cms_GA
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166 rows where "filedate" is on date 2014-07-01
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10335 | 10335 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2011-03-21 | 323 | G | 1 | 0 | S4HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, Incident/Accident Report review, and staff interview, it was determined that the facility failed to ensure that one (1) resident (#1) received the necessary supervision, and Hoyer lift transfer, as specified by the Care Plan to minimize the risk of a fall for one (1) resident (#1), and failed to use floor mats as specified by the Care Plan to serve as a fall precaution for one (1) resident (#4), from a survey sample of six (6) residents who had been assessed as being at risk for falls. Resident #1 subsequently fell and sustained a fracture of the right leg. Findings include: 1. Clinical record review for Resident #1 revealed a record Face Sheet which documented that the resident had [DIAGNOSES REDACTED]. A Care Plan entry of 02/24/2010 identified the resident to be at risk for falls, with Approaches to address this risk which included to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the licensed nurse had been called to the resident's room by a nursing assistant and observed the resident to be sitting on the floor in the room. This Note documented that the resident had fallen while being changed, and that the resident complained of right knee pain, with swelling noted to the right knee and thigh. A Nurse's Notes entry of 02/01/2011 at 3:00 p.m. documented that the physician was notified of the resident's condition, and that an order was received to send the resident to the hospital for evaluation. A Nurse's Notes entry of 02/01/2011 at 3:40 p.m. documented that Emergency Medical Services had arrived to transport the resident to the hospital, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had been admitted to the hospital with [REDACTED]. A 02/01/2011 facility Incident/Accident Report which referenced Resident #1's fall documented that Nursing Assistant In Training "AA" had been providing incontinen… | 2014-07-01 |
| 10336 | 10336 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2011-03-21 | 495 | G | 1 | 0 | S4HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Incident/Accident Report review, and staff interview, the facility failed to ensure that a nursing assistant had demonstrated competency and had been determined competent in the provision of care before allowing the nursing assistant in training to transfer and provide incontinence care for one (1) resident (#1) from a survey sample of six (6) residents. This failure resulted in actual harm ([MEDICAL CONDITION] leg) for Resident #1. Findings include: Cross refer to F323 for more information regarding Resident #1. Clinical record review for Resident #1 revealed a Care Plan entry of 02/24/2010 which identified the resident to be at risk for falls and included the use of a Hoyer lift for all transfers, as well as to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the licensed nurse had been called to the resident's room and observed the resident sitting on the floor in the room, after having fallen while being changed. This Note documented that the resident complained of right knee pain, with swelling noted to the right knee and thigh, and that an order was received to send the resident to the hospital for evaluation. A Nurse's Notes entry of 02/01/2011 at 3:40 p.m. documented that the resident was transported to the hospital, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had a [DIAGNOSES REDACTED]. A 02/01/2011 facility Incident/Accident Report which referenced Resident #1's fall documented that Nursing Assistant In Training "AA" had been providing incontinence care to Resident #1 at the sink, but the resident was unable to hold on and Nursing Assistant "AA" thus slid the resident to the floor. This resulted in the resident sustaining a [MEDICAL CONDITION] distal femur. In a written statement dated 02/01/2011, Nursing Assistant In Training "AA" documented that when Resident #1 needed a changed brief, she assisted … | 2014-07-01 |
| 10337 | 10337 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2011-03-21 | 282 | G | 1 | 0 | S4HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, Incident/Accident Report review, and staff interview, it was determined that the facility failed to ensure that one (1) resident (#1) received supervision and Hoyer lift transfer, as specified by the Care Plan, and failed to use floor mats as specified by the Care Plan for one (1) resident (#4), from a survey sample of six (6) residents. Resident #1 fell and sustained a [MEDICAL CONDITION] leg. Findings include: 1. Cross refer to F323, Example 1, for more information regarding Resident #1. Clinical record review for Resident #1 revealed a Care Plan entry of 02/24/2010 which identified the resident to be at risk for falls, with Approaches which included the use of a Hoyer lift for all transfers and to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the nurse observed the resident on the floor in the room after having fallen while being changed. The resident complained of right knee pain, and swelling was noted to the right knee and thigh. A Nurse's Notes entry of 02/01/2011 at 3:00 p.m. documented that the physician was notified and ordered a hospital transfer, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had been admitted to the hospital with [REDACTED]. A 02/01/2011 facility Incident/Accident Report documented that Nursing Assistant In Training "AA" had been providing incontinence care to Resident #1 at the sink and then slid the resident to the floor. The resident sustained [REDACTED]. During an interview with Nursing Assistant In Training "AA" conducted on 03/02/2011 at 4:10 p.m., the nursing assistant stated she had been working by herself when providing care to Resident #1. In a written statement provided by the Director of Nursing (DON), the DON documented that Resident #1 had been transferred by Nursing Assistant "AA" without the use of a mechanical lift (as specified in the Care Plan), and … | 2014-07-01 |
| 10338 | 10338 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2011-02-01 | 328 | D | 1 | 0 | 4N3N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor the oxygen saturation level, in accordance with the physician's order, for one (1) resident (#1) of five (5) sampled residents. Findings include: Record review for Resident #1 revealed that the January 2011 Physician's Orders sheet, dated as having been reviewed on 12/27/2010, referenced physician's orders to administer oxygen 2.0 liters per minute per nasal cannula as needed for [MEDICAL CONDITION], and to monitor the resident's oxygen saturation to keep the oxygen saturation at 90 percent. The resident's January 2011 PRN Medication Administration Record [REDACTED]. However, further record review, to include review of the line on this PRN Medication Administration Record [REDACTED]. During an interview conducted on 02/01/2011 at 2:50 p.m., the Assistant Administrator acknowledged that the resident's oxygen saturation levels had not been recorded and there was no way to determine the resident's oxygen levels. | 2014-07-01 |
| 10339 | 10339 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2011-03-09 | 225 | D | 1 | 0 | DUNW11 | Based on review of a facility Complaint Form and staff interview, it was determined that the facility failed to report allegations of neglect to the State survey and certification agency for one (1) resident ("A") from a survey sample of ten (10) residents. Findings include: Review of a facility Complaint Form of 01/29/2011 revealed a family member of Resident "A" documented that she had visited the resident at 3:30 p.m. and noticed that the resident was wearing a brief that was soaked and was timed at 5:35 a.m. The family member also documented that the resident was wearing a gown that she had worn for two (2) days, and had been wearing the same socks since the Wednesday before. This Complaint Form documented that the unit manager was notified of these allegations on 01/29/2011. Documentation on the back of this Complaint Form indicated that the unit manager had counseled the staff member and removed the staff member from the resident assignment. On the back of the employee Corrective Counseling Statement, the unit manager included negligence as a reason for the disciplinary action. However, further record review revealed no evidence to indicate that the allegations of neglect referenced above had been reported to the State survey and certification agency. During an interview with the unit manager conducted on 03/09/2011 at 4:10 p.m., this staff member stated that she did not report these allegations of negligence to the State survey and certification agency. During an interview with Nurse "AA" conducted on 03/09/2011 at 4:20 p.m., Nurse "AA", who was responsible for reporting allegations of abuse and neglect to the State survey and certification agency, stated that she had not been made aware of these allegations of neglect, nor had she reported this to the State agency. | 2014-07-01 |
| 10340 | 10340 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2011-03-09 | 315 | D | 1 | 0 | DUNW11 | Based on observation, it was determined that the facility failed to provide the appropriate care to prevent urinary tract infections for one (1) resident (#4), of two (2) residents observed for incontinence care, from a survey sample of ten (10) residents. Findings include: During an observation of incontinence care for Resident #4 conducted at 4:00 p.m. on 03/09/2011, Certified Nursing Assistant "ZZ" failed to change gloves after wiping feces off the resident and before turning the resident on his/her back and wiping the perineal area with the same soiled gloves. | 2014-07-01 |
| 10341 | 10341 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2011-03-09 | 327 | D | 1 | 0 | DUNW11 | **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 adequate hydration was provided for two (2) residents (#1 and #2), who had a history of [REDACTED]. Findings include: 1. Record review for Resident #1 revealed a Care Plan entry of 04/06/2010 which identified the resident to be at risk for urinary tract infections, and referenced as an Approach to encourage fluids by mouth throughout the day. A hospital History and Physical for a 12/21/2009 hospital admission documented that the resident had discharge [DIAGNOSES REDACTED]. Observation of Resident #1 on 03/09/2011 at 1:10 p.m. revealed that the resident was seated in a geri-chair in the hallway outside of her room, and in the resident's room, the water pitcher was observed to be empty. Additional observations of the resident at 2:40 p.m. and 4:40 p.m. on 03/09/2011 revealed that the resident was in her room with the water pitcher still being empty and out of reach, on the window ledge. During an interview with Licensed Staff "SS" on 03/09/2011 at 5:10 p.m., this staff member stated that certified nursing assistants who were responsible for residents on each shift were responsible for checking the water pitcher for each of their assigned residents at the beginning and ending of their shifts. 2. Record review for Resident #2 revealed an 08/28/2010 Care Plan problem of the resident being at risk for fluid volume deficit due to receiving a daily diuretic, with an Approach to encourage fluids by mouth. Additionally, a current physician's orders [REDACTED]. A laboratory report dated 02/17/2010 identified that the resident had an elevated blood urea nitrogen level of 46 (reference range, between 6 to 24), and on the laboratory sheet, the physician wrote orders which included to increase water. However, observations of the resident at 2:50 p.m. and 4:50 p.m. on 03/09/2011 revealed that the resident was on her bed with no thickened water … | 2014-07-01 |
| 10342 | 10342 | RIVERDALE CENTER | 115144 | 315 UPPER RIVERDALE ROAD | RIVERDALE | GA | 30274 | 2009-02-04 | 165 | D | 1 | 1 | UBZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow their grievance process related to missing dentures for one (1) resident ("Q") on a sample of twenty-six (26) residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for resident "Q" revealed the resident had dentures. A Nursing Admission Assessment and Interdisciplinary Progress Note dated 12/01/08 also revealed the resident had upper and lower dentures on admission. On 02/02/09 at 12:52 p.m., the resident's morning care had been completed, and the resident was sitting in a Gerichair in their room. However, no dentures were observed in the resident's mouth at that time. On 02/03/09 at 12:13 p.m., Certified Nursing Assistant (CNA) "OO" located the bottom denture plate only in a cup in the resident's bedside table. On 02/03/09 at 12:18 p.m., the Social Services Director (SSD) stated that she thought a family member had asked her about a week-and-a-half ago about the resident's dentures and where they were. The SSD said it was on a Saturday and she was not able to come into the facility. She stated she called the resident's Power of Attorney (POA) the following Monday and left a message, and called the POA again this past Friday when asked by the family member again about the dentures, but was not able to reach the POA. The SSD said that she had no documentation of this, and at 5:35 p.m. added that in the event of missing items, the Grievance Policy and Procedure should be followed. On 02/04/09 at 8:00 a.m., Licensed Practical Nurse (LPN) Unit Manager "II" stated she did not know at what point the resident's upper dentures were lost. She added she thought a family member and/or SSD had asked about them, but could not remember when. At 10:00 a.m., the SSD stated she was able to reach the POA who verified that the resident had upper and lower dentures when admitted , and that they did not take the dentures home. Review of the facility's Res… | 2014-07-01 |
| 10343 | 10343 | KENTWOOD NURSING FACILITY | 115147 | 1227 WEST WHEELER PARKWAY | AUGUSTA | GA | 30909 | 2009-09-02 | 323 | G | 1 | 0 | 4GZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility document review, hospital document review, and staff interview, it was determined that the facility failed to ensure that adequate supervision was provided to one (1) resident, who required supervision related to wandering, on the survey sample of eighteen (18) residents. The resident subsequently exited the building and experienced a fall, resulting in fracture. Findings include: Record review for Resident #1 revealed a Minimum Data Set (MDS) assessment dated [DATE] which indicated that the resident had short-term and long-term memory problems, had moderately impaired decision making-capacity, and required the supervision of staff with locomotion on the unit. During an interview with the Director of Nursing (DON) conducted on 09/02/2009 at 1:30 p.m., the DON stated that the resident was up in the wheelchair daily and propelled himself/herself in the wheelchair by scooting with one foot throughout the halls. The resident's Care Plan dated 03/17/2009 listed as a problem that the resident had a history of [REDACTED]. Approaches listed on the Care Plan included to ensure that the alarm was on the exit door, to monitor the resident if around exit doors, and to monitor for potential signs of elopement. A Nurse's Note dated 08/28/2009 at 9:15 a.m. documented that nursing staff were summoned to provide assistance to the resident after a fall. This Note documented that Resident #1 was observed to be on the ground six (6) to eight (8) feet from the Richmond Wing door, two (2) feet away from the curb. The Note documented that the resident was laying with the face on the ground, turned slightly on the right side, with a swollen left eye and bleeding from both nostrils. This Note further documented that the resident's status was assessed and Emergency Medical Services (EMS) was contacted. A Nurse's Note of 08/28/2009 at 9:25 a.m. documented that EMS staff had arrived and that the resident was transported to the hospital. … | 2014-07-01 |
| 10344 | 10344 | KENTWOOD NURSING FACILITY | 115147 | 1227 WEST WHEELER PARKWAY | AUGUSTA | GA | 30909 | 2011-01-04 | 323 | G | 1 | 0 | 6FEF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility Incident/Accident Report review, and staff interview, it was determined that the facility failed to ensure that one (1) resident (#1) who utilized a Hoyer Lift for transfers, on the survey sample of ten (10) residents, received adequate supervision to prevent a fall. Resident #1 fell from the Hoyer Lift and sustained actual harm by receiving a fracture of the tibia/fibula. Findings include: Record review for Resident #1 revealed a Minimum Data Set (MDS) assessment of 08/13/2010 which indicated that the resident was totally dependent on staff for transfers, and had [DIAGNOSES REDACTED]. The resident's current Care Plan indicated that the resident was to be mechanically lifted with the use of a Hoyer Lift. A Nurse's Note of 12/16/2010 at 5:00 p.m. documented that Resident #1 had been lifted via a Hoyer Lift from the chair to the bed when the Hoyer Lift pad flipped and the resident fell to the floor. This Note documented that the resident was assessed to have a raised bluish area on the left lower leg, and documented that when contacted, the physician gave an order to transfer the resident to the hospital for evaluation. A Nurse's Note of 12/16/2010 at 6:39 p.m. documented the resident's hospital transfer. A Nurse's Note of 12/17/2010 at 4:30 p.m. documented that the resident had returned to the facility from the hospital after having been diagnosed with [REDACTED]. The 12/16/2010 facility Incident/Accident Report which referenced Resident #1's fall documented that the resident had fallen forward from the Hoyer pad onto the floor. A 12/16/2010 written statement of Certified Nursing Assistant (CNA) "DD" documented that as she and another CNA were putting Resident #1 to bed, they positioned the resident onto the Hoyer net and lifted the resident slightly off the shower chair, and the resident then suddenly fell forward. During an interview with the Administrator conducted on 01/04/2011 at 12:15 p.m., the Administra… | 2014-07-01 |
| 10345 | 10345 | AMARA HEALTH CARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2010-02-01 | 456 | D | 1 | 0 | KVUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to maintain patient care equipment in safe operating condition, related to one (1) of two (2) mechanical lifts utilized in the facility. Findings include: Record review for Resident #5 revealed a Minimum Data Set assessment of 02/02/2010 which indicated that the resident had a history of [REDACTED]. During an observation of a transfer of Resident #5 on 02/01/2010 at 11:00 a.m., two (2) certified nursing assistants (CNAs) were transferring the resident from the wheelchair to the bed via a mechanical lift. The resident was lifted up and over the bed via the lift, but then the lift malfunctioned. The lift would not respond to lower the resident onto the bed, and the resident was suspended in the lift sling above the bed. The CNAs alerted supervisors and maintenance staff, and two (2) replacement batteries were installed, but the lift continued to fail to respond, still leaving the resident suspended over the bed. Eventually, two (2) maintenance staff members evenly caused the lift to lower the resident onto the bed. The resident remained suspended in the lift over the bed for approximately 15 minutes before finally being placed in the bed via the lift. During an interview on 02/01/2010 at the time of the observation referenced above, three (3) CNAs stated that the lift had not been working correctly for weeks, and that this had been reported. | 2014-07-01 |
| 10346 | 10346 | AMARA HEALTH CARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2010-02-01 | 309 | D | 1 | 0 | KVUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide a wound treatment, as ordered by the physician, to one (1) resident (#3) on the survey sample of six (6) residents. Findings include: Record review for Resident #3 revealed that the January 2010 Treatment Record documented that the resident had [DIAGNOSES REDACTED]. A 01/07/2010 Wound Healing Center Physician order [REDACTED]. However, the January 2010 Treatment Record referenced above documented that on the dates of 01/08/2010, 01/09/2010, 01/10/2010, 01/11/2010, 01/12/2010, 01/13/2010, 01/14/2010, 01/16/2010, 01/17/2010, 01/18/2010, 01/19/2010, 01/20/2010, 01/21/2010, 01/23/2010, 01/24/2010, 01/25/2010, and 01/26/2010, the treatment had been done only once per day, on the 3:00 p.m. - 11:00 p.m. shift. During an interview with Nurse "AA" conducted on 01/27/2010 at 1:30 p.m., this nurse stated that it appeared that when the Wound Clinic changed the foot treatment order on 01/07/2010 from a previously existing order, the new treatment order did not get changed on the Treatment Record, and further acknowledged that treatments had been done only once daily. | 2014-07-01 |
