that the resident was receiving therapy but, she could not remember exactly what was being done. She stated that the resident began receiving restorative nursing services at the end on the previous month (May) but that she (RCNA) had been on vacation at the end of May and thought that the form might not have been placed in the notebook. At 10:00 a.m. on 6/9/10, the facility provided a completed May and June Nursing Rehab/Restorative form. Staff had completed the form for 5/22/10 to 5/31/10 and for 6/1/10 to 6/9/10 to indicate the service was provided. Although the RCNA's initials were written on 5/22/10 and 5/23/10, according to the nursing schedule provided by the Director of Nurses, that RCNA had been on vacation from 5/22/10 through 5/28/10.",2015-03-01
10063,LIFE CARE CENTER,115654,176 LINCOLN AVE,FITZGERALD,GA,31750,2010-06-10,469,E,0,1,7UBW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain and effective pest control program to control flies on three of three wings (West, East and South) of the facility. Findings include: During the Group Interview (meeting) on 6/9/10 at 11:00 a.m., all six residents in attendance complained about having seen flies, ants and roaches in the facility. A review of the 5/18/10 Resident Council Minutes revealed that the residents had reported having black ants and roaches in their rooms. During an interview on 6/9/10 at 4:00 p.m., the Maintenance Director stated that the facility was treated for [REDACTED]. He provided documentation that the facility had last been treated for [REDACTED]. South Wing 1. During the initial tour on 6/8/10 between 10:30 a.m. and 11:30 a.m., there were flies in the hallway and common areas on South Wing. It was observed on 6/8/10 at 12:40 p.m. and 1:20 p.m., and on 6/9/10 at 7:30 a.m. and 11:15 a.m. that there were still flies in that hallway. 2. During an observation of incontinence care being provided for resident #7 on 6/9/10 at 11:30 a.m., there was a fly on the bed pillow under the resident's head. The Certified Nursing Assistant (CNA) swatted at the fly with her hand while providing care for the resident. 3. During an observation of pressure sore treatment being provided for resident #7 on 6/10/10 at 10:55 a.m., there were flies on his/her bed covers and flying around the resident. 4. During an observation of the CNA providing incontinence care for resident #6 on 6/9/10 at 9:00 a.m., there were flies on the resident's bed covers and flying around the resident. 5. During a random observation on 6/8/10 at 12:15 p.m., there was an ant crawling on the overbed table in room S25. West Wing 1. During the initial tour on 6/8/10 between 10:30 a.m. and 11:30 a.m., there were flies in the hallway and common areas on West Wing. 2. During the initial tour on 6/8/10 between 10:30 a.m. and 11:30 a.m., the bathroom window in room 15 was open but, there was not a screen on the window. Across the hall from room 15, in room 18, a resident was asleep in the bed with flies crawling on him/her. East Wing 1. During an observation of a bingo game in the East hall dining room on 6/9/10 at 2:35 p.m., flies were flying around the residents. 2. During the medication pass observation on 6/9/10 at 8:05 a.m., while a resident was eating his/her breakfast in his/her room, a fly was flying around his/her food. 3. It was observed at lunch on 6/9/10 at 1:25 p.m. in the East Hall dining room that flies were flying around the residents who were eating. CNAs were attempting to swat at the flies with their hands while assisting residents to eat.",2015-03-01
10064,LIFE CARE CENTER,115654,176 LINCOLN AVE,FITZGERALD,GA,31750,2010-06-10,153,D,0,1,7UBW11,"Based on resident interview, it was determined that the facility failed to ensure the right of one resident (""A"") to review his/her medical record of six residents in the Group Interview. Findings include: During the Group Interview (meeting) on 6/9/10 at 11:00 a.m., resident ""A"" stated that approximately three months ago he/she had requested to review his/her medical record. Resident ""A"" stated that the licensed nurse at that time stated that the Director of Nursing (DON) would have to be notified. Resident ""A"" stated that, several days later, staff reported that the resident's physician would have to be notified prior to the resident having access to his/her medical record. Resident ""A"" stated during the meeting that he/she had not been given his/her medical record for review, and had not requested access to it since that time. During an interview on 6/10/10 at 11:30 a.m., the DON stated that she had not been made aware of the resident's request to review his/her medical record.",2015-03-01