| 10347 | 10347 | AMARA HEALTH CARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2009-10-08 | 309 | J | 1 | 0 | YP7611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received laboratory testing, and timely drug therapy, as ordered related to the administration of the anticoagulant drugs [MEDICATION NAME] and Aspirin. This resulted in serious harm to Resident #3, who was subsequently hospitalized with bruises, bleeding gums, and a [DIAGNOSES REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed on 09/28/2009 and continues. Findings include: Record review for Resident #3 revealed an 08/24/2009 Minimum Data Set assessment which documented that the resident was admitted to the facility on [DATE]. Admission physician's orders [REDACTED].) by mouth daily, [MEDICATION NAME] 75 mgs. by mouth daily, and aspirin 81 mgs. by mouth daily. The resident's September 2009 Medication Record documented that the resident received these drugs daily during the month of September, as ordered, and documented that the resident had [DIAGNOSES REDACTED]. A physician's admission order of 08/13/2009 specified that the laboratory tests Pro-[MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) be done on 08/17/2009, and then every two weeks thereafter. Therefore, in addition to the PT/INR laboratory test due on 08/17/2009, PT/INR tests were due on 08/31/2009 and 09/14/2009. The initial PT/INR results on 08/17/2009 indicated a PT of 19.10 (reference range, 10.0-13.0) and an INR of 2.3 (reference range, 2.0-3.0), with a hemoglobin of 12.1 (reference range 12.5-16.0). However, further record review revealed no evidence to indicate that the ordered PT/INRs were drawn on 08/31/2009 or on 09/14/2009. During an interview conducted on 10/07/2009 at 3:00 p.m., Laboratory Supervisor "CC" acknowledged that PT/INR laboratory tests … | 2014-07-01 |
| 10348 | 10348 | AMARA HEALTH CARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2009-10-08 | 502 | J | 1 | 0 | YP7611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received laboratory testing as ordered related to the administration of the anticoagulant drugs [MEDICATION NAME] and Aspirin. This resulted in serious harm to Resident #3, who was subsequently hospitalized , diagnosed with [REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed on 09/28/2009 and continues. Findings include: Record review for Resident #3 revealed admission physician's orders [REDACTED].) by mouth daily, [MEDICATION NAME] 75 mgs. by mouth daily, and aspirin 81 mgs. by mouth daily. A physician's admission order of 08/13/2009 specified that the laboratory tests Pro-[MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) be done on 08/17/2009, and then every two weeks thereafter. A laboratory Patient Requisition of 08/14/2009 also indicated that PT/INR tests were to be done starting on 08/17/2009, and then every two weeks. Further record review revealed that the initial PT/INR laboratory tests were done on 08/17/2009, however, there was no evidence to indicate that the PT/INRs were drawn on 08/31/2009 or on 09/14/2009, as ordered and requisitioned. During an interview conducted on 10/07/2009 at 3:00 p.m., Laboratory Supervisor "CC" acknowledged that PT/INR laboratory tests had not been done on 08/31/2009 and 09/14/2009, as ordered. A Nurse's Note of 09/24/2009 at 7:00 p.m. documented that bruising was observed to the resident's inner right thigh, bilateral underarms, left outer thigh, and left side, and that when the physician was notified of the bruises, the physician ordered PT/INR laboratory tests. The Physician's Telephone Orders sheet of 09/24/2009, timed at 7:54 p.m., ordered a "Stat" PT/INR. However, record re… | 2014-07-01 |
| 10349 | 10349 | AMARA HEALTH CARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2009-10-08 | 281 | J | 1 | 0 | YP7611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received services in accordance with professional standards of practice. This resulted in serious harm to Resident #3, who was subsequently hospitalized with bruises, bleeding gums, and a [DIAGNOSES REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed on 09/28/2009 and continues. Findings include: Article 43-26-1, The Georgia Registered Professional Nurse Practice Act, Chapter Two - Standards of Nursing Practice, Part 2.2.2., Standards Related to Registered Nurse Responsibility for Nursing Practice Implementation, specifies that the registered nurse will implement treatments and therapy, including medication administration. Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received laboratory testing, and timely drug therapy, as ordered. This resident received the anticoagulant drugs [MEDICATION NAME] and Aspirin. This failure to provide services in accordance with professional standards of practice resulted in Resident #3 being hospitalized with bruises, bleeding gums, and a [DIAGNOSES REDACTED]. Cross refer to F309 and F502 for more information regarding Resident #3. | 2014-07-01 |
| 10350 | 10350 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 309 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow physician's orders related to a bed/chair alarm and blood pressure parameters for two (2) residents (#5 and # 16) from a sample of twenty four (24) residents. Findings include: 1. Observation of resident #5 on 8/24/09 at 8:35 a.m. with Rehabilitation tech "YY" revealed the resident in bed with a sensor alarm on the bed and wheelchair. Observation of incontinence care provided by Certified Nursing Assistant (CNA) "XX" on 08/24/09 at 12:35 p.m. revealed that the bed alarm started sounding. The CNA turned it off and continued care. Review of the clinical record for resident #5 revealed a physician's order dated 8/18/09 to discontinue the bed/chair alarm. Continued review revealed an Interdisciplinary Progress Note dated 08/18/09 indicating that the bed/chair alarm had been discontinued. During interview, record review and observation with Unit Manager (UM) "ZZ" on 08/25/09 at 4:00 P.M., she acknowledged that the bed/chair alarm had not been discontinued as ordered by the physician. 2. Review of the clinical record for resident #16 revealed a [DIAGNOSES REDACTED]. Review of the June, July, and August, 2009 Medication Administration Records (MAR) revealed that the resident received the [MEDICATION NAME] fourteen (14) times when the SBP was less than 120. Interview on 08/26/09 at 11:10 a.m. with, Licensed Practical Nurse (LPN) Unit Manager "CC" revealed that the [MEDICATION NAME] was documented as given on the days it should have been held. | 2014-07-01 |
| 10351 | 10351 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 244 | D | 0 | 1 | 2MEL11 | Based on review of the Resident Council meeting minutes and residents and staff interview, the facility failed to actively work to resolve continued grievances related to timely response to call lights. Findings include: During a group interview on 08/25/09 at 10:00 a.m., eleven (11) of thirteen (13) residents in attendance revealed that they had ongoing problems with timely responses to call lights and that they had voiced these concerns to the facility during Resident Council meetings on more than one occasion. Eleven (11) residents revealed that although the average response time to a call light was about 15 minutes; response time could take 45 minutes or more and was l an ongoing problem. The group members revealed that the greatest concern was not with the initial response to the call light but with the Certified Nursing Assistants (CNA) entering the residents' rooms, turning off the call light, and informing the resident that the CNA would inform the assigned CNA to return to assist the resident. However,on these recalled occasions no one would return. The residents indicated that either ultimately no one followed up with them or that, after long waits, the residents turned the light on again and repeated the process. During an interview with random resident "B", assessed as cognitively intact, on 08/26/09 at 9:00 a.m., he/she revealed that the call light concern had come up more than a few times at the Resident Council meetings and could not recall any specific response from the facility to address the problem about lights being turned off without assistance and follow up care. During an interview with the Activities Director on 08/26/09 at 1:30 p.m., she revealed that she attended and took minutes at each meeting for the residents. She revealed that she recalled that the subject of call light response had come up several times over the last six months during the Resident Council meetings. She cited examples of complaints about a call light on the floor for one resident's roommate and complaints on more th… | 2014-07-01 |
| 10352 | 10352 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 322 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that the appropriate amount of flush/water was administered per Gastrostomy Tube as ordered by the physician for one (1) randomly observed resident during Medication Pass. Findings include: During and observation of Medication Pass on 08/25/09 at 9:01 a.m., Registered Nurse (RN) "JJ", flushed a gastrostomy tube ([DEVICE]) with 120 milliliters (ml) of water after having checked for residual and placement of the tube. Interview on 8/25/09 at 9:01 a.m. with RN "JJ" revealed that she had flushed the tube with 120ml of water. Review of the physician's orders [REDACTED]. Interview at 10:00 a.m. on 08/25/09 with RN "JJ" revealed that she needed to give the resident 230ml more water for hydration purposes. | 2014-07-01 |
| 10353 | 10353 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 441 | D | 0 | 1 | 2MEL11 | Based on observation and staff interview the facility failed to maintain an environment free of the likelihood of infection for one (1) randomly observed resident during Medication Pass. Findings include: Observation during Medication Pass on 08/25/09 at 10:30 a.m. revealed Registered Nurse (RN) "JJ" administering medication to the resident by spoon. After administering a spoonful of pills to the resident the placed the cup of pills with the spoon inside onto the unclean, uncovered bedside table, so that she could give the resident some water. As she began to pick the cup up with the spoon in it, an orange capsule fell out onto the unclean bedside table. "JJ" scooped it up with the spoon, put it back into the cup with the other pills and continued to administer them to the resident. Interview with Licensed Practical Nurse (LPN), Unit Manager "CC" on 08/25/09 at 10:35 a.m. revealed that since it was a orange capsule and easily identifiable it should have been discarded and replaced. It should not have been administered to the resident after it fell on an unclean surface. | 2014-07-01 |
| 10354 | 10354 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 315 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, failed to perform incontinence care in a manner to prevent urinary tract infection [MEDICAL CONDITION] for one (1) resident ( #9) from a sample size of twenty-four (24) residents. Findings include: Observation of incontinence care for resident #9 on 08/25/09 at:28 a.m. provided by Certified Nursing Assistant (CNA) "GG" assisted by Licensed Practical Nurse (LPN) "FF" revealed the CNA used the same disposable wipe a total of seventeen (17) [MEDICAL CONDITION] up and down the right inner thigh and then wiped the middle labia without changing the wipe. The CNA obtained a new wipe and wiped twenty-four (24) [MEDICAL CONDITION] on the left inner thigh and then cleaned the inner vaginal area without rearranging or obtaining a new wipe. The resident was repositioned on his/her left side and after the CNA obtained a new wipe,she wiped repeatedly over the back area and around the open wound area on the gluteal fold using the same wipe. During an interview with CNA "GG" on 08/25/09 at 10:15 a.m. she revealed that she had recently attended inservices on incontinence care. Review of the facility 's policy and inservices on perineal care revealed that for females the labia should be gently separated using downward [MEDICAL CONDITION] from the pubic to rectal area using alternate sites of the cloth with each downward stroke. | 2014-07-01 |
| 10355 | 10355 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 156 | C | 0 | 1 | 2MEL11 | Based on record review and staff interview, the facility failed to ensure that liability and appeal notices for medicare non-coverage were provided for fifteen (15) of seventeen (17) resident records reviewed. This included thirteen (13) randomly-reviewed residents and two (2) residents (#6 and #10) from twenty four (24) sampled residents. Findings include: Review of residents discharged from Medicare services revealed seventeen (17) residents were identified by the facility as no longer meeting the criteria for skilled medicare services, all of whom were still in the facility. Continued review revealed only two (2) Notices of Medicare Provider Non-Coverage forms were located. Interview on 08/26/09 at 11:20 a.m. with the Administrator revealed that she was aware there was a problem with liability notices. Of the seventeen (17) residents discharged from Medicare services in the last three (30 months, only two (2) residents received non-coverage notices. Review of these two Notices revealed that there was no date as to when they had been sent, and no description of the services that were no longer covered. | 2014-07-01 |
| 10356 | 10356 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 502 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that laboratory specimens were drawn as ordered by the physician for one (1) resident (#9) of twenty -four (24) sampled residents. Findings include: Record review of resident #9 revealed [DIAGNOSES REDACTED]. Review of the physicians' orders revealed an order dated 07/25/09 for a [MEDICATION NAME] Time with International Ratio (PT with INR) every Monday and Thursday. Record review revealed no evidence that this laboratory test had been completed on Monday, 08/10/09 or Thursday, 08/13/09. During an interview with the Unit Manager Licensed Practical Nurse (LPN) "CC" on 08/24/09 at 3:45 p.m. she revealed, after checking her records and with the laboratory, that the [MEDICATION NAME] with INRs were not done as ordered. | 2014-07-01 |
| 10357 | 10357 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 279 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a plan of care for the use of [MEDICATION NAME] (a blood thinning medication) for one (1) resident (#4) of the twenty-four (24) sampled residents. Findings include: Review of the clinical record for resident #4 revealed a [DIAGNOSES REDACTED]. Further review of the clinical record revealed no evidence that a plan of care had been developed for the use of [MEDICATION NAME]. Interview with the Minimum Data Set (MDS) Coordinator on 8/24/09 at 1:56 p.m. revealed that there was no plan of care for [MEDICATION NAME] and indicated that there should have been one developed. | 2014-07-01 |
| 10358 | 10358 | MANOR CARE REHABILITATION CENTER - MARIETTA | 115283 | 4360 JOHNSON FERRY PLACE | MARIETTA | GA | 30068 | 2009-04-03 | 315 | E | 1 | 0 | ENNJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide incontinence care in a manner to prevent the spread of urinary tract infections for four (4) residents (#s 1, 2, 3 and 4), who were incontinent and were dependent on staff for toileting, on the survey sample of seven (7) residents. Findings include: 1. Record review for Resident #1 revealed a 03/18/2009 Minimum Data Set (MDS) assessment which indicated that the resident was incontinent of bowel and bladder and was totally dependent on staff for toilet use. During an observation of incontinence care provided to Resident #1 on 04/02/2009 at 7:10 p.m. by Certified Nursing Assistant (CNA) "AA", the CNA placed on gloves and proceeded to clean the resident's rectal area, but failed to clean the resident's front perinea area. The CNA continued to provide care to the resident wearing the soiled gloves used to clean the rectal area, placing a clean diaper and gown on the resident. 2. Record review for Resident #2 revealed a 03/06/2009 MDS assessment which indicated that the resident was incontinent of bowel and bladder and was totally dependent on staff for toilet use. During an observation of incontinence care provided to Resident #2 on 04/02/2009 at 7:25 p.m. by CNA "AA", the CNA placed on gloves prior to providing care, and cleaned the front perinea with a back-to-front wipe. Then, wearing the same gloves used to provide incontinence care, the CNA placed a clean diaper and gown on the resident and pulled the sheets up around the resident. 3. Record review for Resident #3 revealed a 01/06/2009 MDS assessment which indicated that the resident was frequently incontinent of bowel and bladder and required the extensive assistance of staff for toilet use. During an observation of CNA "BB" providing incontinence care to Resident #3 on 04/02/2009 at 7:45 p.m., after cleaning stool from the resident, the CNA placed cream on the resident's buttocks and rectal area, and t… | 2014-07-01 |
| 10359 | 10359 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2010-04-12 | 309 | D | 1 | 0 | 4GY711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer a medication as ordered by the physician to one (1) resident (#3) on the survey sample of seven (7) residents. Findings include: Record review for Resident #3 revealed a physician's orders [REDACTED]. The February 2010 Medication Record (MR) documented that the [MEDICATION NAME] 125 milligram-per-dose therapy was initiated for the 10:00 p.m. dose on 02/04/2010. However, further record review, to include review of the February MR, revealed no evidence to indicate that the resident received the prescribed [MEDICATION NAME] on 02/12/2010, 02/13/2010 and 02/14/2010. During an interview conducted on 04/12/2010 at 3:00 p.m., the Administrator acknowledged that there was no evidence to indicate that the resident received the prescribed [MEDICATION NAME] on 02/12/2010, 02/13/2010 and 02/14/2010. | 2014-07-01 |
| 10360 | 10360 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-04-06 | 323 | G | 1 | 0 | 5ZN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility document review, the facility failed to ensure that two (2) residents (#s 1 and 3), on the survey sample of eight (8) residents, received adequate supervision during transfer and/or the provision of care. This resulted in Resident #3 experiencing a right-leg fracture, thus representing actual harm to the resident. Findings include: 1. Record review for Resident #3 revealed a 02/10/2009 Minimum Data Set (MDS) assessment which indicated that the resident was totally dependent on staff for transfers. A Care Plan entry of 02/12/2009 specified the use of two (2) staff for transfers at all times. A Nurse's Note of 03/28/2009 at 10:00 a.m. documented that the resident was observed with swelling and pain of the right knee, and documented extreme heat on the knee. This Note documented that the physician was called and gave an order to transfer the resident to the hospital emergency room for evaluation. A Nurse's Note of 03/28/2009 at 10:25 a.m. documented that the transport service had arrived and transported the resident to the hospital. A subsequent Nurse's Note of 03/28/2009 at 2:30 p.m. documented that the resident had returned to the facility from the hospital with a splint on the right leg and a [DIAGNOSES REDACTED]. Review of the facility's investigation into this resident's injury revealed a 03/31/2009 written statement by Certified Nursing Assistant (CNA) "BB". In this statement, CNA "BB" documented that on 03/28/2009, she had transferred Resident #3 with the Hoyer lift without any assistance, and that during the transfer, the resident had hit his/her leg against the bed when the CNA was attempting to turn the resident around and place him/her in the Geri-Chair. The CNA further documented that when she laid the resident down, she noted swelling to the resident's right leg. 2. Record review for Resident #1 revealed a 01/09/2009 MDS assessment which indicated that the resident was totally de… | 2014-07-01 |
| 10361 | 10361 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-04-06 | 282 | G | 1 | 0 | 5ZN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility document review, the facility failed to ensure that one (1) resident (#1), on the survey sample of eight (8) residents, was transferred in accordance with the resident's written plan of care. This resulted in Resident #3 experiencing a right-leg fracture, thus representing actual harm to the resident. Findings include: Record review for Resident #3 revealed a Care Plan entry of 02/12/2009 which specified the use of two (2) staff for transfers at all times. A Nurse's Note of 03/28/2009 at 10:00 a.m. documented that the resident was observed with swelling and pain of the right knee, and documented that the physician was called and gave an order to transfer the resident to the hospital. A subsequent Nurse's Note of 03/28/2009 at 2:30 p.m. documented that the resident had returned to the facility from the hospital with a [DIAGNOSES REDACTED]. In a 03/31/2009 written statement by Certified Nursing Assistant (CNA) "BB", this documented that on 03/28/2009, she had transferred Resident #3 with the Hoyer lift without any assistance, and that during the transfer, the resident had hit his/her leg against the bed. The CNA further documented that when she laid the resident down, she noted swelling to the resident's right leg. Cross refer to F323, example 1, for more information regarding Resident #3. | 2014-07-01 |
| 10362 | 10362 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-02-11 | 157 | G | 1 | 0 | O2A612 | Based on record review and staff interview the facility failed to notified the resident's attending physician of blood glucose levels which would require medical intervention. This affected two (2) residents (#10 and #11) from a sample of eighteen (18) residents. The findings include: 1. Record review for resident #10 revealed sliding scale blood glucose monitoring was to be conducted four (4) times daily. The resident's insulin administration was based on this blood glucose monitoring. A review of the resident's Medication Administration Records (MAR) on 2/08/09, 2/09/09, 2/26/09 and 3/05/09 recorded the resident's blood glucose results were below 60. Review of the clinical record revealed the physician had not been notified. An interview with the facility's Director of Nursing (DON) on 3/17/09 at 9:00 a.m. confirmed that the resident's physician was not notified about the low blood sugar results. 2. Record review for resident #11 revealed sliding scale blood glucose monitoring was to be conducted two (2) times per day. The resident's insulin dosage was based on this blood glucose monitoring. A review of the resident's MAR indicated [REDACTED]. An interview with charge nurse LPN "AA" on 3/18/09 at 1:15 p.m. confirmed that physician was not notified about the high blood sugar results. The facility's Diabetic Care Protocol policy directed that the resident's physician be notified if the blood sugar results were less than 60 or more than 400. | 2014-07-01 |
| 10363 | 10363 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-02-11 | 333 | G | 1 | 0 | O2A611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that one (1) resident (#1), in a survey sample of ten (10) residents, was free of a significant medication error, regarding the failure to administer the prescribed dose of [MEDICATION NAME] intended to address the resident's extrapyramidal symptoms resulting from antipsychotic drug therapy. This represented actual harm, as the resident's extrapyramidal symptoms subsequently worsened. Findings include: Record review revealed a Nurse's Note of 09/05/2008 which documented that the resident had been admitted to the facility. A 09/06/2008 physician's orders [REDACTED]. The October and November 2008 Medication Records documented that the resident received doses of [MEDICATION NAME] every six (6) hours as ordered through 11/13/2008. An 11/13/2008 Nurse's Note at 12:25 p.m. documented that a physician's orders [REDACTED]. A Nurse's Note of 11/19/2008 at 11:10 a.m. documented that due to the resident's behavior, the physician had ordered to restart [MEDICATION NAME] 1 milligram every six hours, and to continue the [MEDICATION NAME] therapy. The November Medication Record documented that [MEDICATION NAME] therapy was discontinued on 11/13/2008 and restarted on 11/19/2008 as ordered, and that [MEDICATION NAME] therapy was initiated and administered as ordered from 11/13/2008 through 11/30/2008. The December 2008 Medication Record documented that the [MEDICATION NAME] and [MEDICATION NAME] therapy were administered as ordered from 12/01/2008 through 12/18/2008. Then, a 12/18/2008, 1:10 p.m. Nurse's Note documented that new physician's orders [REDACTED]. The December 2008 Medication Record documented that the [MEDICATION NAME] was changed to be administered on an as-needed basis, and the dose of [MEDICATION NAME] was increased to 75 milligrams twice daily, on 12/18/2008 as ordered, and documented that the resident received these drugs as ordered through 12/31/2008. A Nurse'… | 2014-07-01 |
| 10364 | 10364 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-02-11 | 498 | D | 1 | 0 | O2A611 | Based on review of a facility investigation and hospital record review, one (1) certified nursing assistant (CNA) ("XX"), of six (6) CNAs reviewed, was found to be legally intoxicated while performing duties. Findings include: Review of the Separation Notice for CNA "XX" dated 01/28/2009 revealed that the circumstance of the separation was a gross company violation. The Personnel Action form referencing CNA "XX" documented that during rounds, the charge nurse had smelled alcohol on the CNA and that when the CNA was sent to the hospital for alcohol testing, the CNA failed the test. The Alcohol Testing Form documented a positive result of 0.091 on 01/28/2009. | 2014-07-01 |
| 10365 | 10365 | FAIRBURN HEALTH CARE CTR, INC | 115298 | 178 WEST CAMPBELLTON STREET | FAIRBURN | GA | 30213 | 2009-03-03 | 309 | E | 1 | 0 | TK3H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to do Accuchecks in accordance with physicians' orders for six (6) residents (#s 1, 2, 3, 4, 5 and 6) out of eleven (11) sampled residents. Findings include: 1. Record review for Resident #1 revealed that the Medication Record (MR) documented that the resident had [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The resident also had a current physician's orders [REDACTED]. However, review of the resident's MR for the month of November 2008 revealed no evidence to indicate that Accuchecks were done as ordered and scheduled on 11/08/2008 at 6:30 a.m. and on 11/13/2008 at 4:30 p.m. Review of the November 2008 and December 2008 MR revealed that for the dates of 11/25/2008, 12/01/2008, 12/03/2008 and 12/24/2008, the nurse had initialed the 6:30 a.m. Accuchecks on the MR, circled the initials, and documented in the Nurse's Medication Notes of the MR that the Accuchecks were not done because no strips were available. 2. Record review for Resident #2 revealed that the MR documented that the resident had [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. However, review of the MR for the month of December 2008 revealed no evidence to indicate that Accuchecks were done as ordered and scheduled for the dates of 12/21/2008 and 12/26/2008 at 11:30 a.m., and for 12/10/2008 and 12/16/2008 for at 9:00 p.m. Additional review of this MR revealed that for the dates of 12/02/2008 and 12/24/2008, the nurse had initialed the 6:30 a.m. Accuchecks on the MR, circled the initials, and documented in the Nurse's Medication Notes of the MR that the Accuchecks were not done because no strips were available. 3. Record review for Resident # 3 revealed a current physician's orders [REDACTED]. However, review of the November and December 2008 MRs revealed no evidence to indicate that Accuchecks were done as ordered and scheduled on 11/08/2008 and 12/22… | 2014-07-01 |
| 10366 | 10366 | FIFTH AVENUE HEALTH CARE | 115319 | 505 NORTH FIFTH AVENUE | ROME | GA | 30165 | 2011-02-15 | 333 | D | 1 | 0 | OE0W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to ensure that residents were free of significant medication errors for two (2) residents ("A" and #2) in a survey sample of seven (7) residents. Findings include: 1. Record review for Resident "A" revealed that the January 2011 physician's orders [REDACTED]. Review of a Medication Upon Discharge form for Resident "A" revealed that medications provided to the resident upon discharge from the facility had included [MEDICATION NAME] 1 milligram, [MEDICATION NAME] 10 milligrams and [MEDICATION NAME] 600 milligrams. However, further review of the resident's medical record, including review of the resident's January 2011 physician's orders [REDACTED]. A Grievance/Complaint Report dated 01/09/2011 filed for the family of the resident documented that the resident had been discharged on [DATE], and the family had identified on 01/05/2011 that the resident had been given three (3) of another resident's medications upon discharge, those medications being [MEDICATION NAME] and [MEDICATION NAME]. This Report also documented that Resident "A" had taken three (3) [MEDICATION NAME], two (2) [MEDICATION NAME] and two (2) [MEDICATION NAME], and that these medications had been sent home by accident with the resident. During interview with a family member of Resident "A" conducted on 02/02/2011 at 2:55 p.m., this family member stated that the resident had been discharged from the facility on 01/05/2011. It was stated that the family later discovered, during review of the resident's medications, that medications provided to the resident by the facility at discharge had included three (3) medications that belonged to another resident. It was further stated by the family member that when discussing the incident with the Director of Nursing, she was informed by the Director of Nursing that, based on a medication count of the medication cards, the resident had taken doses of the medic… | 2014-07-01 |
| 10367 | 10367 | FIFTH AVENUE HEALTH CARE | 115319 | 505 NORTH FIFTH AVENUE | ROME | GA | 30165 | 2011-02-15 | 502 | D | 1 | 0 | OE0W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide a potassium level laboratory test in a timely manner, as requested by the nurse practitioner, for one (1) resident (#2) in a survey sample of seven (7) residents. Findings include: Cross refer to F333, Example 2, for more information regarding Resident #2. Record review for Resident #2 revealed a Telephone Orders sheet which referenced a physician's orders [REDACTED]. However, review of the January 2011 Medications sheet revealed that doses of Potassium Chloride 10 milliEquivalents were administered to the resident twice a day, at 9:00 a.m. and 9:00 p.m., on 01/18/2011, 01/19/2011, 01/20/2011, and 01/21/2011, and for the morning dose on 01/22/2011. During interview with the nurse practitioner on 02/02/2011 at 10:45 a.m., this nurse practitioner stated that when she was notified by facility staff during the weekend that the resident's potassium was not discontinued on 01/17/2011, as ordered, she had requested that a potassium level be drawn. However, the nurse practitioner stated she was told by the facility nurse that the nurse could not access the supplies necessary to perform the laboratory test because the supplies were locked up and the nurse supervisor did not have a key, and the hospital would not come to the facility to do the potassium level. Therefore, the nurse practitioner stated that rather than ordering that the potassium level be done as originally requested, the nurse practitioner gave an order to check the potassium level on the following Monday. | 2014-07-01 |
| 10368 | 10368 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 157 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to notify the physician when one resident ("D") who received anticoagulant therapy and was at risk for bleeding, developed unexplained bruising from a sample of thirty-eight (38) residents. Findings include: Record review revealed resident "D" was admitted with multiple health concerns and [DIAGNOSES REDACTED]. The resident was identified by facility assessment and care planned as at risk for bleeding. A Nurse's Admission/Post Hospital Record dated 4/06/12, contained documentation of areas of bruising to the resident's hands. Review of Skilled Daily Nurses Notes dated from 4/06/12 through 5/07/12 continued to document areas of bruising on the resident. During interview with resident "D" on 5/10/12 at 9:09 a.m. she made reference to the bruises that kept reoccurring over her body and she did not know why or what caused them. Review of facility's policy on Resident's Receiving [MEDICATION NAME] Therapy contained instruction that all signs and symptoms of bruising were to be reported to the physician. Review of physician's progress notes indicated no documentation that the MD was aware of the resident's bruising or had been notified of the bruising. Interview with the Director of Nurses on 5/11/12 at 9:42 a.m. revealed the nursing staff should have contacted the physician about the resident's bruises. | 2014-07-01 |
| 10369 | 10369 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 507 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility failed to ensure that laboratory reports were available in the resident's chart and that the physician was notified of the results for three (3) residents (#1, and #103) of thirty-eight (38) sampled residents. Findings include: 1. Resident #1 had a physician's orders [REDACTED]. The previous TSH was done on 2/08/12 with a result of 0.2 (0.35-5.6) which was low with an physician's orders [REDACTED]. An interview on 5/9/12 at 11:45 a.m. with Licensed Practical Nurse (LPN) "JJ" agrees the TSH is not in the chart. LPN "JJ" called the lab and found that the lab had been done on 3/21/12 and had them fax a copy to the facility. The TSH results were 1.71 (0.35-5.6) which are within normal limits. An interview with Licensed Practical Nurse (LPN) on the same day at 2:00 p.m. revealed that the laboratory results needed to be sent to the physician for signature, as the physician had not been notified of the results. 2. Record review for resident #103 revealed that he was receiving [MEDICATION NAME]. Further record review revealed that he had telephone orders for PT/INR tests to be conducted on 2/23/12, 3/01/12 and 3/26/12. These labs results were not in the clinical record and had to be obtained by calling the laboratory used by the facility. Further record review of the clinical record of resident #103 revealed an order for [REDACTED]. A call to the clinical laboratory was made by the facility's Clinical Manager at 10:45 a.m. on 5/09/12. She confirmed that the PT/INR and the BMP tests were performed but the results were not available in the facility and therefore were not in the resident's clinical record. The Clinical Manager also stated in an interview on 5/10/12 at 8:30 a.m. that she did not know if the attending physician had been made aware of the PT/INR or BMP lab results. | 2014-07-01 |
| 10370 | 10370 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 323 | E | 0 | 1 | FDH011 | Based on observation and staff interview the facility failed to keep all resident use and care areas free of accident hazards. Findings include: The second lunch service in the main dining room was observed on 5/09/12 at 1:00 p.m. There was a large amount of food and debris on the floor throughout the room. There was also a large puddle of clear liquid on the floor on the left side of the room from a previous spill. Three (3) ambulatory residents were observed walking in the room during the meal. Several staff members were assisting residents. No one made any attempt to clean up the spilled liquid and food. The Dietary Manager was interviewed on 5/11/12 at 10:10 a.m. and stated the nursing staff is responsible for cleaning food spills between meals. Licensed Practical Nurse (LPN) "JJ" was interviewed on 5/11/12 at 10:45 a.m. and stated she did not notice the spill or food particles. She further stated housekeeping did not clean the dining room between meal services unless requested. | 2014-07-01 |
| 10371 | 10371 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 365 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the facility failed to provide liquids at a consistency appropriate for the needs of it residents. This affected one (1) resident, #112, from a sample of thirty-eight (38) residents. Findings include: A review of the resident #112's physician orders [REDACTED]. There were current orders for nectar thickened and honey thickened consistency liquids. A review of a speech therapy discharge summary dated 11/15/11 revealed a recommendation for honey thick liquids. An observation of beverages in the resident's room on 5/9/12 at 10:00 a.m. revealed that he had 1 carton of honey thickened apple juice and 1 carton of honey thickened water on his over bed table. His personal refrigerator contained 2 cartons of nectar thickened water, 1 carton of nectar thickened lemonade, 2 cartons of nectar thickened apple juice and 1 carton of honey thickened water. In addition, his personal refrigerator contained 3 eight ounce bottles of Ensure Nutrition Shake of regular consistency. An interview with the resident's sister on 5/10/12 at 3:30 p.m. revealed that the family provided the Ensure Nutrition Shake for use in missing food items. The observation of the resident's beverages was confirmed with by the facility's Clinical Manager on 5/10/12 at 10:45 a.m. | 2014-07-01 |
| 10372 | 10372 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 280 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and staff interview the facility failed to develop a care plan with participation of all disciplines determined by the needs of one (1) resident, #112, from a sample of thirty-eight (38) residents. Findings include: Record review for resident #112 revealed that he was admitted to the facility on [DATE] and was under the care of a hospice provider. A review of the resident's care plan revealed no evidence of attendance by representatives of disciplines determined by the resident's needs. The resident had a [DIAGNOSES REDACTED]. He has several restrictions related to his diet and feeding technique, e.g., position to 90 degrees, feed 1/2 tsp bolus, spoon feed all liquids 1/2 tsp., feed to left side of face, remind resident to chin tuck, alternate liquids liquids and solids, ask resident to reswallow, nectar thickened liquids, pureed diet with honey thickened liquids, large portions. Further review of the clinical record revealed that he had been evaluated by a Speech Therapist (ST) from 10/27/11 to 11/15/11 to assess his chewing and swallowing abilities. A review of the ST's discharge summary revealed that recommendations were made as follows: pureed diet, honey-thick liquids, alternation of solids and liquids, rate modifications, bolus size modifications, second dry swallowing, chin tuck upright position for more than 30 minutes after meals. Further record review revealed that he had a current physician's orders [REDACTED]. A review of the residents current care plan revealed that it was updated on 10/27/11 and 11/01/11 to include these interventions. A review of the attendance record for the resident's care plan meetings revealed that the last recorded meeting was on 1/12/12. Further record review revealed that at that meeting the facility had no nursing, dietary, speech therapy, physical therapy, social service or physician representation at the meeting. No other documentation of care plan attendance records were in the clinic… | 2014-07-01 |
| 10373 | 10373 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 156 | E | 0 | 1 | FDH011 | Based on record review and staff interview, the facility failed to fully inform residents and or responsible parties of available options regarding Medicare benefits for three (3) of thirty-eight (38) sampled residents ( #21, #119 and # 123). Findings include: Record review of three (3) resident liability notices (# 21, #119, #123) found that the facility had notified resident and/or responsible party of the facility's intent to discontinue Medicare services within seventy-two (72) hours. However, they failed to provide the resident and his/her legal representative with CMS form Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) which notifies the resident and his/her representative of the estimated cost of these services in order for them to be able to make an informed decision as to whether or not to continue services and pay privately. Interview with the Business Office manager on 5/08/12 at 11:40 a.m. revealed she was not aware that she was supposed to provide residents and responsible parties with this information and that she had not completed this form for any resident. | 2014-07-01 |
| 10374 | 10374 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 164 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to maintain confidentiality of medical records for one resident, # 52 of a sample of thirty-eight (38) residents and for two (2) randomly observed records. This was related to a Medication Administration Record [REDACTED]. Findings include: On 5/08/12 at 8:20 a.m. on A-Hall a medication cart was left unattended with the Medication Administration Record [REDACTED]. The cart and record were unattended from 8:22 a.m. to 8:30 a.m. Licensed Practical Nurse (LPN) "II" was in room [ROOM NUMBER] with the door closed. She returned to the cart at 8:30 a.m. and stated she had left an orientee at the cart. She stated the cart should not have been left unattended with the resident's medication record left open to full view. Additionally, a Laboratory Report dated 5/07/12 was observed on a second cart at the same time at the other end of the A Hall. A nurse was observed to approach the second cart and then leave again. The report was not hidden from view. A second random observation was made on 5/08/12 at 2:29 p.m. The medication cart med on A-Hall had a set of physician's orders [REDACTED]. No staff was observed near the cart. LPN "GG" returned to the cart and stated she should not have left it unattended. The Administrator was interviewed on 5/10/12 at 3:20 p.m. and also stated the residents' records should have been protected from general view. | 2014-07-01 |
| 10375 | 10375 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 166 | E | 0 | 1 | FDH011 | Based on record review, staff and resident interviews, the facility failed to have an effective process in place to report missing items of clothing and to notify resident of status of search for one (1) resident ("C") from a sample of thirty- eight (38). Findings include: Interview with resident "CC" on 5/19/12 at 8:13 a.m. revealed she was missing a pair of pajamas for approximately one (1) week. She further revealed that she had told several staff persons. Record review of facility's Policy on Missing or Lost Resident Items was provided by Licensed Practical Nurse (LPN) "JJ" on 5/10/12 at 8:37 a.m. It contained documentation that a family member or resident was to complete a grievance report as soon as possible. The policy further included Social Services was to start the investigation and enter the missing item on the Missing Item Log. This log was also to note the outcome of the investigation and when the family was notified of dispensation of missing item. Record review of Missing Item Log for 2012 revealed only two entries, both in May 2012. Interview with the Administrator on 5/10/12 at 10:10 a.m. revealed the lost item log was maintained by Social Services. She further revealed that use of the log had just been implemented in May 2012 and that no documentation of lost items had been maintained prior to the log's implementation in May 2012. She was aware this did not meet the procedure outlined in the facility's policy for missing items. | 2014-07-01 |