10065,LIFE CARE CENTER,115654,176 LINCOLN AVE,FITZGERALD,GA,31750,2010-06-10,248,E,0,1,7UBW11,"Based on resident and staff interviews, it was determined that the facility failed to provide activities of interest on Saturdays and Sundays. Findings include: During the Group Interview (meeting) on 6/9/10 at 11:00 a.m., all six residents in attendance stated that activities scheduled according to the activity calendar, were not provided on Saturday and Sunday. According to the June activity calendar, activities scheduled on Saturdays included bingo in the morning and gospel tapes in the afternoon. However, all six residents stated that bingo was not held on Saturdays. Resident ""A"" stated that occasionally someone would play a gospel tape, but it was not done every Saturday as scheduled. The Sundays' scheduled activity included a church/religious activity. On 6/10/10 at 11:00 a.m., the Activity Director stated that activities scheduled for Saturdays and Sundays were not conducted by staff members but by resident volunteers.",2015-03-01
10066,LIFE CARE CENTER,115654,176 LINCOLN AVE,FITZGERALD,GA,31750,2010-06-10,323,E,0,1,7UBW11,"Based on observations, it was determined that the facility failed to maintain the facility free of water on the floor near the air conditioning units on all three halls (East, West and South). Findings include: Water was dripping onto the floor from the ceiling air conditioning units on the West unit, South unit and East unit. During the initial tour on 6/8/10 between 10:20 a.m. and 11 a.m., residents were observed ambulating independently, using walkers, and self propelling their wheelchairs on those units.",2015-03-01
10067,LIFE CARE CENTER,115654,176 LINCOLN AVE,FITZGERALD,GA,31750,2010-06-10,371,F,0,1,7UBW11,"Based on observations, it was determined that the facility failed to maintain the kitchen as an environment that was free of dust, grease, dirt and food debris. Findings include: Observations were made during the initial tour of the kitchen on 6/8/10 at 10:20 a.m., and on 6/9/10 and on 6/9/10 at 12:20 p.m. 1. There were dust, food particles and debris on top of the automatic dishwasher. 2. There was dust on the pipes and on the fan above the automatic dishwashing area. 3. There was a black substance, dust and grease on the air conditioning unit. There were slats missing from the vent in the air conditioning unit. 4. There were food splatters and spills inside of the microwave oven in the East hall pantry.",2015-03-01
10068,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2010-06-04,279,D,0,1,M4C211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record reviews, it was determined that the facility failed to develop a care plan for one resident (#1) to address his/her history of fecal impactions from a total sample of 17 residents. Findings include: Resident #1 had been receiving 100 milligrams (mg) of [MEDICATION NAME] every day since 7/23/09. There was a 7/28/09 order for 30 cubic centimeters (cc) of Milk of Magnesia every day ""as needed"" (prn) constipation. However, a review of the resident's care plan since 8/26/09 did not include the resident's problem of constipation and potential for fecal impaction. On 11/15/09, the nurse's notes documented that the resident complained of lower abdominal pain. The licensed nurse noted that she checked the resident for a fecal impaction and felt large, very hard stool. The resident's doctor was notified. The resident was given a Fleets enema and had good results. On 11/16/09, the physician ordered 30 cubic centimeters (cc) of [MEDICATION NAME] twice a day. The 4/10/10 nurse's notes described the resident as restless and crying from pain. The licensed nurse documented that she assessed the resident and found that he/she was impacted with large hard stool in his/her rectum. The nurse noted that she removed the impaction and gave the resident a Fleets enema and an ""as needed"" laxative. During an interview with the Registered Nurse (RN) Supervisor and Nurse ""JJ"" on 6/4/10 at 11:15 a.m., they stated that they were not aware that the resident had constipation or history of a second fecal impaction on 4/10/10. The RN supervisor stated that interventions to address the resident's potential for having a fecal impaction should have been on the care plan. After reviewing the resident's medical record with the nurse, the Registered Nurse supervisor confirmed that the resident did not have a care plan to address his/her risk for constipation and fecal impactions. See F309 for additional information regarding resident #1.",2015-03-01