| 10376 | 10376 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 167 | C | 0 | 1 | FDH011 | Based on observation and staff interview the facility failed to ensure that the most recent survey was available for examination and did not post where the survey results could be found. Findings include: During initial tour on 5/07/12 at 10:00 a.m. the survey results were not easily located nor was a posting of their location. Interview with the Administrator on 5/08/12 at 2:30 p.m. revealed that the survey results were kept inside the front office, which was locked, due to a wandering, confused resident. She agreed there was no signage to indicate where the survey results could be found. | 2014-07-01 |
| 10377 | 10377 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 225 | E | 0 | 1 | FDH011 | Based on record review and staff interview the facility failed to ensure that criminal background checks were conducted for all staff members prior to their employment. This finding was based on one (1) of ten (10) personnel records reviewed. Findings include: A review of a random sample of ten (10) personnel files of recently employed staff members revealed that a Licensed Practical Nurse (LPN) with an employment date of 3/16/12 did not have a criminal background check in his/her personnel record. The facility's Social Worker (SW) was able to print a copy of the background report by accessing the facility's vendor used for this service. The SW confirmed in an interview on 05/09/12 at 1:30 p.m that there was no evidence that the employee's criminal background report was obtained by the facility prior to his/her employment. | 2014-07-01 |
| 10378 | 10378 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 279 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, staff interviews and record review the facility failed to develop a comprehensive care plan for one (1) resident (#102) for resisting care and for incontinence from thirty-eight (38) sampled residents. Findings include: Resident #102 was admitted to this facility on 5/26/11 with multiple [DIAGNOSES REDACTED]. Record review revealed Minimum Data Set (MDS) annual assessment dated [DATE] had triggered urinary incontinence and indicated that it was to be addressed in the resident's care plan. The resident's two (2) quarterly MDS assessments dated 01/30/12 and 4/30/12 both contained documentation that resident #102 was not resistive to care and assessed the resident as continent of urine. Review of the resident's care plan dated 8/02/11 revealed it did not address urinary incontinence or a persistant rejection of care. Review of Nursing Notes dated 12/23/11, 12/28/11, 01/13/12, 01/18/12, 4/26/12, 5/04/12 contained documentation of the resident being resistant to care. Interview with Certified Nurses Assistant (CNA) "TT" on 5/9/12 at 2:00 p.m. revealed the resident often refuses care. She further stated that at least one (1) or two (2) times a day, the resident refused care for bathing or incontinent care. The resident exhibits behaviors of striking out to staff when they provide care. Interview with the MDS Coordinator "BB" on 5/10/12 at 11:35 a.m. revealed resident #102 was not care planned for incontinence and refusal of care. | 2014-07-01 |
| 10379 | 10379 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 309 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide care and services in accordance with the residents' current clinical orders. This affected three (3) residents (#71, #103 and #112) from a sample of thirty-eight (38) residents. Findings include: 1. A review of the clinical record of resident #103 revealed that he had a current physician's order for [MEDICAL CONDITION] Embolic Deterrent (TED) hose to be on in the morning and off in the evening. Observation on 5/09/12 at 10:30 a.m. revealed the resident was not wearing TED hose stockings. Interview with the Clinical Manager at that time verified the resident was not wearing TED stockings and that there was a sign on the resident's closet door with instructions on how to apply the TED hose with instructions to put on at 6:00 a.m. and take them off at bedtime. Observation on 5/10/12 at 8:30 a.m. revealed the resident was sitting in a Geri chair near the nursing station without the TED hose on. A review of the resident's clinical record at that time verified no change in the physician orders. 2. A review of the resident #112's physician orders revealed conflicting orders for the consistency of liquids on his diet. There were current orders for nectar thickened and honey thickened consistency liquids. A review of a speech therapy discharge summary dated 11/15/11 revealed a recommendation for honey thick liquids. An observation of beverages in the resident's room on 5/9/12 at 10:00 a.m. revealed that he had 1 carton of honey thickened apple juice and 1 carton of honey thickened water on his over bed table. His personal refrigerator contained 2 cartons of nectar thickened water, 1 carton of nectar thickened lemonade, 2 cartons of nectar thickened apple juice and 1 carton of honey thickened water. The observation of the resident's beverages was confirmed with by the facility's Clinical Manager on 5/10/12 at 10:45 a.m. Further review of the clinical record of resident #112 revea… | 2014-07-01 |
| 10380 | 10380 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 325 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that a resident receiving [MEDICAL TREATMENT] services was allowed sufficient time to complete dining prior to being transported to she scheduled [MEDICAL TREATMENT] appointment. This affected one (1) resident, "A", from a sample of thirty-eight (38) residents. Findings include: Record review for resident "A" revealed that she received [MEDICAL TREATMENT] services 3 times per week in the afternoon. An observation made on 5/09/12 at 1:15 p.m. revealed that lunch food trays arrived on Hall-A. Resident #27 received her lunch tray in her room but was only given approximately 5 minutes to eat her lunch before 2 transportation service employees entered her room to transport her to a [MEDICAL TREATMENT] center. The resident stated in an interview (via an interpreter) on 5/09/12 at 1:30 p.m. that she often does not have time to finish her lunch prior to having to leave to go to the [MEDICAL TREATMENT] center. An observation of her lunch meal tray that day revealed that approximately 25% of her food and 50% of her beverages were not consumed. This observation was verified at that time by LPN "GG". | 2014-07-01 |
| 10381 | 10381 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 329 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that unnecessary drugs were administered to residents. This effected one (1) resident, #103, from a sample of thirty-eight (38) residents. Findings include: Record review for resident #103 revealed that his attending physician had issued a telephone order to discontinue Risperdone 0.25 milligrams (mg) on 4/26/12. This medication had previously been given twice per day on a routine basis. A review of the current Physician order [REDACTED]. A review of the Medication Administration Record [REDACTED]. This information was confirmed by the facility's Clinical Manager on 5/09/12 at 10:30 a.m. She also confirmed in the interview that the resident was receiving the medication in error. | 2014-07-01 |
| 10382 | 10382 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 356 | C | 0 | 1 | FDH011 | Based on observation and staff interview the facility failed to include all required information on posted staffing hours and to ensure it was posted in an accessible area. Findings include: On 5/07/12 at 10:30 a.m. and on 5/08/12 at 9:00 a.m. the staffing hours were not posted in the facility. An interview with the Administrator on 5/09/12 at 4:30 p.m. revealed that a list of staff working for the day was posted behind the nurses station which the facility maintains for eighteen months. The Administrator confirmed that staffing hours or census were not included and this was not an accessible area for resident's or visitors. | 2014-07-01 |
| 10383 | 10383 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 431 | E | 0 | 1 | FDH011 | Based on observation and staff interview the facility failed to store all drugs in locked and secure compartments for two (2) Medication Administration Carts secured on one (1) (Hall-A) of three (3) halls. Findings include: On 5/07/2012 at 8:22 a.m. a medication cart at the beginning of Hall-A was left unattended and unlocked. It remained unattended from 8:22 a.m. to 8:30 a.m. Licensed Practical Nurse (LPN) "II" returned to the cart at 8:30 a.m. and stated she had left an orientee at the cart and agreed it should not have been left unlocked. No one else was observed by the cart, or in the hallway during this time. On 5/10/2011 at 2:30 p.m. a medication cart on Hall-A was again left unlocked and unattended with no one for three minutes. "LPN" "GG" returned to the cart and stated she should not have left it unlocked. On 5/10/2012 at 1:40 p.m. a resident in a wheelchair was observed to go up to a locked medication cart on Hall-A and place her right hand on top of the cart and pick up a bottle of Boost. There are several ambulatory residents on Hall-A and a confused resident from another hall was observed on the unit numerous times throughout the survey. | 2014-07-01 |
| 10384 | 10384 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 441 | F | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, staff interviews and record review the facility failed to establish and implement effective procedures for isolation of infectious diseases for one (1) resident # 83 of thirty-eight (38) sampled residents; to ensure that appropriate handwashing were used for dispensing ice to residents; during the serving and setup of meal trays in the main dining room, and that clean linens were handled in an appropriate manner to prevent possible contamination on one (1) of three (3) halls. Census=94. Findings include: 1. An interview on 5/10/12 at 12:00 p.m. with LPN "JJ", Infection Control Coordinator, during infection control review, revealed that residents with Clostridium Difficile (C-Diff) are allowed to leave their rooms as long as the stool was contained in the resident's brief. A red barrel is placed in the resident's bathroom for linens and trash. She stated the Centers for Disease Control (CDC) policy for isolation of[DIAGNOSES REDACTED], Methicillin resistant Staphylococcus aureus (MRSA) or [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) are followed. They do not use gowns but gloves are always available and linens and trash contaminated with fecal matter should be placed in the red barrels located in the bathroom. Resident who were admitted to the facility with an infection are not tracked on the infection Tracking Log. Further interview at 3:25 p.m. with LPN "JJ" revealed she felt the facility policy did meet the CDC requirements by having a 1:10 bleach solution available. She does not have a copy of the CDC recommendation but in the case of an infection that she does not know well, then she will print it off. On 5/10/12 at 12:55 p.m., LPN "JJ" provided the facility policy for[DIAGNOSES REDACTED] which was revised in August 2002. The policy did not include when or how to isolate for[DIAGNOSES REDACTED]. LPN explained visitors or staff are told by the nurse if a resident is in isolation. She offered that gowns are on… | 2014-07-01 |
| 10385 | 10385 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 504 | D | 0 | 1 | FDH011 | Based on Record review and staff interview the facility failed to ensure that all laboratory tests preformed were ordered by a physician for one (1) resident (#103) from a sample of thirty-eight (38) residents. Findings include: Record review of physician orders for resident #103 for PT/INR indicated that labs were to be drawn twice (2) a week. Record review of lab results for PT/INR indicated labs were drawn three (3) times a week for three (3) weeks. During the week of 4/08/12, labs were drawn 4/09/12, 4//12/12 and 4/13. For the week of 4/15/12, PT/INR labs were drawn on 4/16/12, 4/18/12 and 4/20/12. During the week of 4/22/12, PT/INR labs were drawn on 4/23/12, 4/25/12, and 4/27/12. Interview with the Administrator on 5/11/12 at 9:30 a.m. revealed there were no physician orders for the additional PT/INR's that had been drawn. | 2014-07-01 |
| 10386 | 10386 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 518 | F | 0 | 1 | FDH011 | Based on staff interviews and record review the facility failed to ensure that staff was trained for disasters, other than fire, when they begin to work at the facility and to periodically review procedures for all staff. Findings include: A interview on 5/9/12 at 10:14 a.m. with Certified Nursing Assistant ("KK") who works the day shift, revealed she has been employed for two (2 ) months. She stated she received no training on disaster preparedness upon hire. She wasn't aware of the facility policy regarding what to do in a tornado and was unsure of the procedure for dealing with a missing resident. A interview with Licensed Practical Nurse (LPN) "LL" at 10:20 a.m. revealed she normally works on the 3-11 p.m. shift. She had participated in fire drills but not disaster drills. She had been employed for two (2) years and received no disaster training upon hire. She was aware of a weather alert radio at the nurses station but during the 3-11 p.m. shift they have no staff at the nurses station. If a resident was missing she was not aware of who or how to report a missing resident. Observation on 5/07/12 at 3:30 p.m. while sitting at the nursing station, the weather alert radio was sending alerts but they could not be heard due to it being on low volume. Interview on 5/09/12 at 3:30 p.m. with Laundry Aide "ZZ" revealed she has been employed for eight (8) months. She did not go through training upon hire for disaster plan, only for fires procedures, and has not participated in disaster drills except for fire drills. She isn't sure what her role would be in case of a tornado or missing resident. An interview on 5/09/12 at 4:53 p.m. with LPN "PP" who normally works the weekend night shift and has been employed for six (6) months. She received no training upon hire except for fire drills and has not been through any actual or tornado drills. She does not know the difference between Tornado Warning and Watch. An interview on 5/09/12 at 4:59 p.m. with CNA "QQ" who has been employed for six (6) years at the facility. He has… | 2014-07-01 |
| 10387 | 10387 | GOLDEN LIVINGCENTER - THOMASTON | 115329 | 310 AVENUE F | THOMASTON | GA | 30286 | 2009-10-08 | 225 | D | 1 | 0 | BEB111 | Based on record review and staff interview, the facility failed to report to the State Agency (SA) within the required time frames an alleged physical abuse for one (1) resident (#1), from a sample size of seven (7) residents. Findings include: 1. Review of an Interdisciplinary Progress Note (IPN) and Verification of Investigation report dated 09/06/09 at 6:30 p.m. revealed that a family member asked Licensed Practical Nurse (LPN) 'AA' what happened to resident #1's face. After assessment, the LPN revealed that the resident had a one-centimeter (cm) scratch on the right cheek. A Social Services Progress Note dated 09/06/09 revealed that resident #1's daughter asked to speak to him regarding what she felt was a bite mark on the resident's face, since another resident previously had to be redirected out of his/her room. Interview on 10/07/09 at 4:36 p.m., with Certified Nursing Assistant (CNA) 'BB' revealed that she had witnessed resident #3 wander into resident #1's room, saw the two standing face to face with resident #1 holding resident #3's wrists and yelling at him/her to get out, and then resident #3 raising one of his/her hands toward resident #1, at which time the CNA stated she intervened. The CNA was unable to remember the date of this incident. Although there is documentation in resident #3's IPN notes dated 09/03/09 at 8:18 p.m. that he/she had fallen when in another resident's room, there is no documentation of an altercation between the residents. Review of a Facility Incident Report Form related to an injury of unknown origin for resident #1 revealed that the reported date of the alleged incident was 09/06/09. This initial report was faxed to the State Agency (SA) on 09/10/09. The facility's report of the final investigation was sent to the SA on 09/14/09. Interview on 10/07/09 at 2:50 p.m. with the Executive Director revealed that she was the facility's Abuse Coordinator, but was not working on 09/06/09. She acknowledged that she was contacted at home on 09/07/09 in the evening by the Social Service… | 2014-07-01 |
| 10388 | 10388 | GOLDEN LIVINGCENTER - THOMASTON | 115329 | 310 AVENUE F | THOMASTON | GA | 30286 | 2009-10-08 | 514 | D | 1 | 0 | BEB111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure accurate and readily accessible documentation in the clinical records for two (2) residents (#1, and #5) on a sample of seven (7) residents. Findings include: 1. Review of the Interdisciplinary Progress Notes for resident #5 dated 10/07/09 at 10:15 a.m. noted that the resident eloped off the premises and was found safe by the staff. Review of October physician's orders [REDACTED]. Interview on 10/08/09 at 8:42 a.m., with Licensed Practical Nurse (LPN) 'CC' revealed that the Wanderguard had been evaluated on 10/06/09 and it was determined that the bracelet could be discontinued. Continued interview revealed that the LPN got an order from the physician to discontinue the bracelet and did so, therefore, the resident did not have the Wanderguard bracelet on when he/she exited the building. Review of the Interdisciplinary progress notes dated 10/07/09 at 10:55 a.m. revealed that the Wanderguard was reapplied. Review of the Medication Administration Record [REDACTED]. Additionally, there was no documentation that the staff had checked the battery in the Wanderguard on 10/02/09-10/04/09. Interview with the Director of Nurses (DON) on 10/8/09 at 8:45 a.m. revealed that the documentation on the MAR indicated [REDACTED]. Continued interview revealed that there was no evidence that the battery had been checked on the bracelet from 10/02/09-10/04/09. 2. Interview on 10/08/09 at 1:15 p.m. with the DON revealed that the staff did frequent monitoring of resident #3 after physical abuse had been alleged by the family of another resident on 9/6/09. Review of the Safety Behavior Checks sheet revealed that the resident had been monitored on 9/6/09 every fifteen minutes on the 3-11 shift from 7:00 p.m. until 10:30 p.m. The resident was then monitored hourly on the 11-7 shift until 7:00 a.m. There was no evidence that the resident was monitored on 7-3 or 3-11 shift hourly. On 9/8/09 during … | 2014-07-01 |
| 10389 | 10389 | GOLDEN LIVINGCENTER - THOMASTON | 115329 | 310 AVENUE F | THOMASTON | GA | 30286 | 2009-10-08 | 280 | D | 1 | 0 | BEB111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plan for one (1) resident (#3) related to unsafe wandering, resistive, and aggressive behaviors. The sample size was seven (7) residents. Findings include: Review of resident #3's Interdisciplinary Progress Notes (IPN) dated 06/23/09, 07/08/09, 07/19/09, 08/29/09, 08/30/09, 09/08/09, 09/10/09, and 09/15/09 noted that the resident wandered in and out of other residents' rooms; had to be frequently redirected, and was uncooperative and/or fought or cursed with staff seven times on the above dates. Review of Social Services Progress Notes dated 05/04/09, 06/07/09, 08/06/09, and 10/02/09 noted the resident needed cueing and redirection; will resist and refuse care; wanders about facility; will be in others' rooms; and not easily redirected. Continued review revealed that on 09/14/09 a psychiatric consultation was obtained for recommendations for handling resident #3's behaviors, and that the careplan was to be continued. Review of the psychiatric screening done 09/14/09 revealed that the resident had the potential for harm/danger to self or others due to occasional episodes of combativeness and aggression, and wandering. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that resident #3 was assessed with [REDACTED]. There were no behavioral symptoms indicated, including wandering and resisting care. Review of the resident's care plan revealed there were no care plans or interventions in the clinical record related to the wandering, resistive, and aggressive behaviors. On 10/08/09 at 12:45 p.m., the SSD stated printed a behavior care plan developed for wandering that was in the computer however, it was a generic plan without individualized interventions to address all of the documented behaviors. Review of the 'Protecting Our Residents' section in the facility's policy 'Preventing Resident Abuse' noted that a care plan will be developed that refl… | 2014-07-01 |
| 10390 | 10390 | PRUITTHEALTH - AUGUSTA | 115334 | 2541 MILLEDGEVILLE ROAD | AUGUSTA | GA | 30904 | 2011-01-14 | 157 | D | 1 | 0 | UXHX11 | Based on record review and staff interview, the facility failed to immediately consult with the physician and notify the family when there was a change in condition related to skin integrity for one (1) of three (3) sampled residents (#3) with diabetic ulcers. Findings include: Record review for Resident #3 revealed a Care Plan identifying the resident to be at risk for skin breakdown. There was documentation on this Care Plan dated 11/29/2010 that the resident had a scabbed area with redness to his/her left lateral foot. However, further record review revealed no evidence to indicate that the physician and family were notified of this change in condition until 12/25/2010, when there was documentation in the Skin Notes indicating physician and family notification that the area was still present and that Duoderm was ordered every three (3) days. Interview with the Treatment Nurse on 01/13/2011 at 2:50 p.m. revealed she could find no evidence to indicate that staff had notified the physician and the family of the scabbed area to the resident's foot when it was first discovered on 11/29/2010. | 2014-07-01 |
| 10391 | 10391 | MIONA GERIATRIC & DEMENTIA CENTER | 115338 | 201 POPLAR STREET | IDEAL | GA | 31041 | 2010-09-23 | 365 | J | 1 | 0 | 9E5H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident medical record review, staff interview, resident interview, and facility investigative summary review, the facility failed to ensure that one (1) resident (#1), on the survey sample of five (5) residents, was served a pureed diet, in accordance with a physician's pureed diet order and facility policy. Resident #1, who had a [DIAGNOSES REDACTED]. This failure to provide food prepared in a pureed consistency resulted in the likelihood of serious harm to this resident. It was therefore determined that an immediate and serious threat to resident health and safety existed on September 15, 2010, and was removed on September 23, 2010, at which time the facility took action to remove the immediate jeopardy. Findings include: Record review for Resident #1 revealed a Minimum Data Set assessment of 07/16/2010 which documented that the resident had a swallowing problem. The resident's Care Plan documented an admission date of [DATE], and documented that the resident had [DIAGNOSES REDACTED]. A Care Plan entry of 01/20/2010 indicated as a Problem/Need that the resident had difficulty swallowing, and also documented the resident's [DIAGNOSES REDACTED]. Approaches for this problem included to provide and serve the resident's diet as ordered. A September 2010 Medication Orders sheet referenced a physician's orders [REDACTED]. A Nurse's Note of 09/15/2010 at 7:50 p.m. documented that a licensed nurse administered the resident's medications with water without difficulty. A 09/15/2010, 8:10 p.m. Nurse's Notes entry documented that the nurse glanced at the resident and noted the resident to be cyanotic around the mouth and in respiratory distress. This Note documented that the nurse called for assistance from two (2) other nurses and a certified nursing assistant (CNA). A 09/15/2010, 8:15 p.m. Nurse's Notes entry again noted that the resident was in respiratory distress, and also documented that the resident was non-verbal and trying to breathe… | 2014-07-01 |
| 10392 | 10392 | PRUITTHEALTH - TOCCOA | 115345 | 633 FALLS ROAD | TOCCOA | GA | 30577 | 2010-04-13 | 281 | J | 1 | 0 | 7T0Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, hospital History And Physical review, hospital Discharge Summary review, staff interview, and review of the Georgia Practical Nurses Practice Act, the facility failed to ensure that for one (1) resident (#1), on a total survey sample of eleven (11) residents, transfer medication orders were transcribed by nursing staff upon the resident's admission to the facility, in accordance with professional standards of quality. This failure resulted in an interruption in drug therapy for Resident #1, who had [DIAGNOSES REDACTED].#1. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 23, 2010, and was removed on April 13, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: The Georgia Practical Nurses Practice Act, 43-26-32, 7(a), indicates that the practice of licensed practical nursing includes the implementation of services, and 7(d) indicates that the nurse administers medications. Record review for Resident #1 revealed a hospital History And Physical form which documented that the resident had resided in the hospital from 03/14/2010 to 03/23/2010. The hospital Discharge Summary listed discharge [DIAGNOSES REDACTED]. A nursing facility Nurse's Note of 03/23/2010 at 2:00 p.m. documented the resident's admission to the facility from the hospital. Review of the resident's hospital Admission/Discharge Medication Order Sheet transfer physician's orders [REDACTED].) dose of the [MEDICAL CONDITION]/hypertension medication [MEDICATION NAME] twice daily; a 25 mg. dose of the diuretic [MEDICATION NAME] twice daily; a 16 mEq. dose of Potassium Chloride twice daily; a 5 mg. dose of [MEDICATION NAME] twice daily; a 10 mg. dose of [MEDICATION NAME] twice daily; and, a 250 mg. dose of Magnesium Oxide twice daily. However, review of the facility's March 2010 physician's orders [REDACTED]. to the nursing facility. The Marc… | 2014-07-01 |
| 10393 | 10393 | PRUITTHEALTH - TOCCOA | 115345 | 633 FALLS ROAD | TOCCOA | GA | 30577 | 2010-04-13 | 309 | J | 1 | 0 | 7T0Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, hospital History And Physical review, hospital Discharge Summary review, hospital Admission/Discharge Medication Order Sheet review, and staff interview, the facility failed to ensure that one (1) resident (#1), on a total survey sample of eleven (11) residents, received drug therapy in accordance with physician's orders [REDACTED]. In addition, once the facility was made aware of the missed medications and resultant interruption in drug therapy, the medications [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME], and Magnesium Oxide were ordered via the routine pharmacy procedure and not delivered until the following day, resulting in a total of eight (8) days missed for these medications. This failure to provide the ordered drug therapy for Resident #1, who had [DIAGNOSES REDACTED].#1. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 23, 2010, and was removed on April 13, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Record review for Resident #1 revealed a hospital History And Physical form which documented that directly prior to the resident's initial admission to the nursing facility, the resident had resided in the hospital from 03/14/2010 to 03/23/2010. This hospital History and Physical documented that the resident was significant for [MEDICAL CONDITION] and hypertension, further documenting that the resident had New York Heart Association Class IV [MEDICAL CONDITION]. The hospital Discharge Summary listed discharge [DIAGNOSES REDACTED]. The hospital Admission/Discharge Medication Order Sheet documented that while in the hospital, the resident had physicians' orders for [MEDICATION NAME], 25 units each morning; a 25 milligram (mg.) dose of the [MEDICAL CONDITION]/hypertension medication [MEDICATION NAME] twice daily; a 25 mg. dose of the diuretic [MEDICATION NAME] twice daily; a… | 2014-07-01 |
| 10394 | 10394 | PRUITTHEALTH - TOCCOA | 115345 | 633 FALLS ROAD | TOCCOA | GA | 30577 | 2010-04-13 | 333 | J | 1 | 0 | 7T0Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, hospital Discharge Summary review, hospital Admission/Discharge Medication Order sheet review, and staff interview, the facility failed to ensure that one (1) resident (#1), on a total survey sample of eleven (11) residents, received drug therapy in accordance with physician's orders [REDACTED]. This failure to provide the ordered drug therapy for Resident #1, who had [DIAGNOSES REDACTED].#1. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 23, 2010, and was removed on April 13, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Record review for Resident #1 revealed a hospital Discharge Summary from a 03/14/2010 to 03/23/2010 hospital admission, which listed discharge [DIAGNOSES REDACTED]. A nursing facility Nurse's Note of 03/23/2010 at 2:00 p.m. documented the resident's admission to the facility after transfer from the hospital. The hospital Admission/Discharge Medication Order Sheet transfer physician's orders [REDACTED]. However, review of the facility's March 2010 physician's orders [REDACTED]. These omitted orders included [MEDICATION NAME], 25 units each morning; a 25 milligram (mg.) dose of the [MEDICAL CONDITION]/hypertension medication [MEDICATION NAME] twice daily; a 25 mg. dose of the diuretic [MEDICATION NAME] twice daily; and, a 16 mEq. dose of Potassium Chloride twice daily. Further record review, to include review of the March 2010 Medication Record, revealed no evidence to indicate that any of the ordered medications referenced above were administered to the resident from the 03/23/2010 date of admission until a 25 unit dose of [MEDICATION NAME] was documented on the Medication Record as having been administered on 03/30/2010. This Medication Record also documented the initial administration of [MEDICATION NAME], and Potassium Chloride beginning on 03/31/2010, eight (8) days af… | 2014-07-01 |
| 10395 | 10395 | PRUITTHEALTH - TOCCOA | 115345 | 633 FALLS ROAD | TOCCOA | GA | 30577 | 2010-06-17 | 315 | D | 1 | 0 | 8T7111 | Based observation, record review, and staff interview, it was determined that the facility failed to provide urinary incontinence care in a manner likely to prevent urinary tract infections for three (3) residents (#3, #4, and #6) in a survey sample of nineteen (19) residents. Findings include: 1. Record review for Resident #6 revealed a 03/24/2010 Minimum Data Set (MDS) assessment which indicated that Resident #6 was assessed as frequently incontinent of bladder. During an observation of Resident #6 conducted on 06/14/2010 at 3:15 p.m., the resident was observed in pants that were wet in the groin area, with wetness extending down the legs on both thighs. During an observation conducted on 06/14/2010 at 3:25 p.m., Certified Nursing Assistant (CNA) "AA" was observed providing urinary incontinence care by reaching under the resident and cleaning the perineal area from the rectal area forward to the front perineal area as the resident was standing up in the bathroom. Observation of the resident's brief at that time revealed it was saturated with brown/yellow urine that had a strong odor. During an interview with CNA "DD", who was also in attendance at the time of this observation, CNA "DD" stated that the resident's urine had been brown with a strong odor since the previous Wednesday. 2. Record review for Resident #3 revealed a 04/23/2010 MDS assessment which indicated that the resident was assessed as frequently incontinent of bladder. During an observation of Resident #3 conducted on 06/14/2010 at 11:20 a.m., CNA "CC" provided urinary incontinence care by cleaning the resident's perineal area from the rectal area forward to the front perineal area, wiping three (3) times. During an interview conducted at the time of this observation, CNA "CC" acknowledged that she had cleaned the resident by wiping back-to-front. 3. Record review for Resident #4 revealed a 04/07/2010 MDS assessment indicating that Resident #4 was incontinent of bladder. During an observation of Resident #4 conducted on 06/16/2010 at 3:00 p.m., th… | 2014-07-01 |
| 10396 | 10396 | PRUITTHEALTH - TOCCOA | 115345 | 633 FALLS ROAD | TOCCOA | GA | 30577 | 2010-05-12 | 166 | D | 1 | 0 | SR0F11 | Based on review of the Patient/Resident Council Minutes/Report and staff interview, it was determined that the facility failed to make prompt efforts to resolve grievances identified in the April 2010 Resident Council meeting. Twenty (20) residents were documented as having attended this Resident Council meeting. Findings include: Review of the Patient/Resident Council Minutes/Report from the 04/23/2010 Resident Council meeting revealed that resident grievances voiced during the meeting included complaints about showers not being given, cold coffee, coffee not being provided, and double portions of food not being provided. However, further review revealed no evidence to indicate that these resident grievances had been addressed as of the date of this 05/11-12/2010 survey. During an interview with the Activities Director conducted on 05/11/2010 at 12:05 p.m., this staff member acknowledged that the grievances from 04/23/2010 Resident Council meeting had not been addressed. Cross refer to F312 related to the facility's failure to provide resident showers as scheduled. | 2014-07-01 |
| 10397 | 10397 | PRUITTHEALTH - TOCCOA | 115345 | 633 FALLS ROAD | TOCCOA | GA | 30577 | 2010-05-12 | 242 | D | 1 | 0 | SR0F11 | Based on resident record review and resident interview, it was determined that the facility failed to allow two (2) residents ("H" and "K"), in a survey sample of eighteen (18) residents, to dine in their rooms as the residents requested. Findings include: 1. Record review for Resident "H" revealed a May 2010 Minimum Data Set (MDS) assessment which indicated that the resident had no short-term or long-term memory problems and was independent in cognitive skills for daily decision-making. During an interview with Resident "H" conducted on 05/11/2010 at 4:15 p.m., the resident stated that he/she had initially refused to go to the dining room for the noon meal on 05/11/2010. However, the resident further stated that the certified nursing assistants told the resident he/she had to go to the dining room and took her/him to the dining room in the wheelchair, even though the resident stated that she/he did not want to go the dining room. The resident also stated that after his/her transport to the dining room, she/he requested assistance from the certified nursing assistants to go back to the room and was refused. 2. Record review for Resident "K" revealed a March 2010 MDS assessment which indicated that the resident had no short-term or long-term memory problems and was moderately impaired in cognitive skills for daily decision-making. During an interview with Resident "K" conducted on 05/11/2010 at 1:55 p.m., the resident stated that he/she had told staff that he/she did not want to go to the dining room for the noon meal of 05/11/2010, but that staff had taken him/her to the dining room anyway. | 2014-07-01 |
| 10398 | 10398 | PRUITTHEALTH - TOCCOA | 115345 | 633 FALLS ROAD | TOCCOA | GA | 30577 | 2010-05-12 | 312 | E | 1 | 0 | SR0F11 | Based on record review, resident interview, family interview, staff interview, and facility Shower Schedule review, it was determined that the facility failed to provide the necessary assistance with personal hygiene, related to scheduled showers, for five (5) residents (#12, #13, #14, "I", and "M") on the survey sample of eighteen (18) residents. Findings include: Record reviews revealed that the 05/10/2010 Minimum Data Set (MDS) of Resident #12, the 04/27/2010 MDS of Resident #13, the 05/05/2010 MDS of Resident #14, and the April 2010 MDS of Resident "I" indicated that these residents were totally dependent on staff for personal hygiene. Record review revealed that the May 2010 MDS of Resident "M" indicated that this resident required the extensive assistance of staff for personal hygiene. However, review of the Shower Schedule for May 2010 revealed no evidence to indicate that the showers scheduled for May 10, 2010 for Residents #12, #13, #14, "I" and "M" were as given as scheduled. Resident "M" stated during interview on 05/11/2010 at 3:30 p.m. that the bath was not given on May 10, 2010 as scheduled. During an interview with the family of Resident "I" conducted on 05/11/2010 at 2:40 p.m., the family member stated that the resident had not had a bath and had worn the same clothes since the previous Friday, 05/07/2010, four (4) days prior to this complaint survey. During an interview with Registered Nurse "AA" conducted on 05/11/2010 at 2:45 p.m., Nurse "AA" stated that the certified nursing assistant (CNA) responsible for providing the shower to Resident "I" on 05/10/2010 acknowledged that Resident "I" had not received the scheduled shower. Nurse "AA" further stated that the CNA had acknowledged that she had given no scheduled showers on 05/10/2010, due to the facility being short-staffed. | 2014-07-01 |
| 10399 | 10399 | PRUITTHEALTH - TOCCOA | 115345 | 633 FALLS ROAD | TOCCOA | GA | 30577 | 2010-05-12 | 360 | D | 1 | 0 | SR0F11 | Based on resident interview and staff interview, it was determined that the facility failed to provide palatable food to four (4) residents ("G", "H", "J" and "O") in a survey sample of eighteen (18) residents. Findings include: During interviews with Residents "O", "G", and "H" conducted on 5/11/2010 at 1:05 p.m., 1:20 p.m., and 4:15 p.m., respectively, these residents stated that the chicken served on 05/11/2010 at the noon meal was too hard and/or tough to eat. During an interview with Resident "J" conducted on 05/12/2010 at 12:10 p.m., the resident stated that he/she had been unable to eat the chicken served on 05/11/2010 at the noon meal due to it being overcooked. During an interview with the dietary supervisor conducted on 05/11/2010 at 3:35 p.m., the dietary supervisor stated that the chicken was cooked and then kept warm in the oven, and acknowledged that this may have dried the chicken and made it hard. | 2014-07-01 |
| 10400 | 10400 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-07-14 | 203 | E | 1 | 0 | 04R611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, it was determined that the facility failed to notify the resident, and a family member or legal representative, of hospital transfer in writing either before, at the time of, or since the transfer for four (4) residents ("A", #2, #3 and #4) in a survey sample of four (4) residents. Findings include: 1. Record review for Resident "A" revealed a Nurse's Note of 06/11/2009 which documented that the resident was transferred to the hospital. However, further record review revealed no evidence to indicate that either before, at the time of, or since this hospital transfer, the resident and the resident's family had received a written transfer notice indicating the reason for the transfer, the effective date of the transfer, the location to which the resident was being transferred, a statement that the resident had the right to appeal the transfer, and the ombudsman's name, address and telephone number. During an interview with the family of Resident "A" on conducted on 07/14/2009, the family member stated that no written transfer notice had been provided when the resident was transferred to the hospital. 2. Record review for Resident #2 revealed a Nurse's Note which documented that Resident #2 was transferred to the hospital on [DATE]. There was, however, no evidence to indicate that either before, at the time of, or since this hospital transfer, the resident and the resident's family had received a written transfer notice indicating the reason for the transfer, the effective date of the transfer, the location to which the resident was being transferred, a statement that the resident had the right to appeal the transfer, and the ombudsman's name, address and telephone number. 3. Record review for Resident #3 revealed a Nurse's Note which documented that the resident was transferred to the hospital on [DATE] at 11:45 a.m. There was, however, no evidence to indicate that either before, at… | 2014-07-01 |
| 10401 | 10401 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-07-14 | 205 | E | 1 | 0 | 04R611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, it was determined that the facility failed to provide written information to the resident, and family member or legal representative, either at the time of, or since, hospital transfer, that specified the duration of the bed-hold policy for four (4) residents ("A", #2, #3 and #4) in a survey sample of four (4) residents. Findings include: 1. Record review for Resident "A" revealed a Nurse's Note of 06/11/2009 which documented that the resident was transferred to the hospital. There was, however, no evidence to indicate that either at the time of, or since, this hospital transfer, the resident and the resident's family had received written information regarding the duration of the facility's bed-hold policy. During interview with the family member of Resident "A" conducted on 07/14/2009 at 11:00 a.m., it was stated that no written notification specifying the duration of the bed hold policy was provided at the time of resident's transfer to the hospital. 2. Record review for Resident #2 revealed a Nurse's Note which documented that Resident #2 was transferred to the hospital on [DATE]. There was, however, no evidence to indicate that either at the time of, or since, this hospital transfer, the resident and the resident's family had received written information regarding the duration of the facility's bed-hold policy. 3. Record review for Resident #3 revealed a Nurse's Note which documented that the resident was transferred to the hospital on [DATE] at 11:55 a.m. There was, however, no evidence to indicate that either at the time of, or since, this hospital transfer, the resident and the resident's family had received written information regarding the duration of the facility's bed-hold policy. 4. Record review for Resident #4 revealed a Nurse's Note which documented that the resident was transferred to the hospital on [DATE]. There was, however, no evidence to indicate that either a… | 2014-07-01 |