10069,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2010-06-04,309,D,0,1,M4C211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, it was determined that the facility failed to assess a surgical wound for one resident (#9) from a total sample of 17 residents. Findings include: The facility's policy and procedure for ""Wounds/Pressure Ulcers"" documented that residents would have a skin assessment performed by licensed nursing personnel upon admission and at least bi-weekly. Weekly wound rounds would be conducted to evaluate the progress of wound healing. During an interview on 6/4/10 at 10:20 a.m., the treatment nurse stated that both pressure and non-pressure sores were supposed to have documentation of weekly assessments, including wound measurements. On 6/4/10 at 11:15 a.m., the Director of Nursing (DON) stated that both pressure and non-pressure sores were supposed to be assessed at least weekly and a thorough description documented. However, licensed nursing staff failed to thoroughly assess a surgical wound for resident #9. Resident #9 was admitted on [DATE] with a surgical wound following a left total hip arthroplasty, which cultured positive for [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) infection. On the 4/1/10 ""Admission Skin Assessment"" form, licensed nursing staff described the surgical wound as measuring 8.0 cm by 4.0 cm by 3.0 cm and having blood tinged drainage. However, there was no description of the appearance of the wound bed. Following that initial assessment of the surgical wound, there was no evidence that the treatment nurse had assessed the surgical wound weekly. The next documentation was done on 5/25/10, when the treatment nurse documented that the surgical wound had healed.",2015-03-01
10070,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2010-06-04,314,D,0,1,M4C211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility's policy and procedure for wounds and pressure sores, it was determined that the facility failed to ensure that the treatment nurse thoroughly assessed pressure sores to include staging, measurements, and the appearance of the wound bed for two residents (#9 and #12) of seven residents reviewed with pressure sores, from a total sample of 17 residents. Findings include: The US Department of Health and Human Services Clinical Practice Guideline, Number 15: treatment of [REDACTED]. Pressure sores were to be reassessed weekly. (p. 23). The facility's ""Policy and Procedure for Wounds/Pressure Ulcers"" noted that documentation of pressure sores would include: clinical and MDS staging of wounds, ulcer location, length, width, depth, appearance of wound bed and edges,exudate, and the appearance of the surrounding tissue. During an interview on 6/4/10 at 10:20 a.m., the treatment nurse stated that pressure sores should have documentation of weekly assessments, including wound measurements. On 6/4/10 at 11:15 a.m., the Director of Nursing (DON) stated that pressure sores were supposed to be assessed at least weekly and a thorough description of the wounds documented. However, nursing staff failed to thoroughly assess pressure sores for residents #9 and #12. 1. On the 4/1/10 Admission Skin Assessment, licensed nursing staff documented that resident #9 was admitted to the facility with a 1.0 centimeter (cm) by 0.3 cm pressure sore on his/her right heel. Nursing staff obtained a physician's orders [REDACTED]. However, the licensed nurse failed to thoroughly describe the appearance of the wound bed or identify the stage of the pressure sore. After the 4/1/10 Admission Skin Assessment, there was no evidence that the nursing staff had assessed the pressure sore weekly. There was no assessment information about the pressure sore until the 4/23/10 treatment note that it had healed. On 6/3/10 at 9:45 a.m., the Director of Nursing (DON) confirmed that she was unable to locate additional information about the pressure sore on the resident's right heel. 2. The facility's ""Policy and Procedure for Wounds/Pressure Ulcers"" noted that a stage II pressure ulcer might present as an intact or open/ruptured serum-filled blister. Licensed nursing staff identified a pressure ulcer on resident #12's right heel on 4/1/10. The April 2010 Treatment Record described that pressure ulcer as a small blister with a small amount of clear drainage. The initial assessment of the pressure ulcer did not include staging or a measurement. In their assessments on 4/8 and 4/15/10, licensed nursing staff described the ulcer as a burst blister. However, those assessments did not to include the pressure sore's staging or measurements.",2015-03-01
10071,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2010-06-04,159,C,0,1,M4C211,"Based on review of fund balance sheets and staff interviews, it was determined that the facility failed to identify a negative balance in the residents' pooled trust fund account balances for four months. Findings include: Review of the facility's list of residents' trust fund account balances for 5/31/10, 4/30/10, 3/31/10 and 2/28/10 revealed that there was an entry each month listed as ""Interest, Over/Under"" of a negative $17.83. During interviews with the Chief Financial Officer and the Bookkeeper on 6/4/10 at 1:00 p.m., they were unable to explain that negative amount in the residents' line listing of fund balances for those months.",2015-03-01