| 10402 | 10402 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-03-25 | 365 | K | 1 | 0 | 3LZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, facility document review, and staff interview, the facility failed to ensure that six (6) residents ("A", #1, #2, #4, #5 and #7) who had been assessed to need thickened liquids, on the survey sample of nine (9) residents, received thickened liquids to meet their individual needs. The failure of staff to ensure that these residents received thickened liquids represented the likelihood for serious harm for these residents. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 25, 2009, and continues. Findings include: 1. Record review for Resident "A" revealed that the March 2009 physician's orders [REDACTED]. The resident's current Interdisciplinary Care Plan referenced a 12/17/2008 entry identifying the resident to be a nutritional risk, with the Approaches including the provision of thickened liquids as ordered. However, the resident's current Nursing Assistant Care Card failed to indicate that the resident was to receive thickened liquids. During an observation conducted on 03/25/2009 at 8:50 a.m., Resident "A" was observed to be seated in a wheelchair in his/her room by his/her bed. During this observation, a cup containing unthickened water was sitting on an over-bed table directly in front of the resident within his/her reach, and a pitcher of unthickened water was sitting on the window sill to the right of the resident, within the resident's reach. During an interview conducted at the time of the 03/25/2009, 8:50 a.m. observation referenced above, Resident "A" indicated that the unthickened water was his/hers. During an additional observation conducted on 03/25/2009 at 9:40 a.m., Certified Nursing Assistant (CNA) "CC" was observed providing the resident a pitcher containing unthickened water. During an interview with CNA "CC" conducted on 03/25/2009 at 2:30 p.m., CNA "CC" stated that earlier in the day, she had filled Resid… | 2014-07-01 |
| 10403 | 10403 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-03-25 | 282 | K | 1 | 0 | 3LZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to ensure that three (3) residents ("A", #4 and #7) who had been assessed and care planned to receive thickened liquids, on the survey sample of nine (9) residents, received thickened liquids per their care plans. The failure of staff to ensure that these residents received thickened liquids represented the likelihood for serious harm for these residents. It was therefore determined that an immediate and serious threat to resident health and safety existed on March 25, 2009, and continues. Findings include: 1. Record review for Resident "A" revealed that the March 2009 physician's orders [REDACTED]. However, during an observation conducted on 03/25/2009 at 8:50 a.m., Resident "A" was observed to be seated in a wheelchair in his/her room by his/her bed. A cup containing unthickened water was sitting on an over-bed table directly in front of the resident within his/her reach, and a pitcher of unthickened water was sitting on the window sill, within the resident's reach. During an interview conducted at the time of the 03/25/2009, 8:50 a.m. observation referenced above, Resident "A" indicated that the unthickened water was his/hers. During an observation conducted on 03/25/2009 at 9:40 a.m., Certified Nursing Assistant (CNA) "CC" was observed providing the resident a pitcher containing unthickened water. Cross refer to F365, example 1, for more information regarding Resident "A". 2. Record review for Resident #7 revealed a March 2009 Dysphagia Initial Plan Of Treatment (Evaluation) which documented that the resident had a [DIAGNOSES REDACTED]. However, during observations conducted on 03/25/2009 at 08:51 a.m., 12:55 p.m., and 2:15 p.m., the resident was observed in the room in the bed, and a water pitcher containing unthickened water was observed on the cabinet located directly in front of the resident's bed. Cross refer to F365, example 2, for more… | 2014-07-01 |
| 10404 | 10404 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-03-09 | 225 | E | 1 | 0 | FOUN11 | Based on staff interviews and review of facility reports/documentation, the facility failed to ensure that all allegations of abuse, neglect and mistreatment are reported immediately (within 24 hours) to the administrator of the facility and to other officials in accordance with State law through established procedures, including to the State survey and certification agency (SSA). The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the SSA) within 5 working days of the incident. Problems were identified for four (4) resident (#1, #6, #7, and #8 ) from eight ( 8) sampled residents. Findings include: Review of a Facility Grievance/Complaint Report Form revealed resident #8 reported on 2/25/2009 he/she had requested water from a Licensed Practical Nurse and the nurse refused to provide the water to the resident. This report nor findings of the investigation have not been reported to the SSA as of 3/23/2009. Review of a Facility Grievance/Complaint Report Form revealed resident #6 complained of verbal abuse and neglect by one certified nursing assistant (CNA) on 2/23/2009. Review of facility records revealed the facility did not report the alleged abuse to the SSA until 2/25/2009, two (2) days later. An interview with the Administrator conducted on 3/9/2009 at 2:00 p.m. revealed the administrator did not immediately report nor submit evidence of the investigation to the State Survey Agency within 5 working days as required. The Administrator said he/she would sent findings of the investigation today regarding the allegation. The Administrator additionally stated that she/he was not familiar with this regulatory requirement. A review of a Facility Incident Report Form dated 3/9/2009 for resident #7, revealed a CNA reported to the Administrator on 2/26/2009, that on 2/25/09 a licensed practical nurse has been cursing a resident during an emergency situation in which the resident was choking, and was no… | 2014-07-01 |
| 10405 | 10405 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-04-16 | 328 | K | 1 | 0 | S3V211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, review of manufactures' patient manuel, and staff interviews, it was determined that the facility failed to properly administer oxygen therapy for two (2) residents, #1, and #2, and provide appropriate nursing care to prevent harm for resident #2, in a survey sample of twelve (12) residents. This resulted in harm to two resident and the likelihood of possible serious harm to (2) other residents who utilized oxygen concentrators and 4 other resident who received respiratory therapy. It was therefore determined that an immediate and serious threat to resident health and safety existed from March 30, 2009 until April 16, 2009, at which time the facility took action to correct the deficient practice and abate the jeopardy situation. Findings include: 1. The Progress Note dated 3/11/2009 revealed that resident #1 had [DIAGNOSES REDACTED]. The resident's care plan identified as a problem ineffective breathing pattern related to Chronic [MEDICAL CONDITION] Disease and to use oxygen as ordered. The physician's orders [REDACTED]. The Interdisciplinary Progress Notes on 3/30/09 documented that at 12:00 p.m. the certified nursing assistant went into the resident's room and found the resident to be blue and unresponsive. The notes documented the oxygen saturation (O2 sat) was 57% at 4 liters/minute of oxygen via nasal cannula, a blood pressure or pulse could not be obtained, no rise or fall of the resident's chest was observed; therefore facility staff notified the hospice nurse. The notes further documented at 1:00 p.m. the hospice nurse arrived and found the oxygen concentrator humidifier bottle not connected correctly and corrected the problem. It was further documented that the resident was monitored and at 3:00 p.m. the resident's skin was noted to be warm, dry and pink, with capillary refill in less than 3 seconds, the resident was alert and talking, and the O2 stat had improved to 94 % with oxygen being admin… | 2014-07-01 |
| 10406 | 10406 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-04-16 | 465 | D | 1 | 0 | S3V211 | Based on observations and staff interviews, it was determined that the facility failed to provide a safe, sanitary and comfortable area for laundry staff and the public. Findings include: During observation of the laundry area with the laundry supervisor at 10:30 a.m. on 4/15/2009, a large puddle of water was observed under the stairs. Observation of the wall behind the washer and dryer revealed several holes in the wall. In addition, towels and sheets were observed on the floor around the washer. Interview with staff "EE" on 4/15/2009 at 12:00 p.m., revealed that water would come into the laundry room during hard rains from the two corners of the wall behind the washer and dryer. In addition, stated that there were holes in the wall behind the washer and dryer that water came through into the laundry room. It was also observed and identified by staff person that the towels around the washer were wet with water. During the observations the laundry staff were running the washers and dryers. | 2014-07-01 |
| 10407 | 10407 | KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2009-11-04 | 441 | E | 1 | 1 | GI5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to maintain an infection control program to prevent the development and transmission of disease and infection related to incontinence care, monitoring blood sugars and [DIAGNOSES REDACTED] testing for two (2) residents (#2 and #8) from a sample of thirty two (32) residents, two (2) random observations and one (1) employee from seventeen (17) employee files reviewed. Findings include: 1. Observation on 11/03/09 at 11:50 a.m. during medication pass revealed Licensed Practical Nurse (LPN) "UU" gathered her supplies and entered a resident's room to perform a fingerstick blood sugar without washing or sanitizing her hands, however, she did wear gloves. After the procedure was finished, the nurse did not wash or sanitize her hands upon removal of the gloves and returning the supplies to the medication cart. During interview on 11/03/09 at 11:50 a.m. LPN "UU" indicated that she had misplaced her sanitizer. Interview on 11/04/09 at 10:45 a.m. with the staff development and infection control nurse revealed that it is the standard to wash/sanitize hands before and after blood glucose monitoring. 2. Observation on 11:55 a.m. during medication pass revealed LPN "SS" entered a resident's room for blood glucose monitoring. The LPN carried the blood glucose monitoring device into the room and placed it on the bare bedside table, stuck the resident's forefinger with the lancet device, used an alcohol swab to wipe the blood from the finger, and laid the used wipe down on the discarded alcohol swab wrapper sitting on the bedside table. The bloody swab fell off the wrapper and landed on the bare table. The LPN laid it back on the wrapper. After the procedure was finished, the nurse removed her gloves, sanitized her hands and left the room without cleaning the bedside table top. 3. Review of seventeen (17) employee files revealed one (1) employee with no evidence of a [DIAGNOSES REDACT… | 2014-07-01 |
| 10408 | 10408 | KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2009-11-04 | 309 | E | 1 | 1 | GI5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to record the intake of enteral feedings per physician order [REDACTED]. Findings include: 1. Observation on 11/2/09 at 10:37 a.m. revealed resident #5, lying in bed with Glucerna 1.0., an enteral feeding, infusing at 60 cubic centimeters (cc) per hour via pump. Review of the clinical record for resident #5, revealed a physician's orders [REDACTED]. Review of the Comprehensive Intake-Output Record revealed no evidence that the intake had been recorded for the night shift on 9/28/09 or the evening shift on 9/28/09, 11/01/09 and 11/02/09. 2. Observation on 11/2/09 at 3:35 p.m. of resident #21, revealed the resident lying in bed with a bottle of [MEDICATION NAME] 1.5, an enteral feeding, hanging but not infusing. Review of the clinical record for resident #21, revealed a physician's orders [REDACTED]. Review of the Comprehensive Intake-Output Record revealed no evidence that the intake had been recorded as follows: day shift - 9/1, 9/4, 9/5, 9/6, 9/8/09; evening shift - 9/13, 10/28, 10/29/09; night shift - 10/26, 10/28, and 10/29/09. Interview on 11/04/09 at 12:51 p.m. with the Assistant Director of Nursing (ADON) indicated that whatever the physician ordered is what the nurse should do. 3. Observation of resident #30 on 11/4/09 at 10:00 a.m. revealed the resident lying in bed with [MEDICATION NAME] 1.5, enteral feeding, connected to a pump at the bedside but not infusing. Review of the clinical record for resident #30, revealed [DIAGNOSES REDACTED]. The resident was receiving all nutrition and hydration through the GT. Review of the physician's orders [REDACTED]. administration. Continued review of the physician's orders [REDACTED]. Review of the Comprehensive Intake-Output Record dated from 9/9/09-9/30/09 revealed no evidence that the 24-hour total intake was recorded on twenty (20) of the twenty-two (22) days. Additionally, the every 8-hour total for enteral formula w… | 2014-07-01 |
| 10409 | 10409 | KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2009-11-04 | 315 | D | 0 | 1 | GI5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,review of the facility policy for urinary incontinence/indwelling catheter, record review and staff interviews, it was determined that the facility failed to ensure that Certified Nursing Assistants (CNAs) provided appropriate incontinence care and failed to perform a urinary assessment after removal of an indwelling catheter to determine if a toileting program was appropriate for three (3) residents (#7, #9 and #12) from a sample of thirty one (31) residents. Findings include: 1. Observation of incontinence care for resident #12 on 11/03/09 at 11:00 A.M., provided by CNA "QQ" and assisted by CNA "RR" revealed that CNA "QQ" wiped downward over the labia and upward over the rectal area repeatedly without rotating the cloth. During interview with CNA "RR" on 11/03/09 at 11:00 a.m. she acknowledged that CNA "QQ" wiped repeatedly without rotating the cloth. Review of the clinical record for resident #12 revealed a urinalysis with culture and sensitivity done on 08/18/09 that determined that the resident had a Urinary Tract Infection with Escheria Coli as the bacteria. The resident was treated with [MEDICATION NAME] 50 milligrams (mgs) four (4) times a day for two (2) weeks. Review of the facility policy for Urinary Incontinence/Indwelling Catheter, revealed, based on the resident's comprehensive assessment, care and treatment are provided to help the resident restore his/her highest level of normal bladder function as possible and to prevent urinary tract infection. 2. Observation of incontinence care on 11/02/09 at 2:19 p.m for resident #9 revealed that the resident needed maximum assistance to transfer from the wheelchair to the bed. Only a small amount of urine was noted in the incontinent brief. Interview on 11/02/09 at 2:19 p.m. with Certified Nursing Assistant (CNA) "JJ" revealed that the resident would let them know when he/she is soiled, and sometimes would let them know when he/she needs to toilet. Continued intervie… | 2014-07-01 |
| 10410 | 10410 | KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2009-11-04 | 322 | E | 0 | 1 | GI5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that seven (7) of ten (10) residents (#5, #18, #21, #28, #30, #31, and #32) receiving enteral feedings, received the appropriate amount of feeding as ordered by their physician from a sample of thirty-two (32) residents. Findings include: 1. Review of resident #5 physician's order regarding enteral feeding revealed that the resident was to receive Glucerna 1.0 at 60 cubic centimeters (cc) per hour for 16 hours (hrs) via pump per gastrostomy tube ([DEVICE]). The infusion was to start at 6:00 p.m. and continue until 10:00 a.m. OR until total volume is given. The physician's order did not specify what the total volume of the enteral feeding should be. Interview with the RD, "CC" on 11/03/09 at 9:37 a.m. indicated the nurses would need to know to multiply the amount per hour the resident was to receive by the number of hours the feeding was to hang to know what the total volume would need to be and for this resident it would be 960ml. Continued interview revealed that this was a nursing function. Review of the comprehensive intake-output record for resident #5 revealed no evidence that he/she had received the 960 ml of enteral feeding in a twenty four (24) hour period consistently. Continued review of the intake-output record revealed the following: on 9/24, 9/26, 10/12, 10/14, and 10/16 through 10/19/09 the resident received only 840 cc of enteral feeding per twenty four (24) hours. Review of the clinical record revealed that the resident currently has a pressure sore to the left heel which is covered by eschar. Review of the physician's orders for resident #5 revealed an order dated 09/10/09 for the nurse to label the formula container, syringe and administration set with resident's name, date, time and nurse's initials. Observation on 11/2/09 at 10:37 a.m and on 11/3/09 at 8:30 a.m of the enteral feeding for resident #5 revealed no time written on the bottle … | 2014-07-01 |
| 10411 | 10411 | KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2009-11-04 | 518 | D | 0 | 1 | GI5D11 | Based on record review and staff interview the facility failed to train employees in a manner to ensure that they are knowledgeable of disaster procedure and failed to conduct appropriate disaster drills for the calendar year 2008. Resident census=178 Findings include: Disaster interviews were conducted with three direct care staff members, one Licensed Practical Nurse (LPN) and two Certified Nursing Assistants (CNA's). Interview with CNA "OO" on 11/04/09 at 1:00 p.m. indicated that she was unaware if the facility had a back-up generator, did not know if the facility had flashlights or if they did where they would be kept, she was unable to verbalize if there were emergency outlets or what to do in the event of severe weather other than to find her supervisor in order to obtain direction from her. She indicated if a tornado were to happen she would lower the residents bed and wait on instructions from the charge nurse. Continued interview revealed that she had participated in a fire drill and one weather drill but was unable to verbalize how often they have drills. Disaster interview with CNA "ZZ" on 11/04/09 at 1:26 p.m. indicated that if the facility were to lose power the back up lights should come on she guessed but did not know if the facility had flashlights or if they did where they would be stored. CNA "ZZ" was unable to verbalize where the fire alarms were and did not know what a fire alarm looked like. Continued interview revealed that if there was bad weather she would just wait to get instruction from her supervisor and if there was a tornado she would pull the resident away from the window and lower their bed. CNA "ZZ" indicated that she has only participated in a fire drill and had not participated in any disaster drills and does not know how often they are held. Review of the maintenance record related to disaster drills revealed that the facility had conducted only one disaster drill for the calendar year 2008, which was in April, 2008. During interview with the Administrator on 11/04/09 at 10:04 … | 2014-07-01 |
| 10412 | 10412 | SOUTHLAND HEALTHCARE AND REHAB CENTER | 115376 | 606 SIMMONS ST | DUBLIN | GA | 31040 | 2011-01-07 | 225 | D | 1 | 0 | 7DYU11 | Based on record review, facility document review, and staff interview, the facility failed to ensure that all allegations of violations involving misappropriation of resident funds were reported to the State survey and certification agency in a timely manner for two (2) residents (#4 and #5) on a survey sample of eight (8) residents. Findings include: Record review for Resident #4 revealed a Facility Incident Report Form dated 09/21/2010, and sent to the State survey and certification agency on that date, which indicated that the resident's checkbook was found with checks not accounted for and referenced that the Business Office Manager had been terminated. Record review for Resident #5 revealed a Facility Incident Report Form dated 09/21/2010, and sent to the State survey and certification agency on that date, which indicated that an allegation of misappropriation of resident property/funds/exploitation had been identified. During interview with the Administrator conducted on 09/30/2010 at approximately 2:50 p.m., upon inquiry related to the incidents above, as well as an anonymous complaint regarding misappropriation of resident property/funds, the Administrator stated that there had been allegations of misappropriation of property/funds for Residents #4 and #5 as far back as August 27, 2010. The Administrator acknowledged that the facility had failed to report the allegations to the State survey and certification agency at that time. | 2014-07-01 |