10072,"RETREAT, THE",115675,898 COLLEGE ST,MONTICELLO,GA,31064,2010-07-16,332,E,0,1,FW7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations conducted during the medication pass, it was determined that the facility failed to ensure that it was free of a medication error rate of five (5) percent or greater. Findings include: Observations conducted on 7/14/10 beginning at 8:35 a.m., revealed one (1) of three (3) nurses on one (1) of four halls administering medications. Three (3) medication errors were observed out of fifty (50) opportunities. This resulted in a medication error rate of 6 percent. 1. Resident #10 had a physician's orders [REDACTED]. The nurse administered two (2) drops in the resident's right eye without waiting between drops. 2. Resident # 7 had a physician's orders [REDACTED]. Only one (1) tablet was administered by the nurse. This same resident had a physician's orders [REDACTED]. The nurse did not instruct the resident to blow his/her nose prior to administration of the nasal spray.",2015-03-01
10073,"RETREAT, THE",115675,898 COLLEGE ST,MONTICELLO,GA,31064,2010-07-16,425,D,0,1,FW7Z11,"Based upon observation and staff interviews the facility failed to ensure that expired medications were disposed of appropriately and in a timely manner from one (1) of one (1) medication rooms. Findings include: Observation of the medication room and interview with Licensed Practical Nurse (LPN) ""AA"" on 7/14/10 at 3:15 p.m. revealed five (5) vials of Heplock (blood thinner used with intravenous catheters) that expired 12/2007. Interview on 7/14/10 at 3:30 p.m. with the Director of Nursing revealed she was not aware that this medication was in the medicine room and should have been returned to the pharmacy.",2015-03-01
10074,"RETREAT, THE",115675,898 COLLEGE ST,MONTICELLO,GA,31064,2010-07-16,514,D,0,1,FW7Z11,"Based upon review of physician's orders, Medication Administration records and staff interviews the facility failed to ensure that the clinical record was accurate related to administration of Prostat for one (1) resident (#57) of nineteen (19) sampled residents. Findings include: Review of the July, 2010 Physician's Order Summary for resident #57 and signed by the physician 7-14-10 reveal an order for Prostat 30 milliliters (ml) once daily. Review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 7/15/10 at 8:50 a.m. revealed that the Prostat had been discontinued on 4/29/09 per physician's order. Interview on 7/15/10 at 10:00 a.m. with the DON, Administrator, and a Licensed Practical Nurse (LPN) revealed that the facility reviews the Physician Order Summary, which is printed by the pharmacy with a review sheet, monthly and could not explain how the Prostat order remained on the order sheet for over one year.",2015-03-01
10075,"RETREAT, THE",115675,898 COLLEGE ST,MONTICELLO,GA,31064,2010-07-16,309,D,0,1,FW7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow physicians orders for blood pressure monitoring prior to medication administration for two (2) residents (#22 and #26) from a sample of nineteen (19) residents. Findings include: 1. Review of the physician's orders [REDACTED]. Continued review revealed that the medications were to be held if the systolic blood pressure was less than 100. Review of the Medication Administration Record [REDACTED] Review of the July, 2010 MAR indicated [REDACTED] Interview on 7/14/10 with the Director of Nurses revealed that blood pressures should be done prior to administering medication as per the physician order. 2. Review of the physician's orders [REDACTED]. Continued review revealed that the medication were to be held if the blood pressure was less than 100/60. Review of the MARs for March, April, May, June and July, 2010 revealed that the blood pressure was to be monitored two (2) times as day at 9:00 a.m. and 9:00 p.m.. Continued review revealed the following: March 27 and 28-no evidence that the blood pressure was monitored at 9:00 a.m.; April 25 and 29- no evidence that the blood pressure was monitored at 9:00 a.m.; May 10, 19, 22-no evidence that the blood pressure was monitored at 9:00 a.m.; June 16, 24 and 30 no evidence that the blood pressure was monitored at 9:00 a.m. and June 12-no evidence that the blood pressure was monitored at 9:00 p.m. Interview on 7/14/10 at 3:00 p.m. revealed that she could not explain why the blood pressures were not being monitored as ordered. Further interview revealed that if there is no documentation to indicate that things are done, then it is not done.",2015-03-01
10076,WILLOWBROOKE COURT AT LANIER VILLAGE ESTATES,115687,4145 MISTY MORNING WAY,GAINESVILLE,GA,30506,2011-02-04,157,D,0,1,0KUI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to notify the physician of a change in condition for one (1) resident (#52) of twenty five (25) sampled residents. Findings include: Review of the clinical record for resident #52 revealed that the resident was admitted to the facility on [DATE] after a hospitalization for surgical repair of a fractured left hip admission orders [REDACTED]. The PT/INR was drawn on 1/04/2011 and the physician increased the [MEDICATION NAME] to five (5) mg daily. Review of the nurses notes revealed that on 1/10/2011, the resident developed a urinary tract infection and was prescribed Bactrim DS one (1) two times a day for ten (10) days, which carries warnings of drug interaction with [MEDICATION NAME] and can increase the bleeding time. Continued review of the nurses notes revealed that the resident had a syncopal episode on 1/15/11 while being assisted to the toilet. There was no evidence that the physician was notified of the syncopal episode. Interview on 2/4/11 at 12:50 p.m. with the Director of Nursing (DON) and Licensed Practical Nurse ""AA"" revealed that the physician was not notified that resident had a syncopal episode. Telephone interview on 2/4/2011 with the resident's physician revealed that he was not notified of any change in condition for the resident until the resident was admitted to the hospital on [DATE] by the Orthopedic surgeon.",2015-03-01
10077,WILLOWBROOKE COURT AT LANIER VILLAGE ESTATES,115687,4145 MISTY MORNING WAY,GAINESVILLE,GA,30506,2011-02-04,279,J,0,1,0KUI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop a Comprehensive Care Plan with interventions for three (3) residents (#34, #13 and #7) assessed with [REDACTED]. This resulted in an immediate and serious threat to resident safety. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for the three (3 ) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2010 and continues. Findings include: 1. Review of the Clinical Record for resident #34 revealed the resident was admitted to the facility on [DATE]. Review of the initial Minimum Data Assessment ((MDS) dated [DATE] revealed that the resident was assessed as having falls within the last thirty (30) days and the Resident Assessment Protocol Summary (RAPS) indicated that a care plan would be developed for falls. A progress Note dated 1/29/2010 at 9:44 p.m. revealed the resident was at risk for falls related to poor balance and an unsteady gait. Review of the current care plan for this resident revealed that he was at increased risk of falls due to use of anti-depressant medications, a history of falls and unsteady gait. He needed reminders to use his Rolator and needed to request assistance if he felt unsteady. Interventions included: remind to ask for help, keep call light within reach at all times when in room, keep adaptive device/reacher in reach at all times and remind resident to use it, use personal alarm as necessary, place Rolator in reach at all times and do a fall risk assessment on admission, quarterly and after any falls as needed. This Care Plan was not developed until 12/27/2010 Interview on 2/03/2011 at 10:00 a.m. with the MDS/Care Plan Coordinator revealed that there was no Care Plan related to falls prior to 12/27/2010. Interview with Registered Nurse (RN) ""BB"" on 2/4/2011 at 11:00 a.m. revealed the facility's clinical records including Care Plans were not complete. Review of the facility's policy on Falls Reduction and Management revealed the residents were to be assessed upon admission for fall risk and then quarterly using the Fall Risk Assessment Form. Once risk was identified the Interdisciplinary Care Plan Team would identify appropriate preventive measures and interventions. 2. Review of the RAPS from a significant change MDS completed on 1/14/10 for resident #13 indicated that a care plan would be developed for falls. Review of the quarterly MDS dated [DATE] revealed that the resident was assessed with [REDACTED]. Review of the clinical record revealed that this resident had twelve falls between 2/01/2010 and 1/30/2011. There was no evidence a comprehensive care plan to address the resident's falls and safety needs was developed until 12/22/10. The last Fall Risk Assessment was done on 5/22/10 and the score was 20 indicating that the resident was a high risk for falls. Review of the current care plan revealed that he was at risk for falls due to being unsteady on his feet, poor safety awareness and history of falls. Interventions included: assistance from staff, chair alarm, and frequent safety reminders. 3. Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]., abnormal gait, muscle weakness, [MEDICAL CONDITION], urinary urgency and visual hallucinations. Review of the Fall Risk assessment performed on admission indicated the resident was at a high risk for falls. Review of the initial Minimum Data Assessment ((MDS) dated [DATE] revealed that the resident was assessed as having falls within the last thirty (30) days and the Resident Assessment Protocol Summary (RAPS) indicated that a care plan would be developed for falls. There was no evidence a comprehensive care plan to address the resident's falls and safety needs was developed until 12/10/10. Review of the current care plan revealed that the resident was at increased risk of falls due to use of anti depressant medication, had a history of [REDACTED]. Continued review revealed interventions which were not appropriate for the resident such as reminding the resident to use the call light. During an interview on 2/3/10 at 3:00 p.m. the MDS coordinator confirmed the care plan had not been developed until 12/10/10.",2015-03-01