| 10413 | 10413 | CEDAR SPRINGS HEALTH AND REHAB | 115381 | 148 CASON ROAD | CEDARTOWN | GA | 30125 | 2009-06-03 | 365 | K | 1 | 0 | 80UN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital document review, and staff interview, the facility failed to provide food prepared in a form to meet the individual needs of one (1) resident (#1), of a total of five (5) residents on the survey sample who had been assessed to need, and ordered to receive, pureed food, on the total survey sample of twelve (12) residents. A total of fifteen (15) residents (including Residents #1, #3, #8, #9 and #10 on the survey sample) required pureed diets. This resulted in serious harm to Resident #1, who was subsequently diagnosed with [REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed from May 17, 2009 through June 3, 2009, at which time the facility took action to abate the immediate jeopardy. Findings include: Record review for Resident #1 revealed a speech therapy Progress Note of 06/06/2008 which indicated that the resident had been receiving skilled speech therapy and could safely swallow a pureed diet. A 05/09/2008 Telephone Order specified that the resident receive a thin puree diet. Further record review revealed a May 2009 physician's orders [REDACTED]. A Nurse's Note of 05/17/2009 at 9:20 a.m. documented that a certified nursing assistant (CNA) had summoned Nurse "AA" to the South Wing where this nurse observed Resident #1 lying on the floor, and observed another nurse administering the [MEDICATION NAME] Maneuver and a CNA doing mouth sweeps. Nurse "AA" documented that she noted the resident's breathing to be shallow and went to get a Rescue Bag. Nurse "AA" documented that upon returning, she took over administering the [MEDICATION NAME] Maneuver and the other nurse took over doing mouth sweeps. This Note documented that Emergency Medical Technicians then arrived and took over the resident's care, and that the physician was notified. A Nurse's Note of 05/17/2009 at 12:00 p.m. documented that the resident had been transferred to the hospital. A 05/17/… | 2014-07-01 |
| 10414 | 10414 | CEDAR SPRINGS HEALTH AND REHAB | 115381 | 148 CASON ROAD | CEDARTOWN | GA | 30125 | 2009-02-11 | 151 | E | 1 | 1 | Y88V11 | Based on record review and resident and staff interviews, the facility failed to ensure that right to vote for three (3)residents ("B", "C" and "D") of four (4) residents in group interview. Findings include: During group interview conducted on 2/10/09 at 11:00a.m., three (3) residents "B', "C", and "D"complained that the facility did not assist them in voting in the presidential election in November, 2008. The residents indicated that they would have voted if given the opportunity. Resident "B" revealed that the social worker promised that she would assist him/her in completing an absentee ballot but the social worker never followed through. Review of the Facility Admission Packet revealed that under paragraph R., Voter Registration Information, the facility would assist residents to register to vote and obtain absentee ballots. Review of the State of Georgia Application for Voter Registration included instructions that revealed a copy of proper identification should be included with the application. Further review revealed that The postage is prepaid on the application and includes a pocket envelope that allows the application to be sealed with adhesive. Interview with the Administrator on 2/9/09 at 11:45am revealed that the Social Service Director registered several residents to vote but had not returned the registrations to the Elections Board in the appropriate time allocated. The Social Service Director also assisted some residents to vote but returned these ballots to the Elections Board unsealed, without the same signature as the registration, and without proper proof of identification. Further interview with the Administrator on 2/10/09 at 2pm revealed that the right to vote was covered during the admission process by the Social Services Director. Interview with the Activity Director on 2/10/09 at 8:45am revealed the residents are informed of their right to vote and if they are not registered to vote then registration or change of address form are obtained for them. The residents are assisted in completi… | 2014-07-01 |
| 10415 | 10415 | PROVIDENCE OF SPARTA HEALTH AND REHABILITATION | 115397 | 60 PROVIDENCE STREET, PO BOX 86 | SPARTA | GA | 31087 | 2010-08-26 | 281 | K | 1 | 0 | DC0W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident record review that included hospital records, staff interviews, and review of the Georgia Practical Nurses Practice Act, the facility failed to ensure that for two (2) residents (#1 and #8), on a survey sample of thirteen (13) residents, of which six (6) were fed via gastrostomy tube, gastric feeding orders were followed and to ensure that a resident who was fed by gastrostomy tube received the appropriate treatment and services to prevent complications in tube feeding, in accordance with professional standards of quality. This failure resulted in harm for Resident #1, and resulted in the likelihood of serious harm to other residents with gastrostomy tubes. It was therefore determined that an immediate and serious threat to resident health and safety existed as of July 5, 2010 and was removed on August 26, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. The Georgia Practical Nurses Practice Act, 43-26-30, Article 2, Chapter 2, Standards of Nursing Practice, Section 3F, specifies that the licensed practice nurse maintains safe and effective nursing care rendered directly or indirectly. Chapter 2.3.2 (J) 2 Standards Related to Licensed Practical Nurse Professional Accountability indicates that the licensed practical nurse implements treatments and procedures of client care, and Chapter 2.3.2 (K) indicates the nurse documents care provided. Findings include: Cross refer to F322. 1. Review of the Interdisciplinary Progress Notes for Resident #1 revealed Nurse "AA" found the resident's gastrostomy tube ([DEVICE]) not intact on 7/05/2010 at 5:00 a.m., and replaced the [DEVICE] with a size 20 French (Fr.) catheter. However, the July 2010 Physician's Orders signed on July 2, 2010 documented the resident was to have a size #24 Fr. [DEVICE], and there was no physician's order to change the [DEVICE]. There was no documentation on 7/05/2010 that placement of the tube was checked after … | 2014-07-01 |
| 10416 | 10416 | PROVIDENCE OF SPARTA HEALTH AND REHABILITATION | 115397 | 60 PROVIDENCE STREET, PO BOX 86 | SPARTA | GA | 31087 | 2010-08-26 | 322 | K | 1 | 0 | DC0W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, review of hospital records, family interview and staff interviews, the facility failed to ensure that five (5) residents (#1, 5, 6, 8,and 9), on a total survey sample of thirteen (13), six (6) of which were fed via gastrostomy tube, received appropriate treatment and services in accordance with Standards of Care and Physicians' orders. This resulted in serious harm for one (1) resident, (Resident #1), and the likelihood for serious harm to five (5) resident (#5, #6, #8 , #9 and #11). It was therefore determined that an immediate and serious threat to resident health and safety existed as of July, 5, 2010 and was removed on August 26, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: 1. Review of Resident #1's Interdisciplinary Progress Notes dated 7/5/2010 at 5:00 a.m., revealed Nurse "AA" found the resident's [DEVICE] not intact at this time. A [DEVICE] was inserted with a size #20 French (Fr) in one attempt. The note further recorded the [DEVICE] was intact, and feeding and flushes were tolerated well. An addendum to the 7/5/10 Interdisciplinary Progress Notes was dated as written on 7/13/2010 at 11:00 p.m., eight (8) days after the [DEVICE] had been re-inserted and three (3) days after the resident returned from the first hospital visit. The Note documented at 5:00 a.m. on 7/5/2010, the resident was resting quietly in bed. The head of the bed was elevated. A report was given to oncoming nurse "BB". [DEVICE] placement was re-checked again by the 7-3 nurse, and was noted to be intact. An Interdisciplinary Progress Note documented as written by nurse "GG" at 10:00 a.m. on 7/5/10 documented the nurse was informed by a staff member that the resident's respirations were irregular. Upon entering the room, the resident was observed taking short somewhat shallow breaths, and the skin was cool and clammy to touch. The physician extender was notified of sympt… | 2014-07-01 |
| 10417 | 10417 | PROVIDENCE OF SPARTA HEALTH AND REHABILITATION | 115397 | 60 PROVIDENCE STREET, PO BOX 86 | SPARTA | GA | 31087 | 2010-08-26 | 253 | E | 1 | 0 | DC0W11 | Based on environmental observations and resident interview, the facility failed to maintain an orderly, sanitary, and comfortable environment on the 200 hall, one of three halls in the facility. Findings include: Observations conducted on 8/24/2010 during environmental tour identified the following concerns: On 8/24/10 at 11:30 a.m., there were dead insects observed on the window sills in rooms 202, 203, 206, 209, 212 and 213, as well as dirt and trash around baseboards, behind beds and night stands and on the closet floors. Room 212 was observed with dirt and trash noted around baseboards and the floor of the closet. The IV pole, bedside stand, and overbed table were soiled with a sticky white substance. Room 213 was observed to have a 5 feet by 6 inch panel leaning in a corner of the room. During interview with Resident "A" conducted on 8/24/2010 at 12:30 p.m. revealed the resident said it came from the overbed light and had been there for a year. Also, dirt and trash were observed along baseboards and on the floor in the closet. The closet was in disarray and some of the hangers were on the floor, and some clothing was dragging on the floor. There was dirt and cob webs in the corners of the bathroom. There was a dirty plunger and a wire clothes hanger twisted and hanging over the grab bar beside the commode. The resident said ne/she did not use the bathroom, but the residents do in the other room. Resident # 2 in Room 207 was observed on 8/24/2010 at 12:15 p.m. to have a wheelchair with two lap buddies lying across it, each heavily soiled with a sticky substance. | 2014-07-01 |
| 10418 | 10418 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON AVENUE | METTER | GA | 30439 | 2010-12-10 | 224 | J | 1 | 0 | I0JP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, facility report review, facility policy review, and hospital History and Physical review, it was determined that the facility failed to prevent resident neglect for one (1) resident, Resident #1, who had eloped, on a survey sample of three (3) residents. Facility staff failed to ensure a thorough search was conducted when the fence alarm could not be silenced. Resident #1 had eloped and become entangled in an exterior fence. This failure resulted in the resident remaining outside and exposed to an extreme low environmental temperature for approximately 2-3 hours, thus experiencing hypothermia requiring hospitalization and admission to the Intensive Care Unit. It was therefore determined that an immediate and serious threat to resident health and safety existed on December 8, 2010, and was removed as of December 9, 2010, at which time the facility had implemented a plan to remove the immediate jeopardy. Findings include: Cross refer to F323 for more information regarding Resident #1. Review of the clinical record for Resident #1 revealed a Nurse's Note of 12/08/2010 at 7:45 a.m., and a 12/08/2010 Incident Report, which documented that staff notified the Licensed Practical Nurse (LPN) that Resident #1 was outside, hanging over the fence in the D-Wing back yard. This Note documented that staff responded and found the resident to be very cold, hanging upside down, with swelling noted to the facial area. A Nurse's Note of 12/08/2010 at 7:55 a.m. documented that Emergency Medical Services (EMS) was called, and a Nurse's Note of 12/08/2010 at 8:10 a.m. documented that the resident was transported to the hospital. The 12/08/2010 hospital History and Physical documented that it was estimated Resident #1 had been outside for about 3 hours, and documented an assessment of Hypothermia and multiple puncture wounds from the fence. During interview with Resident #1's physician conducted on 12/09/2010 at 1:45 p.m., th… | 2014-07-01 |
| 10419 | 10419 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON AVENUE | METTER | GA | 30439 | 2010-12-10 | 323 | J | 1 | 0 | I0JP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, facility report review, Emergency Medical Services report review, and hospital History and Physical review, it was determined that the facility failed to develop a system to ensure adequate supervision for one (1) resident (#1), on the survey sample of (3) residents, who were identified to be at risk for elopement and/or exposure to extreme weather conditions, such as a below-freezing environmental temperature. This failure resulted in serious harm to one (1) resident, Resident #1, who exited the facility without the knowledge of staff, became entangled in an exterior fence, and remained outside exposed to an extremely low environmental temperature resulting in hypothermia, transfer to the hospital, and admission to the Intensive Care Unit. It was therefore determined that an immediate and serious threat to resident health and safety existed on December 8, 2010, and was removed by December 9, 2010, at which time the facility implemented a plan to abate the immediate jeopardy. Findings include: Review of the clinical record for Resident #1 revealed a facility Standard Admission Record and Agreement (Admission Record) which documented an admitted to the facility of 11/26/2010. This Admission Record documented that the resident was a [AGE] year male who had primary [DIAGNOSES REDACTED]. The Cumulative [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS), which was completed on 12/04/2010, revealed the resident was assessed as having poor recall with a total on the Brief Interview for Mental Status section of three (3) out of a possible fifteen (15). The resident was further assessed on this MDS to have wandering behaviors, but also documented no evidence of the resident frequently trying to elope from the facility. Review of the Nurse's Notes of 12/08/2010 at 7:45 a.m., and a 12/08/2010 Incident Report, revealed that staff notified the Licensed Practical Nurse (LPN) that Resident #1 was … | 2014-07-01 |
| 10420 | 10420 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON AVENUE | METTER | GA | 30439 | 2009-10-27 | 469 | F | 1 | 0 | WIRV12 | Based on observation, resident interview, staff interview, and facility document review, the facility failed to maintain a pest-free environment, related to the presence of insects, on three (3) halls of four (4) halls (B, C and D Halls). Findings include: A. A tour of the facility on 12/22/2009 beginning at 1:55 p.m., and concluding at 5:06 p.m., revealed live roaches in the following locations: 1. On the C Hall -In the Shower room on C Hall, a live roach was crawling on the floor, and was killed by Nurse "AA" who was in attendance at the time. 2. On the D Hall a. Two roaches were observed crawling on the wall in the Pantry across from Nurse's Station. This was observed by Unit Supervisory Staff Member "GG" who was in attendance at that time. b. In Room D4 -Two live roaches were crawling on the floor and were observed by Unit Supervisory Staff Member "GG". 3. On the B Hall - In Room B5, two live roaches were crawling across the floor. B. During an interview with Resident "II" conducted at 4:57 p.m. on 12/22/2009, the resident stated that there was a crack in the baseboard to the right of the closet in his/her room and that he/she had observed roaches coming from that location. C. During interviews with Certified Nursing Assistants (CNAs) "BB" and "CC" conducted at 2:03 p.m. on 12/22/2009, both CNAs stated that they had seen live roaches on both the previous day of 12/21/2009, and on the day of this survey of 12/22/2009, in the C Hall Shower Room. D. During an interview with Nurse "HH" conducted on 12/22/2009 at 3:20 p.m., Nurse "HH" stated that although roach sightings were less than in the past, roaches could still be seen. E. Review of the facility's pest control contract revealed that scheduled monthly service was to be provided, and that in addition to monthly service, the facility could notify the pest control contractor for additional service when pests were observed. Documentation indicated that pest control service had been provided on 08/11/2009, 09/23/2009, 09/26/2009, 10/09/2009, 10/19/2009, 10/28/200… | 2014-07-01 |
| 10421 | 10421 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON AVENUE | METTER | GA | 30439 | 2009-10-27 | 253 | E | 1 | 0 | WIRV12 | Based on observation and staff interview, the facility failed to provide a clean, sanitary, and orderly environment, related to problems which were identified regarding maintenance and housekeeping, for four (4) halls of four (4) halls (A, B, C and D Halls). Findings include: During a tour of the facility beginning at 1:55 p.m., and continuing through 5:06 p.m., on 12/22/2009, the following observations were made: A. On the C Hall: 1. Shower Room -dark, stained tile below the sink; -stained tile around the drain; -a crack in the drywall to the left of the shower; -missing paint and debris on top of the shelf to the right of the door; -open paper towel holder; and, -sink with black debris. 2. Whirlpool Room -white stain in the corner behind the whirlpool tub; -chipped paint on the door frames; -all sprinkler heads rusted; -stained shower chair; and, -debris on the floor beside the waste can. 3. Room C3 -loose sink; -rusty vent to the left of the door in the bathroom; -veneer coming off the bathroom door; -ceiling was peeling beside the vent in the bathroom; and, -bottom drawer in the chest-of-drawers did not close completely. 4. Rooms C5 and C7 Bathroom -Loose sink; and, -dark brown substance on the floor to the left of the commode. 5. Main Dining Room -three dead roaches on the brick wall in the small dining area by the little sink; -all ceiling fans had a buildup of dirt and debris; -areas above the fans had a buildup of dirt and debris; -all the ceiling vents were soiled with dust and dirt; -two (2) wobbling tables in the main dining area; and, -one (1) wobbling table in the back of the dining area by the small sink. 6. Area Behind the Smoke Porch off the Dining Room -black debris on double doors and the floor threshold. 7. Small Dining Room by D Hall Entrance -dead roach on the floor. B. On the D Hall 1. Back Hallway to D Hall -ceiling tiles not in the frame. During a tour with the D Hall Supervisory Staff Member "GG" beginning at 3:07 p.m. on 12/22/2009, the following observations were made: 2. Room D18 -dead… | 2014-07-01 |
| 10422 | 10422 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON AVENUE | METTER | GA | 30439 | 2009-12-23 | 371 | F | 1 | 0 | WIRV12 | Based on observation and staff interview, the facility failed to ensure the sanitary storage and preparation of food by failing to maintain a fully functional stove and oven, failing to provide sanitary storing of glass racks for use in the dishwasher, failing to ensure the cleanliness of the kitchen floor, and failing to provide food storage bins that sealed completely. The facility's current Resident Census And Conditions Of Residents form documented that the facility's census was 114 residents, and further documented that only one (1) resident was fed via tube feeding. Thus, 113 facility residents had the potential to be affected by this deficient practice regarding dietary sanitary conditions. Findings include: Observation of the kitchen with Dietary Supervisory Staff Member "DD" beginning at 2:27 p.m. on 12/22/2009 revealed the following: A. Dish Room: -the lower shelf to the left of the dish machine was rusty, and chemicals were stored on the right side; -glass racks for use in the dish machine were stored on the left side, and white debris was on the floor around the dish machine. B. Main Kitchen Area: -oven doors were discolored across the top; -dark debris around the right, back stove burner; -stained area behind the burners; -oven doors do not close completely; and, -the top of the convection oven had rusted areas. During interview with Staff Member "DD" at 2:27 p.m. on 12/22/2009, this staff member acknowledged the presence of debris around the right back burner on the stove, stating that it would go through the stove top if cleaned. Additionally, during an interview with Kitchen Staff "EE" conducted at 2:35 p.m. on 12/22/2009, this kitchen staff member stated that not all of the stove burners worked properly, further stating that on the date of the survey, only four (4) of the ten (10) burners were functioning. During an interview with the Administrator on 12/23/2009 at 9:30 a.m., the Administrator stated that plans were in progress to replace the stove, however, there was an issue with the grease tra… | 2014-07-01 |
| 10423 | 10423 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON AVENUE | METTER | GA | 30439 | 2009-12-23 | 490 | F | 1 | 0 | WIRV12 | Based on record review, resident interview, staff interview, and facility document review, the facility failed to be administered in a manner to ensure a clean, well-maintained, and pest-free environment in resident care areas, the kitchen, and the Main Dining Area. Findings include: Review of the facility's policies, procedures, and job responsibilities revealed that the facility would be administered in such a manner to maintain a clean and pest-free environment, to ensure the direction of physical plant repairs, and to ensure the implementation of the necessary procedures and controls. A. Cross refer to F253. Based on observation and staff interview, the facility failed to provide a clean, sanitary, and orderly environment, related to problems which were identified regarding maintenance and housekeeping, for four (4) halls of four (4) halls (A, B, C and D Halls). Review of the policy for Environmental Services revealed the maintenance, housekeeping, and laundry services were responsible for monitoring facility practice to ensure compliance with acceptable standards of practice. However, no information was contained in the policy that indicated how this was to be accomplished, nor was there any monitoring information provided. B. Cross refer to F371. Based on observation and staff interview, the facility failed to ensure the sanitary storage and preparation of food by failing to maintain a fully functional stove and oven, failing to provide sanitary storing of glass dishwasher racks, failing to ensure the cleanliness of the kitchen floor, and failing to provide food storage bins that sealed completely. C. Cross refer to F469. Based on observation, resident interview, staff interview, and facility document review, the facility failed to maintain a pest-free environment, related to the presence of insects, on three (3) halls of four (4) halls (B, C and D Halls). The facility's policy for pest control, actually contained in the "Other Environmental Conditions" Policy, indicated that the facility would maintain an … | 2014-07-01 |
| 10424 | 10424 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON AVENUE | METTER | GA | 30439 | 2009-12-23 | 469 | F | 1 | 0 | X2IH11 | Based on observation, resident interview, staff interview, and facility document review, the facility failed to maintain a pest-free environment, related to the presence of insects, on three (3) halls of four (4) halls (B, C and D Halls). Findings include: A. A tour of the facility on 12/22/2009 beginning at 1:55 p.m., and concluding at 5:06 p.m., revealed live roaches in the following locations: 1. On the C Hall -In the Shower room on C Hall, a live roach was crawling on the floor, and was killed by Nurse "AA" who was in attendance at the time. 2. On the D Hall a. Two roaches were observed crawling on the wall in the Pantry across from Nurse's Station. This was observed by Unit Supervisory Staff Member "GG" who was in attendance at that time. b. In Room D4 -Two live roaches were crawling on the floor and were observed by Unit Supervisory Staff Member "GG". 3. On the B Hall - In Room B5, two live roaches were crawling across the floor. B. During an interview with Resident "II" conducted at 4:57 p.m. on 12/22/2009, the resident stated that there was a crack in the baseboard to the right of the closet in his/her room and that he/she had observed roaches coming from that location. C. During interviews with Certified Nursing Assistants (CNAs) "BB" and "CC" conducted at 2:03 p.m. on 12/22/2009, both CNAs stated that they had seen live roaches on both the previous day of 12/21/2009, and on the day of this survey of 12/22/2009, in the C Hall Shower Room. D. During an interview with Nurse "HH" conducted on 12/22/2009 at 3:20 p.m., Nurse "HH" stated that although roach sightings were less than in the past, roaches could still be seen. E. Review of the facility's pest control contract revealed that scheduled monthly service was to be provided, and that in addition to monthly service, the facility could notify the pest control contractor for additional service when pests were observed. Documentation indicated that pest control service had been provided on 08/11/2009, 09/23/2009, 09/26/2009, 10/09/2009, 10/19/2009, 10/28/200… | 2014-07-01 |
| 10425 | 10425 | PRUITTHEALTH - FORSYTH | 115418 | 521 CABINESS ROAD | FORSYTH | GA | 31029 | 2009-04-29 | 157 | D | 1 | 0 | 5I7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to immediately consult with the physician for one (1) resident (#1), of seven (7) sampled residents, when there was a significant change in the resident's physical status, related to the development of significant bruising while on anticoagulant therapy. Findings include: Record review for resident #1 revealed that the resident was on anticoagulant therapy. Additional review revealed a nursing note of 3/18/09 at 8:30 p.m. which documented that the Certified Nursing Assistant called the Licensed Nurse to the resident's room. The note further documented that the resident was observed with large discoloration, purplish color to the right abdomen and the resident would be monitored for any signs and symptoms of bleeding. A note later on this shift at 10:45 p.m. documented no change in size or color of discoloration. There was no further evidence to indicate any monitoring or assessment of the large discoloration until 3/19/09 at 5:45 a.m. At which time, the Licensed Nurse documented no further discoloration noted to the bruised area on abdomen and right flank, no bleeding out noted and will continue to observe. A nursing note of 3/19/09 at 4:10 p.m., documented resident noted to have large discoloration to the right side of abdomen, generalized yellow color and physician notified. The physician ordered that STAT lab work, consisting of Basic Metabolic Panel (BMP), liver panel and [MEDICATION NAME] time with INR (PT/INR), be done at this time. Thus representing a delay of approximately twenty (20) hours since the initial note of 3/18/09 at 8:30 p.m. which documented the large discoloration of the right abdomen. A nursing note of 3/20/09 at 12:25 a.m. documented that the laboratory work was received. Per review of the laboratory work dated 3/20/09, a Panic Call was made to the nursing home to give the critical abnormal values to the Licensed Practical Nurse. The [MEDICATION NAM… | 2014-07-01 |
| 10426 | 10426 | LAKE CROSSING HEALTH CENTER | 115424 | 6698 WASHINGTON ROAD | APPLING | GA | 30802 | 2009-10-21 | 281 | D | 0 | 1 | P8VR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide services that met professional standards of nursing practice. This was evidenced by the failure of staff to clarify oxygen orders with the physician for one (1) resident #14, from nineteen (19) sampled residents. Findings include: Observation of resident #14 on 10/19/09 between 11:15 a.m.- 12:20 p.m., on 10/20/09 at 3:20 p.m. & 4:30 p.m., on 10/21/09 at 9:00 a.m. revealed the resident was receiving oxygen via nasal cannula at two (2) liters per minute. Record review revealed that this resident was hospitalized with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] with physician's orders [REDACTED].> 96%. These orders did not indicate the manner of delivery nor the amount of oxygen to be given. Review of August 2009 Nurses Notes and August 2009 Medicare Charting Flow-Sheets revealed that staff applied a nasal cannula to the resident to deliver oxygen at two (2) liters per minute. There was no documentation of physician's orders [REDACTED]. In an interview on 10/21/09 at 8:00 a.m. the Assistant Director of Nurses, confirmed that no other documentation of physician's orders [REDACTED]. She also acknowledged that nursing staff should have clarified this order with the physician before providing this therapy. In accordance with Standards of Nursing Practice- 2.3.2 Standards Related to Licensed Practical/Vocational Nurse Responsibilities for Nursing Practice Implementation. The licensed practical nurse/vocational nurse [MEDICATION NAME] under the direction of a registered nurse...........licensed physician or other authorized licensed health care provider. E. Seeks clarification of orders when needed. | 2014-07-01 |
| 10427 | 10427 | LAKE CROSSING HEALTH CENTER | 115424 | 6698 WASHINGTON ROAD | APPLING | GA | 30802 | 2009-10-21 | 309 | D | 0 | 1 | P8VR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow physicians's orders to check vital signs for three (3) residents #10, 14, & 15 from nineteen (19) sampled residents. Findings include: Record review revealed that resident #10 had [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. In an interview on 10/20/09 at 12:15 p.m., the Assistant Director of Nurses (ADON) confirmed that there was no other documentation available that the resident's vital signs were checked as ordered by the physician. Record review revealed that resident #14 had [DIAGNOSES REDACTED]. These orders directed staff to hold this medication if the systolic blood pressure was less than 115. Review of the resident's clinical record and the August 2009 Medication Administration Record [REDACTED]. Additionally, on 8/19 the resident's systolic pressure was above 115 and the medication was also not administered. However, on 8/21 & 8/24 the systolic pressure was not checked, but the medication was administered. In an interview on 10/21/09 at 8:00 a.m., the ADON acknowledged that the resident's systolic blood pressure was not being checked and the medication was not being given as ordered. Review of the clinical record for resident #15 revealed a current physician's orders [REDACTED]. Review of the Medication Administration Records for the following dates revealed weekly vital signs were not done as ordered on [DATE], 08/11/09 and 08/25/09. During an interview with Licensed Practical Nurse (LPN) "KK" on 10/20/09 at 3:00 p.m. she confirmed that no other documentation of the resident's vital signs for those dates were available. | 2014-07-01 |
| 10428 | 10428 | LAKE CROSSING HEALTH CENTER | 115424 | 6698 WASHINGTON ROAD | APPLING | GA | 30802 | 2009-10-21 | 328 | D | 0 | 1 | P8VR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that residents receiving oxygen therapy had oxygen saturation levels performed as ordered by the physician for four (4) residents #10, 13, 14, & 15 from nineteen (19) sampled residents. Findings include: Record review revealed that resident #10 had [DIAGNOSES REDACTED]. The resident also had September 2009 and October 2009 physician's orders [REDACTED]. Review of the September 2009 Medication Administration Record (MAR) revealed that this was not done. Within the first nineteen days in October 2009 these levels should have been measured and recorded thirty eight times. Review of the Medication Administration Record (MAR) for October 2009 on 10/20/09 revealed that these levels were measured on 10/17 twice, 10/18 once, and 10/19 twice, a total of five (5) of the thirty eight times expected. In an interview on 10/20/09 at 12:15 p.m., the Assistant Director of Nurses (ADON) confirmed that oxygen saturation levels are only recorded on the MAR and could offer no explanation about why these levels were not being done as ordered. Record review revealed that resident #14 was hospitalized in July 2009 with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] with orders to measure the oxygen saturation level twice a day. Review of the August 2009 and September 2009 MAR's revealed that saturation levels were not done. Review of the October 2009 MAR on 10/21/09 revealed that oxygen saturation levels was done on 10/18 once, 10/19 & 10/20 twice. In an interview on 10/21/09 at 8:00 a.m. the ADON acknowledged that these levels were not done as ordered and that further facility review was needed to address this problem. She added, that the admission orders [REDACTED]. Review of the clinical record for resident #13 revealed monthly physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) for 9/09 revealed oxygen saturation were not measure… | 2014-07-01 |
| 10429 | 10429 | LAKE CROSSING HEALTH CENTER | 115424 | 6698 WASHINGTON ROAD | APPLING | GA | 30802 | 2009-10-21 | 514 | D | 0 | 1 | P8VR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to maintain clinical records in accordance with accepted professional standards that are complete and accurately documented. This was evidenced by the failure to transcribe physician's orders [REDACTED].#13 &14 of nineteen (19) sampled residents. Findings include: Record review revealed that resident #14 was hospitalized and readmitted to the facility on [DATE]. The readmission orders [REDACTED]. Review of the August 2009 and September 2009 physician's orders [REDACTED]. In an interview on 10/21/09 at 8:00 a.m., the Assistant Director of Nurses confirmed that this order had not been transcribed to the monthly physician's orders [REDACTED]. Review of the clinical record for resident #13 revealed the September 2009 physician's orders [REDACTED]. Review of the September 2009 Medication Administration Record [REDACTED]. Interview with the Director of Nursing on 10/20/09 at 2:55 p.m. indicated that this physician's orders [REDACTED]. | 2014-07-01 |
| 10430 | 10430 | LAKE CROSSING HEALTH CENTER | 115424 | 6698 WASHINGTON ROAD | APPLING | GA | 30802 | 2009-10-21 | 323 | D | 0 | 1 | P8VR11 | Based on observation and staff interviews the facility failed to ensure that hot water not reach hazardous temperatures (above one hundred and twenty (120) degrees Fahrenheit) for residents residing in two (2) private rooms on one (1) of three (3) halls. Findings include: Observation with the Maintenance Director on 10/19/09 at 4:55 p.m. revealed hot water temperatures (using the facility thermometers) of 121.0 degrees Fahrenheit (F) in resident rooms B-1 and B-18. The Administrator was notified at that time and the Maintenance Director adjusted the water heater temperature. | 2014-07-01 |
| 10431 | 10431 | LAKE CROSSING HEALTH CENTER | 115424 | 6698 WASHINGTON ROAD | APPLING | GA | 30802 | 2009-10-21 | 441 | D | 0 | 1 | P8VR11 | Based on observation, record review and staff interviews the facility failed to ensure that staff maintain hand hygiene to prevent the transmission of disease and infection. This was evidenced by the failure of staff to remove contaminated gloves after providing perineal care for one (1) resident #2 of nineteen (19) sampled residents. Findings include: Observation of perineal care on 10/19/09 at 1:15 p.m. for resident #2 revealed that Certified Nursing Assistant (CNA) "AA" after completing the care and before removing her contaminated gloves, pulled up the side rails of the bed, moved the resident's catheter bag, adjusted the resident's pressure relief booties and adjusted the linens. Observation on 10/21/09 at 8:45 a.m. revealed that resident #2 was receiving care from CNA "BB". The CNA checked the resident's incontinent brief, and without removing her contaminated gloves obtained barrier cream from the resident's bedside table, applied the cream to the resident's buttocks, then raised the side rails of the bed and adjusted the resident's pressure relief booties. In an interview with CNA "BB" on 10/21/09 at 9:00 a.m. she indicated that she should have removed her gloves prior to touching any clean area. In an interview with CNA "AA" on 10/21/09 at 9:05 a.m. she also indicated that she should have removed her gloves before touching a clean area.. Review of the facility Policy and Procedures for Handwashing revealed that hands should be washed prior to moving from a contaminated body site to a clean body site during resident care and that the use of gloves does not replace handwashing/hand hygiene. During an interview with the Director of Nursing on 10/21/09 at 10:15 a.m. she indicated that this was poor technique and that the contaminated gloves should have been removed before touching a clean area. | 2014-07-01 |
| 10432 | 10432 | SUMMERHILL | 115430 | 500 STANLEY STREET | PERRY | GA | 31069 | 2009-04-01 | 223 | D | 1 | 0 | CVD511 | Based on record review, staff interview, and review of relevant facility documents, the facility failed to ensure that residents have the right to freedom from abuse, related to an incident of physical abuse for one (1) resident (#1) from a survey sample of six (6) residents. Findings include: Record review for Resident #1 revealed a 03/04/2009 Minimum Data Set assessment which indicated that the resident was assessed to have short-term and long-term memory deficits and impaired decision-making capacity. A Nurse's Note of 3/15/09 at 8:30 p.m. documented that the resident was very confused and combative on that date as evidenced by yelling and fighting. The Note further documented that the resident was attempting to go out of the door and the writer brought her back onto the hall. A Facility Incident Report Form dated 3/17/09 documented that on 3/15/2009 at 9:45 p.m., Certified Nursing Assistant (CNA) "BB" alleged that she witnessed Nurse "AA" slap Resident #1 and to tell the resident to "shut up". Nurse "AA" was suspended and an investigation was immediately begun. In a written signed statement dated 3/17/09 by CNA "AA", the CNA documented that on the evening of Sunday 3/15/09, the resident was really combative towards the roommate and when she and another CNA went into the room to intervene and/or assist with the situation, they were unsuccessful and Nurse "AA" came to assist. CNA "BB" further documented that shortly after this, she was coming out of another resident's room nearby and saw Nurse "AA" slap the resident in the face and tell him/her to "shut up". The CNA's statement further documented that Nurse "AA" pushed the resident in a wheelchair down to the nursing station where she tied the resident with a sheet. In a written statement by the Nurse "AA" dated 3/18/09, the nurse documented that on March 15, 2009, the resident was very agitated, confused and combative, and she was unable to calm the resident. In this same statement, Nurse "AA" documented that she did not remember or believe that she had hit th… | 2014-07-01 |
| 10433 | 10433 | SUMMERHILL | 115430 | 500 STANLEY STREET | PERRY | GA | 31069 | 2009-04-01 | 225 | D | 1 | 0 | CVD511 | Based on facility record review and staff interview, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the administrator of the facility for one (1) resident (#1) on a survey sample of six (6) residents. Findings include: A Facility Incident Report Form dated 3/17/09 at 9:30 p.m. documented that it was alleged to the Administrator on 3/17/09 at 9:30 p.m. that on 3/15/09 at 9:45 p.m., Certified Nursing Assistant (CNA) "BB" had witnessed a licensed nurse employee slap Resident #1 and to tell the resident to "shut up". Further record review revealed that although the facility had conducted a thorough investigation, and implemented corrective actions, regarding this alleged incident of abuse of 03/15/2009 once the Administrator was made aware of the allegation on 03/17/2009, CNA "BB" had failed to report the allegation immediately to the facility Administrator. The above findings were acknowledged during interview on 4/01/09 at approximately 4:00 p.m. with the Administrator, the Assistant Administrator, and the Director of Nursing. | 2014-07-01 |
| 10434 | 10434 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 469 | F | 1 | 1 | FH9411 | Based on observation, review of facility records, and staff, resident and family interviews the facility failed to maintain an effective pest control program to remain free of flies in the facility's only dining room and on two (2) of two (2) units. Findings include: During an observation of the lunch meal for resident #14 on 8/25/09 at 8:15 a.m. a fly was noted on the resident's breakfast tray. It was also noted on a container of food which was later consumed by the resident. An observation of resident #18 on 8/26/09 at 12:30 p.m. revealed a fly on the resident's food tray. It was noted to land on the edge of a container of food which was being consumed by the resident. A fly swatter was observed at the bedside of the resident's roommate. In an interview with the Maintenance Supervisor on 8/26/09 at 2:00 p.m., he stated that he was not aware of an issue with flies until this past Monday. Review of the Pest Control record revealed that flies had not been identified as a problem for treatment during the July visit and again on the visit of 8/26/09. During a random observation of lunch in the main dining room on 8/24/09 beginning at 12:55 p.m. a fly was observed on the back of a resident's shirt. At 1:00 p.m. a fly was observed on the open milk carton of a random resident. At 1:15 p.m. the fly was still in the vicinity of this resident and was observed on the rim of the resident's juice glass and on the tip of the straw in the milk carton. The resident was observed to drink from both containers following the fly's presence. The fly was then observed on the beef stroganoff of the resident at the next table at 1:20 p.m. During a random observation of supper on 8/25/09 at 6:05 p.m. a fly was observed around a feeding table inside the door to the right. Four (4) resident's and one (1) Certified Nursing Assistant (CNA) were at the table. The CNA had to swat the fly away from two (2) of the resident's faces two (2) times and also swatted it away with her hands two (2) times from their food. One (1) of the resident's swat… | 2014-07-01 |
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CREATE TABLE [cms_GA] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );