cms_GA
Data source: Big Local News · About: big-local-datasette
147 rows where "filedate" is on date 2015-05-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9689 | 9689 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2010-04-21 | 441 | D | 0 | 1 | 9TT311 | Based on observation and staff interview, the facility failed to ensure that staff washed hands appropriately for one (1) resident (#2), of a sample of twenty-four (24) residents. Findings include: Observation on 04/20/10 at 12:20 p.m. revealed two (2) Certified Nursing Assistants (CNAs) providing incontinence care for resident #2 who had been incontinent of urine and stool. After incontinence care was completed CNA "CC" removed her soiled gloves, gathered a bag of soiled linens including towels and wash cloths, gathered a bag of contaminated gloves and took both bags outside to the soiled linen and trash hampers (both attached to one cart). Continued observation revealed that the CNA returned to the resident's room, arranged the resident's top covers on the bed and placed the call button in reach without washing her hands. CNA "EE" assisted CNA "CC" with care and after care had been completed, removed her gloves, assisted in positioning the resident in bed, pulled up the bed covers without washing her hands. Interviews with CNAs "CC" and "EE" on 04/20/10 at 12:45 p.m. revealed that they should have washed their hands. Interview on 4/21/10 at 2:30 p.m. with the Director of Nurses revealed that whenever you touch dirty, the hands need to be washed before touching the resident again. | 2015-05-01 |
| 9690 | 9690 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2010-04-21 | 253 | C | 0 | 1 | 9TT311 | Based on observation and staff interview, the facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment for six (6) of six (6) halls. Findings include: Observation during intial tour on 04/19/10 and during environmental tour on 04/20/10 at 1:00 P.M. with the Plant Manager and the Housekeeping Supervisor revealed that there were dusty ceiling vents in the Interview on 4/20/10 at 1:00 p.m. with the Plant Manager and Housekeeping Supervisor revealed that the vents were dusty. | 2015-05-01 |
| 9691 | 9691 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2010-04-21 | 241 | D | 0 | 1 | 9TT311 | Based on observations and staff interview, the facility failed to provide a dignified dining experience and failed to promote an environment that enhanced the dignity of two (2) residents (#14 and #17) from a sample of twenty four (24) residents and two (2) randomly observed residents. Findings include: 1. Observation on 4/20/10 at 8:33 a.m. revealed resident #14 seated in the 200 South Hall dining room for breakfast being fed by staff. Continued observation revealed that the staff member, feeding resident #14, was having a conversation with another staff member across the room, who was feeding two (2) residents, instead of interacting with the residents they were feeding. 2. Observation at 1:10 pm on 4/20/2010 of the 200 South hallway revealed a staff member yelling out two (2) resident names to a staff member down the corridor. Anyone in the area could hear the resident's names. Interview on 4/21/2010 at 2:00 pm with Licensed Practical Nurse (LPN) "AA" Unit Manager for the 200 Floor revealed that the staff are expected to give full attention to each resident while feeding or care is being provided. Continued interview revealed that the staff had been inserviced on interaction with the resident. 3. Observation on 04/21/10 beginning at 8:15 a.m. revealed resident #17 being fed by LPN "FF" in the 200 South Hall dining room. The resident exhibited behaviors including being verbally and physically abusive to the staff, refusing to eat her breakfast, and pouring liquids onto the floor. Two staff persons feeding residents and the nurse all laughed at the resident's behavior. Interview with LPN "AA" on 04/21/10 at 8:55 a.m. revealed that these behaviors are frequent for this resident and that staff laughing at the resident could be considered a dignity concern. | 2015-05-01 |
| 9692 | 9692 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-01-04 | 157 | D | 1 | 0 | F5T911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the physician was notified in a timely manner of the need to alter treatment significantly for one (1) resident (#1) from a survey sample of ten (1) residents. Findings include: Closed record review for Resident #1 revealed a Nurse's Notes entry of 07/13/2011 at 1:00 p.m. which documented that the resident had been admitted to the facility with [DIAGNOSES REDACTED]. Record review revealed a 07/13/2011 physician's admission order which specified for Resident #1 to receive [MEDICATION NAME] 5 milligrams (mgs.) daily, and the resident's July 2011 Medication Administration Record [REDACTED]. daily, and the resident's July 2011 MAR indicated [REDACTED] A Nurse's Notes entry of 07/23/2011 at 9:42 p.m. documented that the family member (who was named as the resident's designated legal decision maker per the Durable General Power of Attorney referenced above) had requested that Resident #1 not receive any [MEDICATION NAME] or any [MEDICATION NAME] due to previous adverse reactions the resident had experienced. Further record review revealed no evidence to indicate that facility staff notified the physician at that time of the family member's instruction to not administer [MEDICATION NAME] and [MEDICATION NAME], as ordered. However, the resident's July 2011 MAR indicated [REDACTED]. dose was refused on 07/26/2011, and documented that the [MEDICATION NAME] 5 mg. dose was held on 07/27/2011 at the family member's request. This July 2011 MAR indicated [REDACTED]. The resident's July 2011 MAR indicated [REDACTED]. dose was held on 07/24/2011, and specifically documented that the [MEDICATION NAME] 25 mg. dose was not given on 07/27/2011 per the family member's request. This MAR indicated [REDACTED]. A 07/27/2011, 10:35 p.m. Nurse's Note documented that the family member had again requested that the resident not receive [MEDICATION NAME] or [MEDICATION NAME] due to the resident's… | 2015-05-01 |
| 9693 | 9693 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-01-04 | 309 | D | 1 | 0 | F5T911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer the medications [MEDICATION NAME] and [MEDICATION NAME] per physician's orders to ensure the continuity of care for one (1) resident (#2) from a survey sample of ten (10) residents. Findings include: Record review for Resident #2 revealed a 12/16/2011 verbal physician's order specifying for the resident to receive [MEDICATION NAME] 10 milligrams (mgs.) at bedtime when available. However, although the resident's December 2011 Medication Administration Record [REDACTED]. at bedtime at 9:00 p.m., further review this MAR indicated [REDACTED]. Additionally, a 01/02/2012 verbal physician's order specified to hold [MEDICATION NAME] 10 milligrams at bedtime until available. Record review for Resident #2 also revealed the resident had been receiving [MEDICATION NAME] 10 mgs. daily. A verbal physician's order of 12/16/2011 specified to discontinue the daily order, and to give [MEDICATION NAME] 10 mgs. by mouth twice a day. However, the resident's December 2011 MAR indicated [REDACTED]. The resident's January 2012 MAR indicated [REDACTED]. Documentation on the reverse sides of these MARs specifically indicated that, for December 2011, twenty (20) doses of the [MEDICATION NAME] had not been administered between 12/17/2011 and 12/31/2011, and for January 2012, three (3) doses of [MEDICATION NAME] had not been administered as ordered, due to the medication needing authorization/prior approval from the physician. A verbal physician's order of 01/02/2012 specified to hold [MEDICATION NAME] 10 mg. twice daily therapy until available. A Nurse's Note of 12/16/2011 at 11:45 a.m. documented that when called, the pharmacist informed nursing staff that both the [MEDICATION NAME] and [MEDICATION NAME] drug therapies referenced above would require prior approval and that the pharmacy would facsimile to the physician's office a prior approval form. Nurse's Notes entries of 12/22/2011 and 12/… | 2015-05-01 |
| 9694 | 9694 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-01-04 | 385 | D | 1 | 0 | F5T911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure prompt physician response and follow-up to inquiries regarding the medication drug therapy and medication availability for one (1) resident (#2) on the survey sample of ten (10) residents. Findings include: Please cross refer to F309 for more information regarding Resident #2. Record review for Resident #2 revealed a verbal physician's orders [REDACTED].) patch daily. However, the resident's November 2011 Medication Administration Record [REDACTED]. A Nurse's Notes entry of 11/29/2011 documented that the [MEDICATION NAME] had not been available due to needing prior approval from the physician, and that a nurse at the physician's office had been contacted by the facility's Director of Nursing for clarification. A verbal physician's orders [REDACTED]. Further record review revealed no evidence to indicate that the physician had been contacted by facility staff to obtain additional care instruction prior to 11/29/2011 regarding the resident not receiving the [MEDICATION NAME] as ordered, since the original order date of 11/11/2011.. A Nurse's Notes entry of 11/29/2011 documented that the [MEDICATION NAME] was still not available due to it needing prior approval, per the pharmacist. This Note documented that the necessary forms had been provided by facsimile to the physician's office per the pharmacy, further stating they would facsimile the forms again, which would be the third time. A Nurse's Notes entry of 12/16/2011 at 11:10 a.m. documented when facility staff again placed a telephone call to the pharmacist to inquire about the [MEDICATION NAME]es, the pharmacist stated that the pharmacy was still awaiting prior approval from the physician for this medication. A Nurse's Note of 12/16/2011 at 11:35 a.m. documented that facility staff had received a telephone call from staff at the physician's office stating that prior approval for this medication had been denied to the r… | 2015-05-01 |
| 9695 | 9695 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-01-04 | 514 | D | 1 | 0 | F5T911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the medical record for one (1) resident (#1) was accurate and complete from a survey sample of ten (10) residents. Findings include: Closed record review for Resident #1 revealed 07/13/2011 discharge orders from the hospital referencing an order for [REDACTED]., but did not include the frequency of administration for this medication. Review of the Medication Administration Record [REDACTED]. Resident #1 had a 07/20/2011 physician's orders [REDACTED]. daily. However, there was no order on the resident's written admission orders [REDACTED]. daily. Record review also revealed that Resident #1 had an order for [REDACTED]. Interview with the Director of Nursing on 12/14/2011 at 5:00 p.m. revealed that the physician had been notified of the resident's low blood pressure on 7/29/2011 at 6:00 p.m., while she was on her way home from work. She stated that she had called the unit charge nurse on Unit Four to write the physician's orders [REDACTED]. twice a day and HCTZ 25 mg. daily) on 07/29/2011, a little after 6:00 p.m. However, there was no documentation in the record that an order had been written to hold the afore mentioned blood pressure medications. Further review of the closed record revealed that the [MEDICATION NAME] 20 had been held for the evening dose on 07/28/2011 and for both morning and evening doses on 07/29/2011, 07/30/2011 and 07/31/2011. The HCTZ 25 mg. had been held on 07/29/2011, 07/30/11 and 07/31/2011. | 2015-05-01 |
| 9696 | 9696 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2012-01-04 | 272 | D | 1 | 0 | SDOR11 | Based on record review and staff interview, the facility failed to assess the use of a geri-chair for one (1) resident (#1) of twenty-one (21) sampled residents. Findings include: During an observation in the room of Resident #1 conducted on 10/27/2011 at 9:30 a.m., a geri-chair with a cushion was observed. Review of the medical record for Resident #1 revealed a 04/05/2011 plan of care entry for Activities of Daily Living which indicated that the resident required the extensive assistance of one person for bed mobility and the extensive assistance of two persons for transfers. Additionally, a 04/05/2011 plan of care entry documented the resident as having a fall-risk, with an Intervention being the use of a wheelchair. However, further record review revealed no evidence of an assessment for the use of a geri-chair for Resident #1 to determine if the geri-chair would be a restraint or an enabler for this resident, and to determine if the use of the geri-chair would be safe for the resident. During an interview with the Administrator conducted on 10/27/2011 at 9:20 a.m., the Administrator stated that the resident used both a wheelchair and a geri-chair, according to how she was evaluated for each day. However, the Administrator acknowledged that there was no documented assessment for the use of the geri-chair. During an interview with the Director of Nursing (DON) conducted on 10/27/2011 at 1:05 p.m., the DON stated that Resident #1 would be evaluated daily in order for staff to decide what chair to put her in, either the wheelchair or geri-chair. The DON acknowledged that there was no documentation regarding an assessment for the use of the geri-chair. During an interview with the Minimum Data Sets/Care Plan Director on 10/27/2011 at 2:30 p.m., this staff person stated that she had observed the resident up in a geri-chair for at least 2 - 3 weeks. | 2015-05-01 |
| 9697 | 9697 | HUTCHESON MED CTR SUBACUTE UNI | 115040 | 100 GROSS CRESCENT CIRCLE | FORT OGLETHORPE | GA | 30742 | 2012-01-23 | 441 | D | 1 | 0 | 4O0411 | Based on observation, staff interview, and facility policy review, the facility failed to follow the infection control policy and ensure a sanitary environment related to the use of glucometers for four (4) residents (#7, #8, #9, and #10) in a survey sample of ten (10) residents. Findings include: Review of the operators manual for the glucometer used by the facility revealed that the machine was to be cleaned with a 10% bleach solution and that alcohol was not to be used. However, observation on 01/23/2012 of Nurse "AA" using the glucometer on Residents #7 and #8 at 11:34 a.m. and 11:38 a.m., respectively, revealed that the machine was not cleaned prior to the test on Resident #7, and was cleaned with alcohol after the blood was obtained and the tests were done on Residents #7 and #8. Observation of Patient Care Tech "BB" conducted on 01/23/2012 at 11:45 a.m. revealed that the glucometer was not cleaned prior to taking it into the room of Resident #9. Stains were observed on the over-bed table upon which the box containing the glucometer was placed. The Patient Care Tech was wearing gloves and placed the glucose strip on the over-bed prior to obtaining the blood sample. The glucose strip was then picked up and the resident's blood was placed on the strip. The hands were washed after the procedure, however, the glucometer was not cleaned after the test. Observation of Patient Care Tech "BB" conducted on 01/23/2012 at 11:50 a.m. revealed that the box with the glucometer was taken into the room of Resident #10 without being cleaned. The box with the glucometer was placed on the resident's over-bed table next to personal toiletry items. Wearing gloves, the Patient Care Tech placed the blood on the glucose strip and the test was completed. The hands were washed after the test, however, the glucometer was not cleaned. During an interview with the Infection Control Nurse conducted on 01/23/2012 at 3:00 p.m., this Nurse stated that the infection control policy was that reusable equipment was not used for the care of ano… | 2015-05-01 |
| 9698 | 9698 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2012-01-20 | 279 | E | 1 | 0 | 2VSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop comprehensive care plans which reflected quantifiable Approaches to address the turning and repositioning care needs of four (4) residents (#s 1, 3, 4 and 5), who had pressure sores, and the [MEDICAL CONDITION] care needs of one (1) resident (#10), from a survey sample of ten (10) residents. Findings include: Record review for Resident #s 1, 3, 4 and 5 revealed Care Plan entries of 11/23/2011, 12/07/2011, 11/21/2011, and 02/18/2011, respectively, identifying these residents to have actual pressure ulcers, and identifying Approaches which included to reposition in the chair frequently, and to turn and reposition while in bed frequently, for comfort and pressure reduction. However, these Care Plans failed to identify specific parameters to define the actual frequency of repositioning of the residents while in the chair and the turning and repositioning of the residents while in bed, but instead only directed staff to perform these functions "frequently". During interview with the Administrator and Director of Nursing conducted on 01/06/2012 at 10:00 a.m., these staff members acknowledged that the Care Plans of Residents 1, 3, 4 and 5 did not identify parameters for repositioning in the chair or turning and repositioning in the bed. It was also stated that the Turn and Repositioning Detail Report for each of the residents directed the resident to be turned and repositioned as directed by the plan of care. Additionally, record review for Resident #10 revealed that the resident had had the [DIAGNOSES REDACTED]. However, review of the resident's Care Plan revealed that the Care Plan did not address the care of the resident's [MEDICAL CONDITION]. During an interview with the Director of Nursing conducted on 01/06/2012 at 3:20 p.m., the Director of Nursing acknowledged that the resident's Care Plan did not address the care of the [MEDICAL CONDITION]. | 2015-05-01 |
| 9699 | 9699 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2012-01-20 | 314 | E | 1 | 0 | 2VSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital document review, staff interview, and review of the facility's Skin Management Policy, the facility failed to provide pressure sore prevention and treatment as ordered by the physician to promote healing of pressure sores for three (3) residents (#s 1, 2, and 6) who had pressure sores, failed to obtain physicians' treatment orders but still treated the existing pressure sores of two (2) residents (#s 1 and 3) without orders for treatment, and failed to assess, develop, and implement interventions to ensure pressure relief for the heels of one (1) resident (#1), on the total survey sample of ten (10) residents. Findings include: 1. Record review for Resident #1 revealed the residents' Weekly Pressure Ulcer Record of 11/23/2011 documented that the resident was admitted to the facility with pressure ulcers which included a pressure ulcer on the coccyx. This Weekly Pressure Ulcer Record documented that the Stage Two pressure ulcer measured 8.5 centimeters (cms.) in length by 4.0 cms. in width, with a depth of 0.1 cm., and documented that new treatment orders had been received. A Progress Note of 11/28/2011 documented that the treatment order for this coccyx wound had been changed to Santyl daily and as needed. However, review of the resident's November and December 2011 Treatment Records revealed, and interview the Director of Nursing on 01/06/2012 at 9:40 a.m. acknowledged, that the treatment order noted on 11/28/2011 was not started until 12/02/2011. The 11/23/2011 Weekly Pressure Ulcer Record for Resident #1 also documented that the resident was admitted to the facility with a blister on the left heel measuring 5 cms. in length and 2.5 cms. in width. An 11/23/2011 Progress Note documented that a treatment order for skin prep and a Suresite dressing had been received from the physician. Record review, to include review of the November 2011 Treatment Record, revealed no evidence to indicate that this treatment wa… | 2015-05-01 |
| 9700 | 9700 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2012-01-20 | 361 | D | 1 | 0 | 2VSV11 | Based on record review and staff interview, the facility failed to ensure an initial nutritional assessment by the Registered Dietitian which included the assessment of pressure sores for one (1) resident (#1) on the survey sample of ten (10) residents. Findings include: Record review for Resident #1 revealed the residents' Weekly Pressure Ulcer Record of 11/23/2011 documented that the resident was admitted to the facility with an open pressure ulcer on the coccyx, a blister on the left heel measuring 5 centimeters (cms.) in length and 2.5 cms. in width, and a blister on the right heel measuring 5 cms. in length and 3.1 cms. in width. However, review of the resident's Medical Nutritional Therapy Review dated 11/23/2011 completed by the Registered Dietician revealed no reference to the resident's coccyx and bilateral heel pressure sores, and no evidence of assessment of these pressure sores by the dietician. During an interview with the Registered Dietician conducted on 12/30/2011 at 2:30 p.m., the dietician stated that she was not aware of the resident's breakdown, and acknowledged that the skin breakdown was not addressed in the nutritional assessment. | 2015-05-01 |
| 9701 | 9701 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2012-01-20 | 502 | D | 1 | 0 | 2VSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to do a drug sensitivity test for a sputum specimen as ordered by the physician for one (1) resident (#1) in a survey sample of ten (10) residents. Findings include: Record review for Resident #1 revealed an undated Physician's Telephone Orders sheet, included with the November 2011 physician's orders [REDACTED]. However, further record review revealed no evidence that this sensitivity test had been done. During an interview with the Director of Nursing conducted on 01/06/2011 at 2:00 p.m., the Director of Nursing acknowledged that the laboratory sensitivity test for the drugs identified in the physician's orders [REDACTED]. | 2015-05-01 |
| 9702 | 9702 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2010-07-27 | 253 | E | 0 | 1 | BR6U11 | Based on observation and staff interview, it was determined that the facility failed to maintain an environment that was free from dust, dirt, rust, stained ceiling tiles, torn vinyl and torn positioning wedges in isolated areas on Unit I and Unit II. Findings include: Observations were made on 7/13/10 at 9:20 a.m. and 2:05 p.m., on 7/14/10 at 4:15 p.m., on 7/15/10 at 8:00 a.m. and during the General Observations Tour of the Facility on 7/15/10 at 10:30 a.m. Unit I 1. There was a heavy build up of dust on the return air ceiling vents near rooms 21 and 22. 2. There was black dust and dirt on the ceiling vents and ceiling tiles in the hall near rooms 9, 10, 11, 12, 15, 16 and 18. 3. There were two brown stained ceiling tiles in the hall near the nurse's station. 4. There was a brown stained ceiling tile in the residents and public sitting room near the nurse's station. Unit II 1. Resident #206's geri-chair had dust and dirt on the plastic flap underneath the chair and on the frame of the chair. The footrest was bent in the center. 2. Resident #204's electric wheelchair had dust, dirt and pine straw on the seat and the base of the chair. During an interview on 7/15/10 at 12:40 p.m., the housekeeping supervisor stated that the residents' geri-chairs and wheelchairs were cleaned once a month. 3. There were brown dried stained ceiling tiles in rooms 200 (1), 201 (2), 203 (2), 204 (2), 207 (1), 208 (4), 209 (4), 211 (1), 212 (2) and 213 (2). There were six brown dried stained ceiling tiles in the 200 hallway and seven stained ceiling tiles in the dining room. 4. In room 201(B ), there was one vinyl lap buddy that was torn in four places which exposed the foam interior. 5. The bathroom ceiling vents had a build up of dust in rooms 400, 402, 403, 410 and 411. 6. There were brown dried stained ceiling tiles in rooms 402 and 410. 7. The ceiling air vent covers had several rusty areas in rooms 403, 406 and 410. 8. The four straps on the vinyl covered side rail padding were torn in room 400C. 9. In the bathroom of room 300, t… | 2015-05-01 |
| 9703 | 9703 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2010-07-27 | 441 | K | 0 | 1 | BR6U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, review of the facility's infection control logs and policies and procedures, and review of documentation about the facility's surface disinfectant, it was determined that the facility failed to maintain an Infection Control Program that ensured proper infection control and provision of aseptic technique to prevent cross contamination and prevent indirect contact transmission of a blood borne infection or a microscopic pathogen by failing to ensure one licensed nurse practiced effective hand hygiene, and by one nurse on Unit I and six nurses on Unit II failing to clean and disinfect glucometers between residents and, the facility's failure to monitor their infection control policy and procedures to ensure their implementation. These practices effected sixteen insulin dependent, sampled residents but had the potential to effect all of the residents whose blood sugar levels required monitoring. Therefore, it was determined that an immediate jeopardy existed for 37 residents who had diabetes and required fingerstick blood glucose monitoring from July 14, 2010 through July 15, 2010 when a plan of correction was implemented by the facility to remove the jeopardy. Therefore, it was determined that the immediate jeopardy was removed on 7/16/10 and the scope and severity was lowered to an "E" level. However, the facility remains out of compliance in order to ensure that licensed nursing staff continued to implement the correct procedures to clean and disinfect blood glucose testing machines; that supervisory nursing staff continues to monitor to ensure that blood glucose testing machines are clean and disinfected according to the manufacturer's directions; and that the Performance Improvement Committee monitors the facility's interventions to ensure that the infection control policies and procedures are implemented as planned. The Center for Disease Control's (CDC) section "Diabetes Care Procedur… | 2015-05-01 |
| 9704 | 9704 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2010-07-27 | 371 | F | 0 | 1 | BR6U11 | Based on observation and staff interview, it was determined that the facility failed to maintain the kitchen environment free of dust, dirt, rust and peeling paint on Unit II. Findings include: Unit II Observations were made during the initial tour of the kitchen on 7/13/10 at 10:20 a.m. and on 7/14/10 at 11:10 a.m. During an interview on 7/14/10 at 11:10 a.m., the Dietary Manager stated that the air conditioning units were cleaned once a month and had last been cleaned in June 2010. There were four air conditioner units in the kitchen. They were above the sanitizer sink, the two door cooler, the food preparation sink and the clean dish storage racks. However, it was observed that the air conditioning units were dusty and dirty. They were rusty and had rusty metal pieces dangling off of them as well as paint peeling off of them. | 2015-05-01 |
| 9705 | 9705 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2010-07-27 | 328 | D | 0 | 1 | BR6U11 | **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 clean, date and properly store nebulizer mouth pieces on Unit II and failed to ensure that an oxygen concentrator filter was intact for one resident (#223) on Unit II. Findings include: Unit II During an interview on 7/15/10 at 12:40 p.m., the Director of Nursing (DON) stated that it was the facility's policy to change and/or clean oxygen concentrator filters once a week on Mondays. However, there was not an air filter on the oxygen concentrator being used for resident #223. 1. Oxygen concentrators are designed to work with an air filter. However, it was observed on 7/13/10 at 9:20 a.m. that resident #223 had oxygen infusing at 2 liters per minute via nasal cannula but, there was not an air filter in the oxygen concentrator. 2. In an observation during the initial tour on 7/13/10 at 9:20 a.m., there was a mouthpiece for a nebulizer being stored on the resident's nightstand in room [ROOM NUMBER]B. The mouthpiece was being stored uncovered and undated. 3. During observations on 7/13/10 at 10:00 a.m. and on 7/15/10 at 12:00 p.m., there was a build up of a dried brown substance along the edges of resident #202's nebulizer machine. On 7/14/10 at 9:20 a.m., the nebulizer machine was dusty and dirty. Although the nebulizer was next to the resident's bed and available for use, the treatment nurse said at that time that the resident had not used it for months. | 2015-05-01 |
| 9706 | 9706 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2010-07-27 | 170 | D | 0 | 1 | BR6U11 | Based on resident and staff interviews, and record review, it was determined that the facility failed to ensure that mail was delivered unopened to one resident ("Z") in a group sample of six residents on Unit II. Findings include: Unit II During the group interview conducted on 7/14/10 at 10:30 a.m., resident "Z" complained that his/her mail was frequently opened by staff prior to being delivered. There was a signed 2/21/06 "Consent regarding Correspondence" form for resident "Z" that the administrator of the facility or designee would assist him/her in opening financially related mail addressed to him/her such as checks, medical bills or statements. During an interview on 7/15/10 at 4:10 p.m., resident "Z" stated that he/she had not given the facility staff permission to open his/her mail without his/her being present. He/She said that providing assistance did not mean to open his/her mail without his/her knowledge. During an interview on 7/14/10 at 4:00 p.m., the Activity Director stated that all personal mail was delivered unopened to the residents unless it looked like a bill. If the residents' mail looked like a bill, then she/he gave it to the social services director or the bookkeeper to open. He/she stated that the residents should not get any bills. During an interview on 7/14/10 at 4:10 p.m., the Social Services Director (SSD) confirmed that if a resident's mail looked like a bill, then the resident was not given the mail. He/she stated that the residents should not get bills so, they did not need to worry about it. He/she stated that, "a lot of the time" the residents never saw the bills. He/she stated that he/she felt it would upset the residents to see any bills. | 2015-05-01 |
| 9707 | 9707 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2010-07-27 | 490 | K | 0 | 1 | BR6U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility's infection control policies and procedures, it was determined that the facility failed to be administered in a manner that ensured that staff were trained and had implemented effective procedures to clean and disinfect glucometers between each resident who received blood glucose level checks by fingersticks, and that all infections were tracked and trended in order for each resident to attain and/or maintain his/her highest practicable physical well-being. Immediate jeopardy was identified on July 14, 2010 after observations of blood glucose testing revealed a failure to clean and disinfect glucometers between residents "A", "B", "C" and "D" on Unit I, and between residents #223 and #220; residents #204 and #220; residents #225 and #222; residents #226 and #222; resident #227; residents #213 and #216; residents #214 and #215; and for resident #224 on Unit II through July 15, 2010 when a plan of correction was implemented by the facility to remove the jeopardy. The facility remained out of compliance at a lower scope and severity of 'E', a pattern of deficiency with the potential for more than minimal harm, for all residents who received blood glucose monitoring in order to complete training of all licensed nursing staff; to ensure that the facility's system for at least 20 random observations of glucometer tests per month was maintained; and to ensure that the findings of the observations were reported to the Administrator and the Performance Improvement committee as planned. Findings include: 1. The facility failed to maintain and Infection Control program that ensured proper infection control and provision of aseptic technique to prevent cross contamination and prevent indirect contact transmission of a bloodborne infection or a microscopic pathogen by failing to ensure that a licensed nurse practiced effective hand hygiene, that seven nurses effectively cleaned and disinfec… | 2015-05-01 |
| 9708 | 9708 | GOLDEN LIVINGCENTER - WINDERMERE | 115291 | 3618 J DEWEY GRAY CIRCLE | AUGUSTA | GA | 30909 | 2010-08-26 | 279 | D | 0 | 1 | DEJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop a comprehensive care plan related to mouth care and prevention of contractures for two (2) residents, resident "L" and #29 on a sample of twenty-four (24) residents. Findings include: Resident "L" was admitted to the facility on [DATE] for rehabilitation following a hospital stay. Resident "L" has left sided weakness and required assistance with mouth care. Interview with resident "L" on 8/23/2010 at 1:30 p.m. revealed that they had not had their teeth brushed since admission. Review of the interim plan of care for the resident revealed that there was nothing to address the resident's needs for activities of daily living. Interview with Licensed Practical Nurse (LPN) "DD" on 8/25/2010 at 3: 00 p.m. confirmed that the care plan addressed pressure sores, falls, nutrition and pain but did not address the resident's need for activities of daily living related to mouth care. Observation of resident #29 on 8/25/10 at 3:00 p.m. revealed the resident seated in a wheelchair with his left arm bent at the elbow and his left leg was bent at the knee with the foot rotated outward. Record review revealed a Minimum (MDS) data set [DATE] assessing the resident as requiring extensive assistance or dependence for activities of daily living (ADL) with partial loss of range of motion (ROM) on one side. The Resident Assessment Protocol (RAP) dated 1/22/10 stated the resident had left upper and lower extremity contractures. A review of the resident's plan of care revealed no care plan was developed for range of motion limitations or contractures. | 2015-05-01 |
| 9709 | 9709 | GOLDEN LIVINGCENTER - WINDERMERE | 115291 | 3618 J DEWEY GRAY CIRCLE | AUGUSTA | GA | 30909 | 2010-08-26 | 312 | D | 0 | 1 | DEJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide mouth care for one (1) resident, resident "L" on a sample of twenty-four (24) residents. Findings include: Interview with resident "L" on 8/23/2010 at 1:35 p.m. revealed that they had not had their teeth brushed since their admission to the facility. Review of the intial resident assessment dated [DATE] revealed that the resident had their own teeth, the gum lines were intact and the mucous membranes were moist. The resident also had left sided weakness and required assistance with activities of daily living. Interview with the Director of Nurses (DON) on 8/25/2010 at 2:00 p.m. revealed that the expectation was that the Certified Nursing Assistants (CNA's) would provide mouth care twice a day. Interview with Licensed Practical Nurse (LPN) "CC" at that time revealed that if the resident can physically do their own mouth care the nursing staff needs to prepare the equipment for the resident to brush their teeth. If the resident is physically unable to brush their teeth the staff should provide the mouth care. Interview on 8/26/2010 at 8:35 am with Certified Nursing Assistants (CNA"AA" and "BB" confirmed that whom ever has the resident should assist with mouth care when providing their morning care. Interview with resident "L" on 8/26/2010 at 8:15 am revealed that they asked for the equipment to brush their teeth yesterday before going to the doctor and the staff provided assistance for them to brush their teeth. The resident stated that that was the first time they had brushed their teeth since admission. | 2015-05-01 |
| 9710 | 9710 | GOLDEN LIVINGCENTER - WINDERMERE | 115291 | 3618 J DEWEY GRAY CIRCLE | AUGUSTA | GA | 30909 | 2010-08-26 | 281 | D | 0 | 1 | DEJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide range of motion services for one (1) resident (#29) on a sample of twenty-four (24) residents. Record review for resident #29 revealed the Resident Assessment Protocol (RAP) dated 1/22/10 stating the resident had left upper and lower extremity contractures. Physical Therapy notes dated 3/15/10 stated the resident was being discharged from therapy secondary to having reached maximum potential and that the resident would benefit from a restorative nursing program addressing Range of Motion of lower extremities so the contractures do not progress which could cause further disability. A review of the current Minimum (MDS) data set [DATE] revealed no restorative nursing program for this resident. Interview with the Director of Nurses on 8/25/10 at 12:35 p.m. revealed that the referral to the restorative nursing program was not made in March. | 2015-05-01 |
| 9711 | 9711 | GOLDEN LIVINGCENTER - WINDERMERE | 115291 | 3618 J DEWEY GRAY CIRCLE | AUGUSTA | GA | 30909 | 2010-08-26 | 309 | D | 0 | 1 | DEJ311 | Based on record review and staff interview the facility failed to ensure that a surgical referral ordered by the physician was followed for one (1) resident (#21) on a sample of twenty- four (24) residents. Finding included. Review of a Nurses Note dated 6/04/10 at 2:00 pm documented resident #21 was noted that the resident's fifth (5th) finger of the right hand was painful to touch and bruised. The physician was notified and the physician ordered an X-ray the right hand. Review of radiology report dated 6/04/10 document the right hand showed a fracture at the base of the fifth proximal phalanx (finger). Further review of this report revealed the physician signed the report and documented on the report that the resident was to be referred to a orthopedic surgeon. There was no evidence in the resident's record that a orthopedic surgeon referral had been done. Interview with the Director of Nurses on 8/25/10 at 11:55 am revealed the resident was never referred to a orthopedic surgeon for the fractured 5th finger. | 2015-05-01 |
| 9712 | 9712 | GOLDEN LIVINGCENTER - WINDERMERE | 115291 | 3618 J DEWEY GRAY CIRCLE | AUGUSTA | GA | 30909 | 2010-08-26 | 502 | D | 0 | 1 | DEJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that laboratory tests ordered by the physician was followed for one (1) resident (#21) on a sample of twenty-four (24) residents. Findings include. Review of Note to the Attending Physician dated 5/24/10 revealed the Pharmacist documented that resident #21 was receiving [MEDICATION NAME] Acid which may cause blood dyscrasias and impair liver function especially in early therapy. The pharmacist also documented the resident was receiving sliding scale insulin and [MEDICATION NAME] and recommended the physician consider ordering a Complete Blood Collection (CBC) with differential. liver function tests, a basic metabolic profile and hemoglobin A1C test every six (6) months. The physician signed this note on 6/01/10 and checked he agreed with the pharmacist recommendation to have the laboratory test done. There was no evidence in the resident's record that the laboratory test were done other than the HGB AIC which was done on 5/31/10. Interview with the Director of Nurses on 8/25/10 at 12:35 p.m. revealed that these laboratory tests were not done as ordered. | 2015-05-01 |
| 9713 | 9713 | PRUITTHEALTH - LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2010-08-16 | 279 | D | 0 | 1 | 2ZZ211 | Based on observations, record reviews and staff interviews the facility failed to develop care plans and interventions to address inappropriate behavior for one (1) resident (#132) and to prevent decline in range of motion for one (1) resident (#14) of thirty (30) sampled residents. Findings include: 1. Observations of Resident #14 on 8/9/10 at 9:10am, 10:00am, and 3:00pm, 8/10/10 at 10:05am, and 8/12/10 at 10:00am revealed the resident had hand contractures with no hand rolls or splints in use. Review of the most recent assessments revealed a Minimum Data Set (MDS) for significant change dated 7/8/10, and a Quarterly dated 5/21/10 which assessed the resident with limitation and partial loss in both arms, hands, legs and feet. The assessments further revealed the resident had not received any therapies or restorative nursing interventions to prevent decline with range of motion (ROM). Review of the Care Plan dated 7/15/10 revealed no mention of and no interventions to decline in ROM. Interview with the Licensed Practical Nurse (LPN) unit manager "LL" on 8/12/10 at 12:25pm revealed that the resident had a decline in December of 2009, and was placed on comfort measures. The resident has since improved, and the facility failed to reassess ROM needs. Interview with Occupational Therapy (OT) "NN" on 8/12/10 at 12:15pm revealed the resident was discharged from OT on 3/3/09 due to achieving goals. "NN" indicated that resident's hands did not have full ROM but were functional. The resident has not been assessed or evaluated since 3/3/09. Further interview with "NN" on 8/16/10 at 10:30am revealed the facility had overlooked the resident's need for ROM exercises. 2. Review of the clinical record for resident #132 revealed he admission MDS completed 6/24/10 which assessed the resident as resisting care. The resident's resistance to care was not easily altered per this assessment. Review of the Nurse's Notes revealed resident exhibited anxiety, agitation and was combative. These behaviors were present daily and required medi… | 2015-05-01 |
| 9714 | 9714 | PRUITTHEALTH - LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2010-08-16 | 317 | D | 0 | 1 | 2ZZ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews, the facility failed to prevent further decline in range of motion (ROM) for one (1) resident (#14) from a sample of thirty (30) residents. Findings include: Observation of resident #14 on 8/9/10 at 9:10am revealed the resident was sitting in a geri chair, at 10:00am resident was back in bed and appeared asleep. A further observation at 3:00pm revealed the resident lying in bed, appeared asleep. There were no splints, or hand rolls observed with any of the 8/9/10 observations and hand contractures were observed. On 8/10/10 at 10:05am resident was sitting in geri chair, and both hands contracted. There were no hand rolls or splints observed. On 8/12/10 at 10:00am the resident was lying in bed waiting for care. Hands were curled with both thumbs placed between the first and second fingers. Record review revealed the resident had [DIAGNOSES REDACTED]. Further review of the Occupational Therapy (OT) notes indicated the resident was discharged from OT on 3/3/09 and referred to restorative nursing. Review of the Restorative Nursing summary dated 12/10/09 indicated the resident had been discontinued from the program due to health issues. The resident had been receiving active ROM to both upper and lower extremities, bed mobility, and had a palm guard in the left hand at all times. The resident had been assessed with [REDACTED]. Review of the most recent assessments revealed a Minimum Data Set (MDS) for significant change dated 7/8/10, and a Quarterly dated 5/21/10 which assessed the resident with limitation and partial loss in both arms, hands, legs and feet. Review of the resident's Care Plan dated 7/15/10 indicated there were no interventions to prevent contractures or decline in ROM. Interview with the LPN charge nurse "MM" on 8/12/10 at 11:00am revealed the resident's care plan did not address ROM. Interview with the Director of Nursing (DON) on 8/12/10 at 11:15am revealed the resident'… | 2015-05-01 |
| 9715 | 9715 | PRUITTHEALTH - LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2010-08-16 | 309 | D | 0 | 1 | 2ZZ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow a physician's order for a nutritional supplement for one (1) resident (72) from thirty (30) sampled residents. Findings include: Record review revealed that resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Yearly Weight Record revealed that since admission the resident had experienced weight loss and that on 7/9/10 the physician wrote an order for [REDACTED]. Interview on 8/10/10 at 2:45 p.m. with Licensed Practical Nurse (LPN) "MM" revealed that administration of nutritional supplements is recorded in the Medication Administration Records (MAR). Review of the resident's July 2010 MAR revealed that from 7/10/10 to 7/31/10 (a total of 22 days) there was no indication that the resident received the Medpass as ordered. During interview with the Assistant Director of Nurses on 8/10/10 at 4:00 p.m., she acknowledged that the supplement was not given to the resident in July 2010. She indicated that the physician's order was not transcribed to the July MAR and was overlooked. | 2015-05-01 |
| 9716 | 9716 | PRUITTHEALTH - LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2010-08-16 | 329 | D | 0 | 1 | 2ZZ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews , and review of facility policy, the facility failed to provide adequate monitoring for one (1) resident #121, receiving a psychotic medication, from thirty (30) sampled residents. Findings include: Record review revealed that resident #121 had a [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. Record review revealed that this resident's Psychoactive Medication Monthly Flow Record for March, May, and July 2010 did not indicate that target behavior symptoms and side effects of these drugs were being monitored. Interview on 8/12/10 at 1:30 p.m. with Medical Records staff revealed that April and June 2010 Psychoactive Medication Monthly Flow Records were not available. Interview on 8/12/10 at 2:00 p.m. with Licensed Practical Nurse (LPN) "JJ" confirmed that these Flow Records did not indicate that staff was monitoring this resident for side effects of the medication. Interview with the Pharmacist on 8/12/10 at 3:30 p.m. revealed that a new psychoactive medication monitoring form had been developed for use in March 2010 and that he had conducted an inservice for the nursing staff in January 2010 on the use of this form. However, he indicated, that during his drug reviews from April thru July 2010, the new psychoactive monitoring sheets were not accurate and complete. Review of the facility's policy on Monitoring of Antipsychotics revealed that when antipsychotic therapy is initiated, the patient/resident is monitored to determine the effectiveness of the medication and the presence of adverse reactions. There was no evidence that this was done for resident #121. | 2015-05-01 |
| 9717 | 9717 | TREUTLEN COUNTY HEALTH AND REHABILITATION | 115358 | 2249 COLLEGE STREET, NORTH | SOPERTON | GA | 30457 | 2010-09-30 | 315 | D | 0 | 1 | NGYN11 | Based on observation and staff interview, it was determined that the facility failed to thoroughly clean one (1) resident (#6) from a sample of thirteen (1)3 residents. Findings include: Resident #6 was coded on the 9/19/10 Initial Minimum Data Set (MDS) as requiring total assistance with toileting. On 9/28/10, the resident left for a doctor's appointment and did not return until 2:00 p.m. The resident was observed on 9/28/10 at 2:00 p.m. lying in the bed wearing pants that were visibly wet. A urine odor was present in the room. Certified Nursing Assistant (CNA) "RR" was observed walking out the resident's bathroom with a wet towel and stated that she was preparing to give the resident incontinence care. After the CNA removed the resident's wet pants and saturated brief, a strong urine smell could be detected. During the observation of incontinence care, CNA "RR" sprayed the resident's perineal area with peri-wash solution and cleaned the area with one end of the wet towel, refolding areas on the towel between each wipe. The CNA then dried the resident with the other end of the towel. The resident was assisted to his/her right side and the CNA then wiped the resident's buttocks area with the wet end of the same towel failing to spray peri-wash on the area before wiping the buttocks. The CNA dried the resident's buttocks with the other end of the towel and then applied a clean brief to the resident. | 2015-05-01 |
| 9718 | 9718 | TREUTLEN COUNTY HEALTH AND REHABILITATION | 115358 | 2249 COLLEGE STREET, NORTH | SOPERTON | GA | 30457 | 2010-09-30 | 371 | F | 0 | 1 | NGYN11 | Based on observation and staff interview, it was determined that the facility failed to maintain the proper amount of sanitizer in the low temperature dishwasher and failed to promote staff hygiene while working in the food preparation area. Findings include: 1. During observation of the use of the low temperature dishwasher on 9/29/10 at 9:00 a.m., the sanitizer did not register on the chemical strip after the dietary aide attempted to check the amount of sanitizer in the rinse cycle. The food service supervisor came into the dishwasher area and called for another dietary staff member to come check the sanitizer instructing them to try pumping the primer button located on the side of the machine. Three (3) more attempts to check the sanitizer level revealed that the chemical strip did not register, indicating that the sanitizer chemical was not entering the dishwashing machine. A review of the facility's dishwasher log at that time, revealed that the sanitizer and temperatures had already been logged in as being within the acceptable ranges although it was only 9:00 a.m. 2. During observations of the dietary department on 9/29/10 at 9:00 a.m. and 11:30 a.m. the food service supervisor was seen wearing a hair net that failed to completely restrained the front of his/her hair while he/she was working in the dietary department. | 2015-05-01 |
| 9719 | 9719 | TREUTLEN COUNTY HEALTH AND REHABILITATION | 115358 | 2249 COLLEGE STREET, NORTH | SOPERTON | GA | 30457 | 2010-09-30 | 246 | D | 0 | 1 | NGYN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and resident and staff interviews, it was determined that the facility failed to ensure that one (1) resident ("A") was not served his/her food dislikes from a total sample of thirteen (13) residents. Findings include: Resident "A" had a physician's orders [REDACTED]. However, on 9/28/10 at 1:05 p.m., staff served the resident mashed potatoes with gravy for lunch. The resident consumed only a few bites of the mashed potatoes with gravy. On 9/29/10 at 12:45 p.m., staff served the resident chopped beef tips with gravy for lunch. The resident consumed only a few bites of the chopped beef tips with gravy. Interview on 9/29/10 at 12:45 p.m. with Resident "A" revealed that he/she did not like gravy and had told staff on several occasions that he/she did not like gravy but the staff continued to serve him/her food items with gravy. Interview on 9/30/10 at 10:10 a.m. with the dietary manager revealed that resident "A" had a physician's orders [REDACTED]. She acknowledged that the resident chose his/her food items for each meal from the "Select Menu" card and that dietary staff served the resident those foods that he/she had chosen. Continued interview revealed that mechanical soft meats were often served with a sauce or gravy to make them more palatable and that the "Select Menu" card did not document the resident's likes and dislikes. Review of the dietary card for resident "A" revealed that under special request, the words no gravy are written and under the dislikes column, the word gravy is written. | 2015-05-01 |
| 9720 | 9720 | KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2012-01-26 | 328 | D | 1 | 0 | 5SCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility staff interview, physician interview, and respiratory therapist interview, the facility failed to administer oxygen at the rate ordered by the physician for one (1) resident (#2), who had a tracheotomy, of the sampled sixteen (16) residents. Finding include: Record review for Resident #2 revealed an admission date of [DATE]. A physician's orders [REDACTED]. However, observations of Resident #2 conducted on 01/24/2012 at 9:40 a.m., 10:15 a.m., 11:25 a.m. and 3:15 p.m. revealed the oxygen concentrator flow meter was set on four (4) LPM, instead of two (2) LPM as ordered by the physician. Additional observations conducted on 01/25/2012 at 9:00 a.m. and 10:55 a.m. revealed the oxygen concentrator flow meter remained set at four (4) LPM. During an interview conducted on 01/25/2012 at 9:40 a.m. with the attending physician, the physician stated that Resident #2's oxygen was to be infused at two (2) LPM, per the physician's orders [REDACTED]. During an interview conducted on 01/25/2012 at 10:55 a.m. with the Director of Nursing and the Respiratory Therapist while at the resident's beside, both staff members verified the resident's oxygen concentrator remained at four (4) LPM, not at the two (2) LPM rate as ordered by the physician. | 2015-05-01 |
| 9721 | 9721 | KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2012-01-26 | 329 | J | 1 | 0 | 5SCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and attending physician interview, the facility failed to ensure that the drug regimen of one (1) resident (#1), on the total survey sample of sixteen (16) residents, was free of an unnecessary drug. Specifically, Resident #1, who was ordered to received two (2) doses of KCL 40 milliequivalents (mEq.), was administered four (4) additional doses of the drug and subsequently died after a laboratory test indicated a critical potassium level. Based on the above, it was determined that the facility's failure to administer KCL as ordered by the physician, and thus administering the drug for excessive duration, had caused serious harm to, and contributed to the death of, Resident #1. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on [DATE] and continued through [DATE], at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of [DATE]. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on [DATE] at 1:55 p.m. Findings include: Please cross refer to F333 for more information regarding Resident #1. Record review for Resident #1 revealed a Progress Notes entry dated [DATE] at 1:30 p.m. which documented that Resident #1 arrived at the nursing facility. This Note documented that the resident was alert upon admission and was able to ambulate to the bathroom with the assistance of one. A Resident Progress Notes entry of [DATE] at 11:00 p.m. for Resident #1 documented that physician's orders [REDACTED]. [DATE]. However, review of the [DATE] Medication Record (MR) for Resident #1 revealed documentation indicating that Resident #1 actually received 40 mEq. doses of KCL at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. on [DATE], and at 1:00 a.m. and 5:00 a.m. on [DATE]. Thus, Resident #1 … | 2015-05-01 |
| 9722 | 9722 | KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2012-01-26 | 333 | J | 1 | 0 | 5SCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, hospital Discharge Summary review, review of the facility's Policy/Procedure for Verbal/Telephone Orders, National Library of Medicine reference information review, facility staff interview, attending physician interview, and physical therapist interview, the facility failed to ensure that each resident was free of any significant medication errors by failing to administer potassium chloride (KCL) in accordance with the physician's orders [REDACTED].#1), of (9) residents on the survey sample who received KCL therapy, and by failing to administer [MEDICAL CONDITION] medication [MEDICATION NAME] in accordance with the physician's orders [REDACTED].#2), on the total survey sample of sixteen (16) residents. Resident #1, who was ordered to received two (2) doses of KCL 40 milliequivalents (mEq), was administered four (4) additional doses of the drug and subsequently died after a laboratory test indicated a critical potassium level. Based on the above, it was determined that the facility's failure to administer KCL as ordered by the physician had caused serious harm to, and contributed to the death of, Resident #1. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on [DATE] and continued through [DATE], at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of [DATE]. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on [DATE] at 1:55 p.m. Findings include: 1. Review of the facility's Policy/Procedure for Verbal/Telephone Orders, dated as having been last revised on [DATE], revealed a heading which read "Caution: Following the procedure below is very important to prevent confusion, medication errors and maintain communication between the disciplines." Part 2 of the Procedure … | 2015-05-01 |
| 9723 | 9723 | KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2012-01-26 | 514 | J | 1 | 0 | 5SCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, hospital Medication Profile review, facility staff interview, and attending physician interview, the facility failed to ensure that the clinical records of four (4) residents (#s 1, 2, 6, and 7), on the total survey sample of sixteen (16) residents, were accurate, related to the transcription of a physician's orders [REDACTED]. Specifically, Resident #1 had a physician's orders [REDACTED]. This resulted in the resident receiving four (4) additional doses of the drug in error, and the resident subsequently died after a laboratory test indicated a critical potassium level. Based on the above, it was determined that the facility's failure to accurately transcribe the order, and failure to thus administer KCL as ordered by the physician, had caused serious harm to, and contributed to the death of, Resident #1. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on [DATE] and continued through [DATE], at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of [DATE]. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on [DATE] at 1:55 p.m. Findings include: 1. Cross refer to F329 and F333, example 1, for more information regarding Resident #1. Record review for Resident #1 revealed a Physician's Telephone Orders sheet dated [DATE] which specified an order to administer KCL forty (40) mEq. by mouth every four (4) hours times two (2) doses. However, review of the [DATE] Medication Record (MR) for Resident #1 revealed that the physician's orders [REDACTED]. Further review of this MR revealed documentation indicating that Resident #1 received 40 mEq. doses of KCL at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. on [DATE], and at 1:00 a.m. and 5:00 a.m. on [DATE]. Thus,… | 2015-05-01 |
| 9724 | 9724 | MONTEZUMA HEALTH CARE CENTER | 115364 | 506 SUMTER ST | MONTEZUMA | GA | 31063 | 2010-07-22 | 315 | D | 0 | 1 | ESUR11 | Based on observation, record review, and staff interview, the facility failed to ensure that Certified Nursing Assistants (CNAs) provided appropriate incontinent/catheter care for one (1) resident (#15) of the twenty-five (25) sampled residents. Findings include: Observation on 7/20/10 at 4:38 p.m., of resident #15 revealed the resident in a low bed with the catheter bag, which was full of yellow colored urine, lying flat on the floor under the bed without a privacy bag. Observation of incontinent care on 7/21/10 at 10:08 a.m. for resident #15 provided by CNA "AA" and assisted CNA "BB". CNA "AA" after donning her gloves, removed resident's soiled incontinent pad and using a wet wipe, cleaned the left side of the perineal area with an up and down motion, twice. After changing gloves, the CNA continued the incontinent care. Continued observation revealed that the resident was rolled to the right side, revealing that the resident had been incontinent of stool. CNA "AA" took a wet wipe and wiped toward the residents vagina. After changing gloves and getting another wipe, the CNA repeated the same motion, toward the vagina, twice. After finishing the care, the CNA changed her gloves and applied cream to the resident's buttocks, then rolled resident onto his/her back. Interview with the Director of Nursing (DON) on 7/21/10 at 10:45 a.m., revealed that the CNA's just had their annual competency check and return demonstration for catheter and incontinent care in April or May 2010. Continued interview revealed that staff are taught to wipe front to back and never wipe toward the vagina. Interview with CNA "AA" at 1:30 pm on 7/21/10, revealed that she attended the 4/10 inservice for incontinent care/catheter care and knew that she should wipe away from the vagina. Continued interview revealed that she was aware that she wiped twice toward the vagina.. | 2015-05-01 |
| 9725 | 9725 | MONTEZUMA HEALTH CARE CENTER | 115364 | 506 SUMTER ST | MONTEZUMA | GA | 31063 | 2010-07-22 | 279 | D | 0 | 1 | ESUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care plan for decreased vision for one resident (#57) on a sample of twenty-five (25) residents. Findings include: Record review for resident #57 revealed an annual Minimum Data Set (MDS) dated 6/27/10 assessing the resident as having decreased vision, only seeing large print and having no glasses. previous MDS assessments had not assessed the resident with visual problems. Continued review revealed no evidence that the resident's decreased visual acuity had been care planned with interventions related to the decreased vision. Review of the Resident Assessment Protocol revealed that the reduced visual acuity was secondary to a history of [MEDICAL CONDITIONS] and that glasses were recommended Observation of the resident on 7/21/10 at 9:30 a.m. revealed the resident in a wheelchair, outside for supervised smoking. The resident had no glasses on. Interview with the Director of Nurses on 7/21/10 at 10:30 a.m. revealed that the resident and her family were unable to afford the price of the glasses at that time. Interview on 7/21/10 at 10:50 a.m. with the MDS and Care Plan Coordinator revealed that when rethinking circumstances that she should have had interventions related to decreased vision in the resident's plan of care. | 2015-05-01 |
| 9726 | 9726 | MONTEZUMA HEALTH CARE CENTER | 115364 | 506 SUMTER ST | MONTEZUMA | GA | 31063 | 2010-07-22 | 371 | F | 0 | 1 | ESUR11 | Based on observation and staff interview the facility failed to maintain the walk in cooler at appropriate temperatures to ensure safe consumption of food products. Total of residents consuming food products from kitchen = 89. Findings include: During the intial kitchen tour at 10:25 a.m. on 07/19/10 the walk-in cooler thermometers indicated 45 and 50 degrees Farenheit (F) on the two (2) thermometers within the cooler. Observations on 07/19/10 at 12:45 p.m. revealed the two (2) thermometers in the walk-in cooler indicated that the temperature in the cooler was 48.5 and 50 degrees F. Two milks removed from the boxes and an additional milk product sitting on the shelf of the walk in cooler revealed temperature readings of a minimum of 49.6 degrees F . Four (4) milks had been taken from one of the 2 boxes in the walk- in cooler and had been served and consumed by four (4) random residents during lunch. Temperature checks at -3:30 p.m. 07/19/10 revealed that the temperatures in the coolers remained elevated at 45 degrees F and 48 degrees F. Interview with the Corporate Director of Environmental services on 07/21/10 at 9:15 a.m. revealed that the cooler had been assessed and would require replacement of the evaporator coil and condenser unit and expansion valve. | 2015-05-01 |
| 9727 | 9727 | MONTEZUMA HEALTH CARE CENTER | 115364 | 506 SUMTER ST | MONTEZUMA | GA | 31063 | 2010-07-22 | 246 | D | 0 | 1 | ESUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review resident and staff interviews, the facility failed to ensure that the call light system accommodated the needs of one (1) resident ("A") from a total sample of twenty-five (25) residents. Findings include: Observation of resident "A" on 07/19/10 at 4:30 p.m. and on 07/20/10 at 7:30 a.m., revealed the call light button was tied to the right side rail of his bed and above the right of his head. Continued observation at 11:00 a.m. revealed the call button was draped over the right upper side rail Review of the medical record for resident "A"revealed [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had been assessed as totally dependent for all Activities of Daily Living (ADLs). Body control and hand dexterity problems were identified on the assessment worksheets. There was no evidence that an assessment related to use of the call button had been done. Interview with Resident "A" at 7:30 a.m. on 07/20/10, revealed that the resident could not reach the call button because he/she was unable to move his/her arms to get to the call button. During interview with the Director of Nursing on 07/20/10 at 11:00 a.m., she acknowledged that the resident could not reach his/her call button Review of the medical record revealed that a therapy screening had been done in 2005 but there was no evidence that there had been any further assessment by therapy. There was no evidence that an assessment had been done to provide an adapted call button system for use by the resident. Interview on 07/20/10 12:00 p.m. with the MDS Coordinator "DD"and Resident Care Coordinator"CC" revealed that the resident had been severely contracted for a long time and was unable to move his/her extremities. | 2015-05-01 |
| 9728 | 9728 | THOMSON HEALTH AND REHABILITATION | 115365 | 511 MT. PLEASANT ROAD | THOMSON | GA | 30824 | 2010-11-18 | 332 | E | 0 | 1 | EC2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations conducted during the medication pass and record review, the facility failed to ensure that it was free of a medication error rate of five (5) percent or greater. Errors occurred for three (3) residents (#54, #86, and #16). Findings include: Observations conducted on 11/16/10 and 11/17/10, revealed errors by two (2) of five (5) nurses, on three of six (6) halls, that were administering medications. Four (4) medications errors were observed out of fifty (50) opportunities, resulting in a error rate of 8.0%. 1. Observation on 11/16/10 at 10:11 a.m., of the medication administration for resident #54, performed by Licensed Practical Nurse (LPN) "AA" revealed that prior to administration of medications in the resident's gastrointestinal tube ([DEVICE]), LPN "AA" failed to flush the [DEVICE] with thirty (30) centimeter (cc) of water. Also during the medication administration of resident #54, LPN "AA" administered liquid multivitamin with minerals fifteen (15) cc into the [DEVICE]. The instructions on the label of the multivitamin with minerals bottle documented to shake the medication well. LPN "AA" did not shake the medication prior to administering the multivitamin with minerals. Review of the facility's policy on Enteral Tube Medication Administration documented that the [DEVICE] should be flushed with 30 cc of water prior to medication administration. Interview with LPN "AA" on 11/16/10 at 10:30 a.m. confirmed she did not flush the [DEVICE] with 30 cc of water prior to the medication administration nor did she shake the bottle of the multivitamin as indicated on the label. 2. Observation on 11/16/10 at 1:32 p.m., of the medication administration for resident #86, performed by LPN "AA" revealed that the nurse administered [MEDICATION NAME] HFA 90 micrograms (mcg) inhalation. The physicians order was to inhale two (2) puffs by mouth and wait one (1) minute between puffs. LPN "AA" administered the inhalations but did not wait … | 2015-05-01 |
| 9729 | 9729 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2010-09-16 | 318 | D | 0 | 1 | 45OR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and observations, the facility failed to provide services to improve or prevent the potential for further decline in range of motion for one (1) resident (#9), from a sample of twenty-two (22) residents. Findings include: Review of the physician's orders [REDACTED]. Observations of the resident on 9/13/10 at 12:45 p.m., in the restorative dining room, revealed that the only device on the resident was the knee splint. Further observations on 9/14/10 at 8:00 a.m and 10:00 a.m. revealed that the resident had the knee splint and the hand splint in place but did not have the foot splint on. Continued observation on 9/15/10 at 8:15 a.m. revealed the resident in the wheelchair without any splints applied. | 2015-05-01 |
| 9730 | 9730 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2010-09-16 | 411 | D | 0 | 1 | 45OR11 | Based on record review and staff interview the facility failed to obtain outside dental services for one (1) resident (#22) from a sample of twenty two (22) residents. Findings include: Review of the clinical record for resident #22 revealed on 02/27/10 the physician performed an oral assessment and indicated in his progress note dated for the same day that the resident had Dental decay and needed a dental appointment. There was no evidence in the clinical record that a dental appointment was made for the resident. Interview on 09/15/10 at 8:39 a.m. with Assistant Director of Nursing (ADON), revealed that the physician did indicate in his progress wrote that he wanted a dental appointment to be arranged for the resident. Interview 09/15/10 at 2:29 p.m. with the Resident's Physician "AA" revealed that he recommend that the nurse make an appointment for the resident to see a dentist in February 2010. Further interview revealed that he just believes that the resident needs to have a dental assessment every 1-2 years to make sure everything is okay. | 2015-05-01 |
| 9731 | 9731 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2010-09-16 | 309 | D | 0 | 1 | 45OR11 | Based on observations and record review , the facility failed to follow physician's orders related to Bunny Boots to bilateral feet for one (1) resident (#9) from a sample of twenty two (22) residents. Findings include: Review of the physician's orders for resident #9 revealed a current order for Bunny Boots to bilateral feet/heels every day. Observation of the resident on 9/13/10 at 12:45 p.m, 9/14/10 at 8:00 a.m and 10:00 a.m. and on 9/15/10 at 8:15 a.m. and 9:15 a.m. revealed the resident without the Bunny Boots in place. | 2015-05-01 |
| 9732 | 9732 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2011-04-21 | 309 | D | 0 | 1 | IV4J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide care and/or services in accordance to each resident's assessed needs or physician orders. The facility failed to obtain laboratory studies as ordered by the physician for one (1) resident (#79) for a sample of thirty-one (31) residents. Findings include: Record review for resident #79 revealed a physician order [REDACTED]. This laboratory test was not done until 3/24/11. the residents from the test was high with the PT being 35.2 and the INR being 3.5. A physician's orders [REDACTED]. A physician's orders [REDACTED]. daily and recheck the PT/INR in one (1) week. The lab test was not conducted as ordered. Interview with the Director of Nursing on 4/18/11 at 11:45 am revealed that a PT/INR for resident #79 had not been done since 3/24/11. | 2015-05-01 |
| 9733 | 9733 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2011-04-21 | 329 | D | 0 | 1 | IV4J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility failed to ensure a supporting [DIAGNOSES REDACTED].#36) for Vitamin B-12 injections of thirty-one (31) sampled residents Findings include: Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #36 had been receiving monthly B-12 injections since admission. A Vitamin B-12 level (blood level test) was obtained on 9/16/10 with a result of 496 and normal limits of 180-914. An interview with the Director of Nursing on 4/19/11 at 2:30 p.m. revealed that she was not sure of the supporting [DIAGNOSES REDACTED]. An interview with the Consulting Pharmacist "EE" on 4/20/2011 at 9:39 a.m. revealed there was no supporting [DIAGNOSES REDACTED]. | 2015-05-01 |
| 9734 | 9734 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2011-04-21 | 514 | D | 0 | 1 | IV4J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that the clinical record was a clear and accurate representation of each resident's condition. There was a lack of documentation regarding advance directive decisions for one resident's (#71) and the progression and/or decline in a non-pressure sore wound for another resident (#35) from a sample of thirty-one (31) residents. Findings include:1. Resident #71 was admitted to the facility from the hospital after experiencing a left [MEDICAL CONDITION]. Other admission [DIAGNOSES REDACTED]. Record review of Nurse's Notes, Social Worker's Notes and the Minimum Data Set (MDS) 3.0 assessment dated [DATE] referenced the resident had problems with cognition and poor decision making. Review of the Advanced Directive and Do Not Resuscitate (DNR) Face Sheet in the resident's record indicated the resident had a Do Not Resuscitate Order, however the DNR order sheet for residents without decision making capacity had not been signed by the physician. Review of the Social Services Progress Noted dated 1/07/11 documented a DNR was in place. Review of a Nurse's Note dated 1/09/11 at 7:45 p.m. revealed the resident had become unresponsive and a call was made for Emergency Medical Services (EMS). The resident's family member was present at that time and stated he had signed a paper requesting no recitative services be done. The family member repeated his request for DNR and the EMS was canceled. Interview with the physician on 4/20/11 at 2:35 p.m. revealed that he had seen the resident on 1/05/11 and failed to sign the DNR order. 2. Resident #35 had a multiple [DIAGNOSES REDACTED]. Record review revealed the resident was seen on 4/20/2011 for a follow up appointment due to a wound of the right lower leg. Recommendations for this wound included aggressive wound care for the venous ulcer of the right lower leg. The Treatment Administration Record (TAR) documented treatments are being done but … | 2015-05-01 |
| 9735 | 9735 | PRUITTHEALTH - FORSYTH | 115418 | 521 CABINESS ROAD | FORSYTH | GA | 31029 | 2010-10-08 | 441 | D | 0 | 1 | CKK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to follow their policy for Methicillin Resistant Staphylococcus Aureus (MRSA) General Recommendations for Healthcare Centers for one (1) resident (#69) from a sample of twenty-one (21) residents. Findings include: Review of the clinical record for resident #69 revealed a laboratory report dated 6/19/10 for a culture done on the eyes indicating MRSA in the eyes. Continued review revealed another laboratory report of a culture done on the right axilla dated 7/04/10 indicating a heavy growth of MRSA in the right axilla. Review of the physician's orders [REDACTED]. On 9/15/10, the [MEDICATION NAME] eye drops were reorder to continue for six (6) weeks. Review of the nurses notes revealed that drainage from the eyes was observed and noted nine (9) times from 9/27/10 thru 10/4/10. There is no evidence in the clinical record that any type of protective dressing was in place to prevent the drainage from the eye from coming in contact with any one/thing else or that contact precautions were in use Review of the the facility policy for MRSA general recommendations for Healthcare Centers issued 2/2008 revealed that it was the policy of this health care center to place resident on contact precautions who are displaying symptoms of active MRSA infection if the resident has a draining wound that is infected with MRSA and the drainage cannot be contained. Interview with the Registered Nurse (RN)/ Infection Control Nurse on 10/08/10 at 3:08pm revealed that because there were nurses notes to indicate that there was drainage from the eyes as late as 10/04/10, the resident should be on contact isolation. Telephone interview on 10/17/10 at 10:30 a.m., during the Quality Assurance (QA) process, with the Director of Nurses revealed that the resident was not on contact isolation because she was cognitively intact and knew what to do to take care of her eyes. Review of the quarterly Minimum… | 2015-05-01 |
| 9736 | 9736 | BRIAN CENTER HEALTH & REHABILITATION/CANTON | 115508 | 150 HOSPITAL CIRCLE N.W. | CANTON | GA | 30114 | 2010-10-08 | 441 | D | 0 | 1 | BCRX11 | Based on one (1) random observation, review of facility records and staff interview it was determined that facility failed to ensure that proper cleaning and disinfecting for blood glucose meter used for multiple residents. Finding includes: One (1) random observation of a resident receiving glucose testing using a glucose meter on 10/8/10 at 8:31 a.m. revealed that License Practical Nurse (LPN) "FF" removed the glucose meter from the medication cart, wiped it off with an alcohol wipe, cleaned the finger with alcohol wipe, use a new lancet and pricked the resident's finger, applied blood to the test strip, read the glucose level, cleaned the glucometer with a new alcohol wipe and put it away. The meter was not cleaned and sanitized appropriately. Interview with License Practical Nurse (LPN) "DD" on 10/8/10 at 8:25 a.m. revealed that she used Alcohol only to clean the glucose meter. Interview with Infection Control Nurse "AA" on 10/8/10 @ 8:35 a.m. revealed that the she is the primary source of training for staff in proper techniques related to infection control and the proper cleaning of the glucose meter. She revealed that until receiving information from Center for Medicare and Medicaid Services (CMS) regarding new procedures for cleaning and disinfecting glucose meters, the facility had used alcohol as the cleaning agent. She further indicated that since receiving the CMS information the facility was now using Sani-Wipes to clean and disinfect the machine before and after each resident use. She was unaware that some of the nurses were still using alcohol to clean the glucose meters. Review of facility inservices revealed that "FF" and "DD" had been trained on 3/31/10 to use Sani-Cloth wipes to clean and sanitize glucometers. As per the inservice training, Sani wipes were to be used before, after and in-between resident use. | 2015-05-01 |
| 9737 | 9737 | BRIAN CENTER HEALTH & REHABILITATION/CANTON | 115508 | 150 HOSPITAL CIRCLE N.W. | CANTON | GA | 30114 | 2010-10-08 | 514 | D | 0 | 1 | BCRX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure that a resident weight was accurately documented in the medical record for one (1) resident (#175) for nineteen (19) sampled residents. Findings include: Record review revealed that resident #175 had an admission was admitted to the facility on [DATE] with a weight of 136.6 pounds. Review of the weight flow sheet indicated that the next weight recorded was on 8/23/10 and this resident weighed 148.6 pounds. On 9/1/10 the weight was 137.6 pounds. Further record review revealed that the resident had weekly weights conducted for four weeks following admission. These weights were documented as 132.6, 137.6, 132.2 and 136.6 pounds. Review of the dietary progress notes dated 8/26/10 and 8/28/10 revealed the resident's weights were 132.2 pounds. A note dated 9/13/10 revealed the resident weighed 132.6 pounds. Interview conducted 10/7/2010 at 9:50 a.m. with Unit Manager"BB" revealed that the facility Staff Development staff is responsible for documenting weights in each resident's medical record. Interview conducted 10/7/2010 at 10:00 a.m. with Staff Development staff "AA" revealed that she had made a mistake in documentation and had confused resident #175 with her roommate and no significant weight changes had occurred. | 2015-05-01 |
| 9738 | 9738 | PRUITTHEALTH - WEST ATLANTA | 115512 | 2645 WHITING STREET N.W. | ATLANTA | GA | 30318 | 2012-01-30 | 322 | D | 1 | 0 | RE7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure that one (1) resident (#2) who had a gastrostomy tube feeding, of four (4) residents receiving tube feedings on the survey sample of six (6) residents, received the tube feeding formula at the rate prescribed by the physician. Findings include: Record review for Resident #2 revealed that the resident had a previous physician's orders [REDACTED].) per hour times twenty-four (24) hours. A Physician's Interim Orders form dated 12/19/2011 contained a physician's orders [REDACTED]. per hour times twenty-four (24) hours, and to discontinue the previous tube feeding order. The resident's January 2012 monthly physician's orders [REDACTED]. per hour. However, during observations conducted on 01/30/2012 at 12:45 p.m. and 3:30 p.m., Resident #2 had a gastrostomy tube feeding infusing at only fifty-five (55) mls. per hour per pump. The bottle had been hung at 6:30 a.m. During an interview conducted on 01/30/2012 at 4:00 p.m., Charge Nurse "AA" stated she did not know the resident's tube feeding order had been changed. She further acknowledged that the resident's tube feeding formula had been running at fifty-five (55) mls. per hour but should be running at sixty (60) mls. per hour. | 2015-05-01 |
| 9739 | 9739 | TWIN OAKS CONVALESCENT CENTER | 115513 | 301 S0UTH BAKER STREET | ALMA | GA | 31510 | 2010-07-09 | 371 | F | 0 | 1 | 1GY311 | Based on observation, record review, and staff interview, it was determined that the facility failed to store ice in a sanitary manner and failed to prevent the potential for cross-contamination in the use of snap-lids on trash receptacles at the handwashing sinks in the kitchen. Findings include: 1. During an observation of the kitchen with the Dietary Manager on 7/07/10 at 11:10 a.m., there was a black substance on the plastic shield inside the ice machine. According to the facility's ice machine cleaning log and an interview with the Dietary Manager at that time, the ice machine was cleaned once a month. Staff had most recently been cleaned it on 6/13/10. During an interview on 7/08/10 at 11:50 a.m., the Dietary Manager stated that the ice machine needed to be cleaned twice a month because of the high humidity. 2. During an observation of the kitchen with the Dietary Manager on 7/07/10 at 11:10 a.m., there were three handwashing sinks without foot pedal operated trash receptacles. The trash receptacles in the kitchen were industrial barrel garbage cans with snap-on lids. Therefore, when the kitchen staff washed their hands, they contaminated their hands when they opened the garbage can's snap on lid to dispose of their soiled paper towels. During an interview on 7/08/10 at 11:50 a.m., the Dietary Manager confirmed that the kitchen staff were unable to dispose of their soiled paper towels without touching the 'dirty' lid of the garbage can. | 2015-05-01 |
| 9740 | 9740 | TWIN OAKS CONVALESCENT CENTER | 115513 | 301 S0UTH BAKER STREET | ALMA | GA | 31510 | 2010-07-09 | 282 | D | 0 | 1 | 1GY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to implement the plan of care to keep the head of the bed elevated for one resident (#5) from a sample of three residents with gastrostomy tubes in a total sample of 16 residents. Findings include: Resident #5 had a care plan for requiring gastrostomy tube feedings because of [DIAGNOSES REDACTED]. There was a care plan intervention since 2/22/10 for nursing staff to keep the head of the resident's bed elevated at all times except during activities-of-daily living (ADL) care. \However, on 7/08/10 at 11:15 a.m., it was observed that staff had not elevated the head of the bed. During that observation, licensed nurse "LL" administered medication and a water flush to the resident through the gastrostomy tube. It was observed that upon completion of that medication administration and water flush, licensed nurse "LL" did not elevate the head of the resident's bed. See F322 for additional information regarding resident #5. | 2015-05-01 |
| 9741 | 9741 | TWIN OAKS CONVALESCENT CENTER | 115513 | 301 S0UTH BAKER STREET | ALMA | GA | 31510 | 2010-07-09 | 322 | D | 0 | 1 | 1GY311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record review, it was determined that the facility failed to ensure that one resident (#5) of three residents with gastrostomy tubes received the appropriate treatment to prevent complications from a total sample of 16 residents. Findings include: Resident #5 had [DIAGNOSES REDACTED]. The resident had a care plan to address his/her gastrostomy tube feedings which included an intervention since 2/22/10 for licensed nursing staff to keep the head of the resident's bed elevated at all times except during the provision of activities of daily living care. The resident had a physician's orders [REDACTED]. However, it was observed prior to administration of medication and a water flush on 7/08/10 at 11:15 a.m., that the head of the resident's bed was not elevated. L licensed nurse "LL" failed to elevate the head of the resident's bed from the flat position before he/she administered the medication and water flush. The head of the the resident's bed was not elevated during the water flush or administration of medication. Upon completion of that administration of medication and the water flush, licensed nurse "LL" did not elevate the head of the bed . | 2015-05-01 |
| 9742 | 9742 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2010-12-02 | 157 | D | 0 | 1 | M7BJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to notify the physician and/or responsible party (RP) of the development of a heel blister for one (1) resident (#94), and the development of a Stage II pressure ulcer for one (1) resident (#63). The sample size was thirty-two (32) residents. Findings include: 1. Review of resident #94's medical record revealed that they were admitted to the facility on [DATE] after having a [MEDICAL CONDITION] surgically repaired. The resident had a history of [REDACTED]. Review of Nurse's Notes revealed that on 11/24/10, the resident was noted to have a fluid-filled blister to the left inner heel, that the outside area was purplish in color, and that the staff nurse would let the hospice nurse know. On 12/01/10 at 9:33 a.m., resident #94 was observed to have a purplish blister that encompassed most of their left heel. On 12/01/10 at 3:30 p.m., Licensed Practical Nurse (LPN) 'DD' stated that when a pressure ulcer was identified for a hospice resident, that the doctor was contacted for orders and a treatment plan coordinated with hospice team. She verified that the hospice nurse was not notified until 11/26/10 (two days after the blister was discovered), and that the physician and RP were not notified. On 12/02/10 at 9:00 a.m., the Director of Nurses verified that there was no documentation in resident #94's medical record that the physician or RP were notified when the blister was discovered. 2. Record review revealed that resident #63 was admitted to the facility on [DATE], was cognitively impaired, and had [DIAGNOSES REDACTED]. The most recent Full Minimum Data Set assessment indicated that the resident was at risk for pressure sore development. Review of a Nurse's Note dated 10/29/10 revealed that Licensed Practical Nurse (LPN) "KK" observed a Stage II pressure sore approximately 1 centimeter (cm) in diameter between the resident's buttocks. Further record review revealed that th… | 2015-05-01 |
| 9743 | 9743 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2010-12-02 | 166 | D | 0 | 1 | M7BJ11 | Based on record review, resident and staff interview, the facility failed to have a procedure in place to ensure that complaints of lost personal items were addressed for one (1) resident ("A"). The sample size was thirty-two (32) residents. Findings include: On 11/30/10 at 8:19 a.m., resident "A" stated that he/she had two missing caps, one of which they wore while sleeping at night. They stated that when they went out to take a bath recently, both of them were missing from the bedside cabinet when they returned to their room. They added that they told several staff about it, but the staff told him/her that they didn't know anything about it. At 3:55 p.m., Licensed Practical Nurse (LPN) "GG" stated that if a resident reported something missing, they wrote it down and passed it along to the next shift, and then everybody knew to look for it. She added that she guessed the next shift would pass it along to Social Services if they couldn't find it. At 4:08 p.m., the Social Services Director (SSD) stated they did not fill out a form for missing items, and that all communication was verbal. She added that the resident had some caps missing in the past that were found, but not aware of any missing items at the present time. At 5:20 p.m., the SSD stated that after talking to the daughter and resident, the resident was indeed missing caps for the second time, but she was not aware that they were missing again as the staff did not notify her. On 12/01/10 at 10:15 a.m., the SSD stated that they did not have a policy that addressed how to handle missing items, unless it was suspected to be a deliberate theft. She verified that there was no "paper trail" when an item was reported missing, and that the resident's missing caps "fell through the cracks" as they were not verbally reported to her. | 2015-05-01 |
| 9744 | 9744 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2010-12-02 | 225 | D | 0 | 1 | M7BJ11 | Based on record review and staff interview, the facility failed to follow their policy to investigate and report allegations of abuse for one (1) resident (#62) on a sample of thirty-two (32) residents. Findings include: A review of the facility's Grievance file revealed a complaint dated 2/03/10. The complaint was made anonymously on behalf of resident #62. A Certified Nursing Assistant (CNA) was witnessed to threaten the resident by putting her finger in the resident's face and yelling at her. The incident made the resident cry. Interview on 12/02/10 at 9:00 a.m. with the Nursing Home Administrator revealed that no investigation was done, and that the allegation of verbal and psychological abuse was not reported to the state agency as required. Interview on 12/02/10 at 8:45 a.m. with the Social Service Director revealed that the allegation was not reported to the state agency and should have been. | 2015-05-01 |
| 9745 | 9745 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2010-12-02 | 312 | D | 0 | 1 | M7BJ11 | Based on observation and staff interview, the facility failed to provide assistance with appropriate dressing (ADLs) for two (2) residents (#14 and 67) on a sample of thirty-two (32) residents. Findings include: 1. Record review for resident #14 revealed that the resident had lived in the facility since 2001 and required maximum to total dependence for dressing and personal hygiene. Social Service notes dated 3/19/10 revealed that the resident's decision making required cues and supervision. The resident's plan of care contained an intervention to provide clean, appropriate clothing daily and as needed. Observation on 11/30/10 at 12:55 p.m. revealed the resident to have on a sweat shirt with six (6) small holes on the lower right sleeve. The wrist bands and the collar band of the shirt were worn and frayed over the entire circumference. Interview on 11/30/10 at 3:55 p.m. with Licensed Practical Nurse (LPN) "AA" revealed that the Certified Nursing Assistants (CNAs) should have noticed the condition of the shirt when dressing the resident that morning and selected another shirt. The LPN then asked the evening shift CNAs to assist the resident out of bed for supper. When the resident was escorted into the hall he was wearing the same frayed sweatshirt. Interview on 12/01/10 at 10:00 a.m. with the Social Worker revealed that the CNAs or LPNs were to notify her when a resident required additional clothing. 2. Record review revealed that resident #67 was cognitively impaired and was assessed on the Minimum Data Set as needing total assistance with dressing. The resident's most recent care plan for activities of daily living indicated that the resident would receive assistance with dressing. Observation on 12/01/10 at 12:10 p.m. revealed that the resident was waiting to be served lunch in the large dining room. The resident was wearing a faded navy sweat shirt that was heavily sprinkled with food crumbs. In an interview on 12/02/10 at 1:00 p.m. with Licensed Practical Nurse "GG" she indicated that she would have expecte… | 2015-05-01 |
| 9746 | 9746 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2010-12-02 | 314 | D | 0 | 1 | M7BJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to document monitoring and appearance of a heel blister for one (1) resident (#94), so that any changes could be evaluated and treatment begun if indicated. The facility failed to monitor and assess pressure sores one (1) resident (#32). The sample size was thirty-two (32) residents. Findings include: Review of resident #94's medical record revealed that they were admitted to the facility after surgical repair of a [MEDICAL CONDITION]. Other [DIAGNOSES REDACTED]. The resident was admitted to hospice services on 10/09/10. A Registered Dietician recommendation to the physician on 10/20/10 noted severely depleted visceral protein stores, and a protein supplement was given from 10/26/10 through 11/24/10. A Significant Change Minimum Data Set done 10/23/10 noted the resident was totally dependent on staff for all activities of daily living, except eating. The Resident Assessment Protocol (RAP) for Pressure Ulcers dated 10/25/10 noted the resident was at risk for pressure ulcers related to diagnoses, decreased mobility, and being bedbound. A Pressure Ulcer Risk assessment dated [DATE] noted the resident was high risk for skin breakdown. A skin assessment dated [DATE] noted that the skin on the resident's feet was intact. Review of Nurse's Notes dated 11/24/10 noted a fluid-filled blister to left inner heel, with the outside area purplish in color. There were no measurements recorded. On 11/29/10 at 4:48 p.m., Licensed Practical Nurse (LPN) "LL" stated that resident #94 did not have a pressure area. On 12/01/10 at 7:30 a.m., Treatment Aide "CC" stated that the resident did not have any pressure areas to her feet. On 12/01/10 at 9:33 a.m., the resident was noted to have a purplish blister encompassing most of the left heel. At 3:30 p.m., LPN "DD" stated the hospice nurse was not notified of the blister until 11/26/10 (two days after it was discovered). She added the physici… | 2015-05-01 |
| 9747 | 9747 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2010-12-02 | 356 | B | 0 | 1 | M7BJ11 | Based on observation and staff interview, the facility failed to include the number of hours worked by staff on the daily staff posting. Findings include: A review of the daily posting of staff throughout the survey revealed the number of staff in the required categories but not the number of hours worked. Interview with the Registered Nurse "BB" on 12/02/10 at 8:30 a.m. revealed that it was her responsibility to complete the form but she was not aware that the number of hours was required on the form. | 2015-05-01 |
| 9748 | 9748 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2010-12-02 | 372 | C | 0 | 1 | M7BJ11 | Based on observation, staff interview and review of facility documents the facility failed to ensure that dumpsters containing garbage and refuse had lids or were covered. This failure had the potential to affect all residents. The resident census was ninety five (95). Findings include: Observation of the kitchen/food service on 11/30/10 at 3:30 p.m. with the Dietary Manager revealed that a large dumpster located behind the facility was about half full with plastic bags of kitchen and facility waste. The dumpster was uncovered and had no cover available. The Dietary Manager presented a letter from the City's Public Works Department indicating that the City's rear-loading sanitation trucks are unable to accommodate dumpsters with lids. However, there was no indication that other refuse collection sources were considered or that any other attempts were made to temporarily cover this container. Additionally, the Dietary Manager indicated that the facility's waste fat was bottled, bagged and placed by this dumpster. She was unsure of who or how it was discarded. | 2015-05-01 |
| 9749 | 9749 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2010-12-02 | 467 | B | 0 | 1 | M7BJ11 | Based on observation, review of the facility smoking policy and staff interview the facility failed to ensure that (cigarette/smoke) odors were contained within the indoor smoking lounge on one (1) hall ("C" Hall) of five (5) halls and for two (2) of two (2) entrance doors prevented smoke and/or smoke odors from entering the building. Findings include: During the 4 days of the survey (11/29/10-12/02/10) cigarette smoke odor was noted along the "C" Hall from the area room C-3 area to the A, B and C nurses stations. A small room located on the "C" Hall was a designated smoking area. Observation of this room on 11/30/10 at 3:30 p.m. revealed there were two (2) vent fans but a heavy smoke odor was present in the room and outside of the smoking room on the "C" Hall. An interview with the Administrator on 12/02/10 at 10:00 a.m. revealed the area is the smoking area used by both residents and staff. Observation on 11/30/10 at 2:30 p.m. revealed a Certified Nursing Assistant exiting the double doors at the end of "A" Hall and to smoke a cigarette just outside the door. Observation on 12/02/10 at 1:17 p.m. during Environmental tour with the Maintenance Director (MD) revealed that there were large gaps at the locking area and at the bottom of the double doors on both the "A" and "B" Halls. An ashtray was found just outside the double doors on the "A and B" halls. The MD stated the facility had made some improvements in keeping the smoke smell contained but agreed it continued to be a problem. On 11/29/10 at 3:07 p.m., a family member of resident "B" stated that staff often smoked just outside of the exit door at the end of the "A" hall, where he/she often entered the building when visiting, and that some of that smoke would follow him/her in the building when the door was opened. The family member added that there was an indoor smoking room on the "C" hall, and that the smoke smell was very strong and was worst on weekends. | 2015-05-01 |
| 9750 | 9750 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2010-12-02 | 469 | F | 0 | 1 | M7BJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of facility documents the facility failed to maintain an effective pest control program to prevent roaches in the kitchen, the men's shower room and the Solarium/Dining room. This failure had the potential to affect all residents who ate food prepared in the kitchen and used these resident areas. Findings include: Observation of the kitchen/food service with the Dietary Manager on the following dates: 11/30/10 between 3:00 p.m. to 4:15 p.m., 12/01/10 at 8:50 p.m. and 12/02/10 at 12:00 p.m. revealed roaches crawling on food preparation surfaces, in the microwave oven, on walls, and on the floor. On 11/30/10 at 4:00 p.m. the Dietary Manger indicated that this has been an on-going problem since August 2010. Review of the facility's Pest Control Service Agreement dated 8/18/09 revealed that the facility would receive monthly treatment for [REDACTED]. This agreement also indicated that spot treatments would be provided as needed. Review of the most recent Pest Control Service Order dated 11/22/10 revealed that on that day the facility (which included the kitchen) received their routine monthly treatment. This information was confirmed in an interview with the Dietary Manager on 11/30/10 at 4:00 p.m. There was no documentation that the facility had spot treatments performed as indicated in the Pest Control Agreement from August 2010 through November 30, 2010 to address the continuing roach activity in the kitchen. Observation 11/29/10 at 2:00 p.m. of two (2) roaches crawling under the door of a residents bathroom on the C Hall and into the conference room. Observation on 11/29/10 3:40 p.m. revealed a large roach running across the floor of the Dinning/Solarium room. Observation and interview with the Maintenance Director on 11/30/10 at 3:35 p.m. of the men's shower room revealed seven (7) dead bugs on the floor between the tub and the door and one live roach crawling in the same area as the dead bugs… | 2015-05-01 |
| 9751 | 9751 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2010-12-02 | 465 | E | 0 | 1 | M7BJ11 | Based upon observation and staff interviews the facility failed to ensure that thermostats on two (2) (A and B) of five (5) halls were working properly to ensure that temperatures were comfortable for residents; that the fascia boards in the courtyard at the end of "B" hall and along the entire length of "D" hall were in good repair; that the wood surrounding the air conditioning units on "D" hall were intact and the chairs in the Solarium/Dining Room were stable. Findings include: Observation during environmental rounds with the Maintenance Director on 12/02/10 at 1:35 p.m. revealed a large hole in the rotted fascia board at the end of "B" hall at the inside of the courtyard and along fascia of "D" Hall at inside courtyard. The wood that surrounded the air conditioning units for the "D" hall in the fenced courtyard was rotted with holes. A interview at that time with the Maintenance Director revealed he was not aware of the rotted fascia and/or wood surrounding the air conditioner units. Observation on 11/29/10 at 4:10 p.m. revealed that chairs used for resident's during dining in the Solarium/Dining Room were loose and wobbled. The Administrator and Maintenance Director were notified on the same day at 4:45 p.m. and agreed the chairs should be removed. Eleven (11) of eleven (11) chairs were found to be unstable. The Activity Director who was present during the observation revealed she was aware of the unsteady chairs but did not think they could be repaired. | 2015-05-01 |
| 9752 | 9752 | ROSEMONT AT STONE MOUNTAIN | 115565 | 5160 SPRING VIEW AVENUE | STONE MOUNTAIN | GA | 30083 | 2012-01-31 | 315 | D | 1 | 0 | 6WXR11 | Based on observation, record review, facility policy review, and staff interview, the facility failed to ensure that appropriate incontinent care was provided to two (2) residents (#3 and #4) to prevent the possible spread of infection, on the total survey sample of four (4) residents. Findings include: Review of facility's Perineal and Incontinence Care Policy dated 02/05 revealed that for female residents, the Policy specified the following: "Wash the pubic area first, including the mons and labia majora. Separate the labia and wash downward on each side of the labia using different corners of the washcloth. Wash downward in the middle over the urethra and vaginal openings using a different area of the washcloth. Always wash downward toward the anus to prevent infection. Rinse, using the same method, pat dry and inspect the perineal area." For male residents, the Policy specified the following: "Wash the penis from the urethral opening at the tip of the penis down towards the bottom of the penis. Wash the scrotum." 1.) During observation with Certified Nursing Assistant (CNA) "AA" conducted on 01/31/2012 at 10:10 a.m. with Resident #3 during incontinent care, the CNA washed across the resident's perineal area, changed the direction of the washcloth, washed down the right side then the left side, then changed gloves and obtained a new washcloth. However, the CNA separated the labia and washed the resident with an upward stroke from the rectal area toward the vagina twice with the same cloth, not changing the direction. The CNA then changed gloves and water, rinsed the left and right sides, changing the direction of the cloth; however, she did not separate the labia to rinse the resident and she wiped with the same cloth, upwards from the rectum. 2.) During observation with CNA "BB" for Resident #4 during incontinent care on 01/31/2012 at 10:40 a.m., the CNA washed the resident's peri area on the left side with a downward stroke, then rinsed and washed the right side with a downward stroke and rinsed. Then, she w… | 2015-05-01 |
| 9753 | 9753 | ROSEMONT AT STONE MOUNTAIN | 115565 | 5160 SPRING VIEW AVENUE | STONE MOUNTAIN | GA | 30083 | 2012-01-31 | 441 | D | 1 | 0 | 6WXR11 | Based on observation, facility policy review, and staff interview, the facility failed to ensure that appropriate infection control practices were followed related to changing gloves during incontinent care for two (2) residents (#3 and #4) on the survey sample of four (4) residents. Findings include: Review of facility's Handwashing and Related Infection Control Practices Policy dated 7/09 revealed that gloves should be changed during resident care if moving from a contaminated body site to a clean body site. 1.) During incontinent care observation for Resident #3 on 01/31/2012 at 10:10 a.m. with Certified Nursing Assistant (CNA) "AA", the CNA did not change her soiled gloves, after having provided incontinence care, when she put barrier cream and a new incontinent brief on the resident. After this, staff took off the gloves and washed her hands. 2.) Prior to starting incontinent care for Resident #4 on 01/31/2012 at 10:40 a.m., CNA "CC" removed Resident #4's lightly soiled brief while CNA "BB" was obtaining water and other supplies; however, after removing the brief, CNA "CC" did not remove her soiled gloves and wash her hands. Throughout the incontinent care procedure, she was observed assisting CNA "BB" with care by helping turn the resident, handing CNA "BB" clean towels to dry the resident, handling clean linen, and touching the resident on his face and head. She did change her gloves when CNA "BB" was finished with incontinent care. In addition, during the observation with CNA "BB," after getting her supplies ready for Resident #4 on 01/31/2012 at 10:40 a.m., the CNA removed a lightly soiled pad from underneath the resident and did not change her soiled gloves prior to starting the incontinent care procedure. During an interview with the Staff Development Nurse on 01/31/2012 at 2:00 p.m., she indicated that the last inservice on peri care and gloving was on 01/23/2012 and that she goes over this in the monthly CNA meetings. She concurred that staff are to change gloves when they go from anything dirty to c… | 2015-05-01 |
| 9754 | 9754 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 159 | B | 0 | 1 | 506W11 | Based on resident and staff interviews, it was determined that the facility failed to ensure that residents had reasonable access to their personal trust fund money on weekends, holidays and before or after the business office closed each day. Findings include: During an interview on 10/01/12 at 12:58 p.m., resident "A" complained that he/she could not get petty cash from her personal trust fund money before 10 a.m. on weekdays or at night or on weekends and holidays. On 10/5/12 at 9:00 a.m., the facility's staff member, who handled the resident's trust accounts, stated that the receptionist and/or the accounts payable staff person handled resident's request for petty cash from their accounts. She stated that staff worked on Monday through Friday from 9 a.m. to 5 p.m. but, the facility had "banking" hours for residents to get money which were were 10 a.m. to 4 p.m. She said that if the resident requested money after 5 p.m. then, the other receptionist, who worked Monday through Friday, was able to get money from the petty cash fund for residents until the business office staff left for the day at 6 p.m. She said that the petty cash was locked up in the safe at that time. She stated that the residents were told about the times that they could withdraw money from their accounts. She confirmed that petty cash from the residents' trust fund was not available to residents on weekends and holidays. | 2015-05-01 |
| 9755 | 9755 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 279 | D | 0 | 1 | 506W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with staff and residents, it was determined that the facility failed to develop a comprehensive care plan to address the Activities of Daily Living needs for one resident (#142), the use of psychoactive medications for two residents ("E" and "D"), and the use of assistive devices for one resident ("B") from a sample of 40 residents. Findings include: 1. Resident "B" has multiple [DIAGNOSES REDACTED]. The resident was totally dependent upon staff for all Activities of Daily Living (ADL). During an interview with resident "B" on 10/2/12 at 9:46 a.m., resident "B" stated that the staff did not offer her/him fluids other than during meals and during medication administration. The resident was assessed by licensed staff as totally dependent for eating on the 7/16/12 and 9/3/12 Minimum Data Set (MDS) assessments. During an interview on 10/2/12 at 9:00 a.m., the family member of resident "B" stated that the resident had a speial cup and cup holder for his/her wheelchair and needed a long straw to self-hydrate. The family member said that the resident said that staff was giving him/her anything to drink unless it is with a meal. I have asked for long straws for his drinking cup, but he hasn't got any yet. Although the residnet's care plan included his/her potential for altered nutritional status, there was not a plan to include the resident's individualized needs to promote adequate and self-hydration. See F327 for additional information regarding resident "B." 2. Resident "D" had [DIAGNOSES REDACTED]. The 10/03/12 MDS assessment coded the resident as not having received any skilled therapies or restorative nursing services. There was not a plan of care developed to address the resident's limitations. During an interview on 10/3/12 at 9:45 a.m., Minimum Data Set (MDS) Coordinator "AA" confirmed that was not a care plan in place to address the physical limitations of resident "D". 3. Resident "E" waa… | 2015-05-01 |
| 9756 | 9756 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 280 | D | 0 | 1 | 506W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to revise a care plan to address the use of psychoactive medication for one resident (#96) from a sample of 40 residents. Findings include: Resident #96 was coded on the 8/17/12 quarterly Minimum Data Set (MDS) assessment as having a psychiatric disorder, and having received antipsychotic and antidepressant medications. There was a care plan since 7/19/12 to address the resident's behaviors related to receiving [MEDICATION NAME] (antipsychotic) for dementia with delusions. The resident had an order to be given [MEDICATION NAME] (a medication) for depression. However, there was not a care plan in the clinical record to address the resident's depression and use of the antidepressant medication. During an interview on 10/03/12 at 2:15 p.m., the MDS Coordinator "AAA" confirmed that there was not a care plan to address the resident's depression or use of antidepressant medication. However, at 2:45 p.m., after surveyor inquiry, the MDS Coordinator stated that she had found a copy of the resident's original 7/13/11 care plan for his/her problem with depression. She said that somehow it had been removed from the chart. The 7/13/11 care plan to address the resident's depression and use of [MEDICATION NAME] had not been reviewed since 11/28/11. | 2015-05-01 |
| 9757 | 9757 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 312 | D | 0 | 1 | 506W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews with residents and staff, it was determined that the facility had failed to provide nail care for two residents ("C" and "D") in a sample of 40 residents. Findings include: 1. It was observed on 10/1/12 at 11:15 a.m. that all 10 of resident "C's fingernails extended about a quarter (1/4) of an inch beyond the finger tip. The resident had [DIAGNOSES REDACTED]. Licensed staff had coded the resident as needing extensive assistance with grooming on the 2/22/12 Minimum Data Set (MDS) assessment. The resident was unable to independently do his/her own nail care because of left sided [MEDICAL CONDITION]. In an interview on 10/01/12 at 11:17 a.m., resident "C" said that in the past two months he/she had asked staff members to trim his/her fingernails. Resident "C" said that he/she was unable to provide nail care for his/herself. During an interview on 10/04/12 at 12:04 p.m., the Assistant Director of Nursing Services (ADNS) stated that nail care which included trimming the nails was supposed to be done by certified nursing assistants (CNAs) as part of a resident's routine care. The ADNS said that following the daily assessment of the resident, the CNA assigned to the resident was expected to do nail care as needed. During an interview on 10/04/12 at 12:40 p.m., certified occupational therapy assistant "OO" stated that nursing staff was supposed to do nail care for resident "C" as a required as part of daily personal hygiene care. There were instructions documented on the "Resident Functional Performance Record" that nail care for resident "C" was to be completed as needed during hygiene care on the 7a.m to 3 p.m. shift. There was a care plan problem about the resident's self-care deficits which included an intervention for (nursing) staff's assistance with all activities of daily living. 2. Resident "D" was observed on initial tour 10/01/12 at 1:59 p.m. to have had long (1/4 inch), untrimmed finger… | 2015-05-01 |
| 9758 | 9758 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 317 | D | 0 | 1 | 506W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interview, it was determined that the facility failed to identify one resident's (#144) contractures and to implement interventions to prevent a further decline range of motion in a sample of 40 residents. Findings include: Resident #144 had [DIAGNOSES REDACTED]. The resident was receiving hospice services. During an interview on 10/01/12 at 2:31 p.m., licensed nurse "MM" reported that both of the resident #144's knees were contracted. However, a review of the clinical record revealed no evidence that either skilled therapy or restorative nurses services had been provided. During an observation of the resident with Assistant Director of Nursing (ADON), Director of Nursing (DON) and Certified Nursing Assistant (CNA) "SS" on 10/03/12 at 9:05 a.m., the resident's knees could not be completely extended due to limited range of motion. During an interview on 10/03/12 at 12:39 p.m., the DON confirmed that both of the resident's knees were now slightly contracted. She was unable to identify when the contractures had occurred. After surveyor inquiry, she said that she would request that the physical therapist assess the resident. During an interview on 10/3/12 at 2:45 p.m., Physical Therapist "TT" stated that he had done an assessment of the resident's knees and described them as now having slight contractures. He described the contractures as being new and said that they could be corrected or prevented from getting worse with the use of knee splints. "TT" said that because the resident was receiving hospice services, it would be their decision whether or not to use them. He said that he thought that the certified nursing assistants (CNAs) should be doing passive range of motion (ROM) while providing care to the resident. He was unable to give a reason for the development of the contractures of the resident's knees. | 2015-05-01 |
| 9759 | 9759 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 318 | D | 0 | 1 | 506W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview with a resident and staff, it was determined that the facility failed to ensure that restorative services were implemented to prevent a further decrease in range of motion (ROM) for one (1) resident "D" from a sample of forty (40) residents. Findings include: Resident "D" had a [DIAGNOSES REDACTED]. There was not any coding on the 10/03/12 MDS assessment to indicate that the resident had received skilled therapy services or restorative nursing services. In an interview with on 10/03/12 at 11:40 a.m. , Occupational Therapist (OT) "WW" said that resident "D" had been evaluated on 4/25/11 for positioning needs in order to feed himself/herself. Occupational therapist"WW" reported that the resident had improved to needing only minimum staff assistance with the use of a large handled spoon to eat so, he/she was discharged to restorative (nursing) services on 5/31/11 for self feeding and active/ passive range of motion (A/PROM) exercises. "WW" said the resident had been assessed and treated for [REDACTED]. "WW" said that hand rolls were applied because, the finger splints had been ordered but never arrived. "WW" stated the resident had been discharged on [DATE] to restorative nursing services for active and passive range of motion to all extremities and applications of the hand rolls. However, there was no evidence that restorative nursing staff had ever provided range of motion exercises or the application of hand rolls for the resident. Although the occupation therapist "WW" looked in the resident's room, she was unable to locate any hand rolls for the resident. It was observed at the lunch meal on 10/1/12 at 1:50 p.m. that staff fed the resident. It was observed that the resident was not wearing splints nor had hand rolls been applied. The resident's care plan since 5/14/12 did not address his/her risk of developing contractures or care to prevent them from developing or care to prevent further d… | 2015-05-01 |
| 9760 | 9760 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 323 | D | 0 | 1 | 506W11 | Based on observations, it was determined that the facility failed to ensure that the residents' environment was free of potential accident hazards from loose commode seats in six rooms ( 212, 215, 206, 400, 403, 411) to prevent injury to the residents on two (200 and 400) of seven halls. Findings include: The following environmental observations were made with the Maintenance Director and the Housekeeping Supervisor Random on 10/03/12 at 11:00 a.m. The commode seats were loose and could be moved in the bathrooms for rooms 212, 206, 400, 403, 410 and 411. The two towel bars in the bathroom in room 215 were loose. There were loose screws on one end of the lower towel bar. | 2015-05-01 |
| 9761 | 9761 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 327 | D | 0 | 1 | 506W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interviews, it was determined that the facility failed to provide and ensure adequate hydration for one resident ("B") in a total sample of 40 residents. Findings include: Resident "B" had multiple [DIAGNOSES REDACTED]. The resident was currently on antibiotic therapy for treatment of [REDACTED]. There was a 10/3/12 physician's orders [REDACTED]. The resident had received speech therapy services from 7/09 through 7/30/12 and had been assessed to be able to safely swallow. During an interview on 10/02/12 at 9:00 a.m., a family member of resident "B" stated that the resident had told family members that staff was not giving him/her anything to drink unless it was with a meal. . The family member stated that several weeks ago during a visit, there was dried blood on the resident's dry, cracked lips. The family member said that the resident was upset and said staff was not giving him/her anything to drink. The family member said that the resident could drink from his cup with a long straw. The family member said that there was a cup holder that attached to the resident's wheelchair. The family member said that he/she had asked staff for long straws to put in the resident's drinking cup but none had been provided yet During an interview on 10/2/12 at 9:46 a.m., resident "B" stated that the staff did not offer her/him fluids other than during meals and during medication administration. The resident said that when she/he had been in another facility, staff brought a cart around during the day and offered residents something to drink. The resident stated that, in the past, he/she had a special cup with a long straw and a cup holder that would attach either to the wheel chair or to his/her bed. He/She said that the staff was not putting them on his/her bed or wheelchair so he/she could use them. The resident said that he/she did not know where they were. During an interview on 10/3/12 at 1:00 p.m., resid… | 2015-05-01 |
| 9762 | 9762 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 333 | D | 0 | 1 | 506W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of physician's orders, medication administration records (MARs), laboratory test ([MEDICATION NAME] level) results, and staff interview, the facility failed to ensure one resident (#27) was free from a significant error from a sample of forty (40) residents. Findings include: According to the 6/6/2012 physician's order nursing staff was supposed to administer one hundred (100) milligrams (mg) of [MEDICATION NAME] to resident #27 every eight (8) hours. The current active orders which had been signed by the physician contained the same orders for administering [MEDICATION NAME]. However, review of nursing staff's documenation on the MARs for July, August, and September 2012 revealed that nursing staff had incorrectly adminstered [MEDICATION NAME] 100mg at 8:00am, 12:00pm, and 4:00pm daily for all three (3) months. The facility obtained the resident's [MEDICATION NAME] levels. The resident's [MEDICATION NAME] level was 19.7 (normal range was reported as 10 to 20) on 9/19/2012. It was reported as 21.4 on 8/4/12. It was 19.2 on 8/25/12. HIs/her free [MEDICATION NAME] level was 3.0 (normal range was 1.0 to 2.0) on 8/16/12. The [MEDICATION NAME] level was 24.2 on 8/13/12. It was 18.7 on 7/9/12. It was 20.1 on 6/28/12. It was 9.6 on 6/12/12. During an interview on 10/4/12 at noon, Licensed Practical Nurse (LPN) "BBB" confirmed that the [MEDICATION NAME] medication was not scheduled or given as ordered. After surveyor inquiry, the physician was notified and had directed nursing staff to give the resident 100 mg of [MEDICATION NAME] every eight (8) hours as previously ordered. | 2015-05-01 |
| 9763 | 9763 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 371 | F | 0 | 1 | 506W11 | Based upon observation, staff interview, and record review, it was determined that the facility failed to properly sanitize dishes in the automatic dishwasher. Findings include: During initial tour of the kitchen on 10/1/12 at 10:25 a.m., kitchen staff "UU" was finishing running breakfast dishes through the dishmachine. At that time, when the dietary manager used a test strip to measure the concentration of chemical sanitizer in the water in dishwasher, the test strip did not change color. The DM then ran another empty tray through the dishmachine and the used another test strip to check the concentration of chemical sanitizer in the water but again it did not change color. On the same day at 10:45 a.m., the dietary staff discovered the amount of chemical sanitizer in the storage bucket was low so, it was not automatically being dispensed into water in the dishmachine. At 10:55 a.m., kitchen staff "UU" said that she was not aware that the concentration of the chemical sanitizer (sanitizer level) should be checked so, he/she had not checked it. At that time, the Dietary Manager stated that the sanitizer level was supposed to be checked each meal before dishes were washed, three (3) times a day. She could not explain why it was not done. There was not documentation on the facility's October sanitization log that the sanitization level was not recorded on 10/01/12. | 2015-05-01 |
| 9764 | 9764 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 412 | D | 0 | 1 | 506W11 | Based on observation, staff interview and record review, it was determined that the facility failed to provide dental services to address the dental needs of one resident ("A") in a sample of 40 residents. Finding include: During an interview on 10/01/12 at 12:55 p.m., resident "A" said that he/she had problems chewing and eating and wiht his/her gums. He/She said tha all of his/her teeth were missing and wanted dentures. The resident said that he/she had asked for dentures since admission. It was observed at that time that the resident did not have any teeth. In an interview on 10/03/12 at 8:22 a.m., the East wing Social Services staff said that resident " A" was on a dental program and had been examined by a dentist at the facility. However, there was no evidence that the resident had been seen by a dentist. In a subsquent interview at 11:45 a.m., the East wing Social Services staff said that the resident did not receive dental services because of the failure to get authorization from a responsible party. She provided a fax from Senior Dental (services) that attempts to contact the resident's family on 12/2/10, 12/8/10, 1/12/11 and 1/20/11 had been unsuccessful. The Social Worker said that the facility had not followed through with their initial plan to get dental services and dentures for the resident. During an interview on 10/3/12 at 12:50 p.m., the Business office Manager confirmed that resident "A" did not have a dental plan. | 2015-05-01 |
| 9765 | 9765 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 431 | D | 0 | 1 | 506W11 | Based on observations and staff interviews, it was determined that the facility failed to ensure that ten bottles of insulin were properly labeled and/or used within 28 days of opening the vials. Findings include: According to the American Diabetes Association's guidelines for insulin storage, even though a vial of insulin vial was stamped with an expiration date, the insulin might have a loss of potency after the vial had been in use (opened) for more than 30 days. The "Insulin Dependent Diabetes Trust" noted that to ensure that insulin remained effective, stable and undamaged, the 'in use' insulin should be discarded after 28 days. However, the facility failed to discard insulin within a recommended timeframe. 1. 700 East hall medication cart There was one vial of Novolin R insulin and one vial of Novolog insulin which were opened but neither vial was dated as to when it had been opened. There were two vials of Lantus insulin which did not have the open date noted on the vials. There were five (5) vials of insulin which had notations of opening dates in excess of 30 days. One vial of Novolin 70/30 insulin had been opened on 8/9/12. Levemir 100 units/ml insulin had been opened on 7/24/12. A vial of Novolin R insulin had been opened on 8/7/12, One vial of Novolin R insulin had been opened on 7/24/12. One vial of Novolin R insulin had been opened on 6/11/12. 2. The 600 East hall medication cart contained a vial of Lantus insulin for resident "X" which had been opened on 8/07/12. During an interview on 10/4/12 at 12:24 p.m., licensed nurse "YY" stated that all insulins were supposed to be dated at the time they were opened. He said that the Lantus insulin should have been discarded after twenty-eight (28) days. He stated that the nursing staff had been trained on how to administer insulin including dating (the vial) and disposal. At 12:27 p.m., licensed nurse "XX" stated that all vials of insulin were supposed to be dated when the vial was opened. She said that Lantus insulin was good for 28 days. She stated that r… | 2015-05-01 |
| 9766 | 9766 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 441 | F | 0 | 1 | 506W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, it was determined that the facility failed to ensure proper procedures were followed for contact isolation and disinfecting, and that one resident's family ("B") was educated regarding isolation procedures in a sample of 40 residents in a census of 146 residents. Findings include: The facility's infection control "precaution guidelines" for staff included the following actions to be taken: Place a red sign on the resident's door frame. Contact Precautions: In addition to Standard Precautions, use contact precautions for resident known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact such as handling environmental surfaces or resident care items. Example: MRSA Inform the resident and family of the need for precautions. Reassure the resident/family that care will continue. Explain the procedures that they will need to follow with regards to precautions and the need to protect other residents, family members and staff. Inform the staff of the need and type of precautions required. Gather the necessary equipment-precaution cart Notify the housekeeping department so that appropriate daily and terminal cleaning is completed and other departments are necessary. Each shift, bags of linen and trash are appropriately tied, and discarded. Wear clean gloves and gown when entering the room Wear gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Wear gown for all interactions that may involved contact with the resident or potentially contaminated areas in resident's environment. Change gloves after each contact with infective material (fecal material or wound drainage may contain high concentrations of microorganism. Limit resident movement. When transport is necessary, ensure that precautions are maintained and that infective material is contained. The fac… | 2015-05-01 |
| 9767 | 9767 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2012-10-04 | 514 | D | 0 | 1 | 506W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, record reviews, and interviews with staff and family, it was determined that the facility failed to maintain accurate clinical records for one resident (#144) about pressure sore treatment and about consultation with a physician for one resident ("E") in a sample of 40 residents. Findings include: 1. Resident #144 had developed a Stage IV pressure ulcer on his/her sacrum on 2/6/12 which nursing documented had been resolved on 9/18/12. Nursing staff's documentation on the resident's 9/12 Treatment Administration Record (TAR) that treatment of [REDACTED]. However even thought the treatment had been discon, licensed nurse "MM" documented having done the wound care treatment to the resident on 9/20, 9/21/12, and 10/01/12. During an interview on 10/02/12 at 2:00 p.m., licensed nurse "MM" stated that she had done pressure sore treatment for [REDACTED]. However, according to the 9/18/12 Wound Physician's Progress Notes, the resident's wound/wounds were resolved. On 10/03/12 at 8:50 a.m., the DON stated that she had observed the resident's sacrum yesterday, after surveyor inquiry, and the pressure sore was healed. She said that there had not been a dressing on the resident's sacral area and it would be inappropriate to apply the previously ordered Santyl to a healed wound. During an observation with the Assistant Director of Nursing (ADON) on 10/3/12 at 9:05 a.m., it was noted that the sacral pressure sore was healed and did not have a dressing on it. On 10/03/12 at 9:15 a.m., the DON said that it appeared that licensed nurse "MM" had documented having done treatments on resident #144 on Monday and Tuesday but, she did not think that they were done. 2. During an interview on 10/04/12 at 12:00 p.m., the family member of resident "E" stated that "E" had been admitted to the hospital. The family member said that he/she was notified that the resident's blood sugar was elevated above 500. The family member said that the resident h… | 2015-05-01 |
| 9768 | 9768 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2010-06-17 | 431 | E | 0 | 1 | CNHB11 | Based upon observation, record review and staff interviews the facility failed to ensure that two (2) of two (2) medication storage refrigerators were held at the appropriate temperatures. Findings include: Observation on 6/16/10 at 9:40 a.m. of front hall small medication refrigerator with Licensed Practical Nurse (LPN) "BB" revealed a heavy, thick ice build up around the freezer area within one (1) to two (2) inches of medications stored in the refrigerator. No thermometer was visible. Interview on 6/16/10 at 11:30 a.m. with LPN "AA" revealed that that all Insulin is kept in the small medication storage refrigerators on each hall and that housekeeping is responsible for checking the temperatures of the refrigerators. Interview with the Housekeeping Director "DD"on 6/16/10 at 12:10 p.m. revealed that he checks the refrigerator temperatures once per week and keeps a log but he is not aware of what the temperatures should be. Observation of the back hall refrigerator on 6/16/10 at 12:10 p.m. revealed a thermometer under the medication that registered the temperature at thirty four (34) degrees Farenheit (F) Three (3) vials of Pneumococcal Vaccine were located in this refrigerator, labeled to be held between 36-46 degrees F. Review of the facility policy for checking medication refrigerator temps revealed that the housekeeping staff will check the refrigerator weekly, on Friday's, and the temperature should be between 36-46 degrees. If the housekeeping supervisor is unavailable then the nurses will check the temperature. Review of the weekly temperature logs revealed the following: front hall small refrigerator- 34 degrees F on 4/14/10, 4/16/10, and 5/17/10; 32 degrees F on 4/28/10 and 5/5/10 and 30 degrees F on 5/28/10. The back hall small refrigerator-34 degrees F on 4/14/10, 4/16/10, and 4/28/10 and 32 degrees F on 5/17/10 and 5/28/10. There was no evidence that the temperatures were taken during the week of 5/9/10 thru 5/15/10. Observation on 6/17/10 at 8:35 a.m. of the front hall small refrigerator with the As… | 2015-05-01 |
| 9769 | 9769 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2010-06-17 | 157 | D | 0 | 1 | CNHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the physician of significant changes in resident condition for three (3) residents (#85, #92, and #111) from a sample of twenty-six (26). Findings include: 1. Review of the clinical record for resident #111 revealed that the resident was admitted to the hospital on [DATE] after the nurse assessed the resident with shortness of breath. The resident was given a breathing treatment and after the treatment the oxygen saturation was 89%. The resident was transferred to the hospital for evaluation and later admitted with Pneumonia. The family was notified, but there was no evidence in the clinical record that the physician was notified. 2. Review of the clinical record for resident #92 revealed that the resident was admitted to the hospital on [DATE] after being assessed with [REDACTED]. The resident was transferred to the hospital for evaluation and later admitted . The family was present and accompanied the resident to the hospital, but there was no evidence in the clinical record that the physician was notified. 3. Review of the clinical record for resident #85 revealed that the resident was admitted to the hospital on [DATE] after complaining of shortness of breath. The resident was receiving four (4) liters of oxygen per nasal cannula and was assessed with [REDACTED]. The resident was fully alert and responsive. The resident was transferred to the hospital for evaluation and later admitted . The son was notified but there was no evidence in the clinical record that the physician was notified. Interview with the Director of Nursing (DON) on 06/15/10 at 3:39 p.m. revealed that the nurse should call the physician of any change in condition and if it is an emergency she is still to call and notify the physician that the resident is being sent to the hospital. Interview on 06/16/10 at 9:48 a.m. with the DON revealed that when the nurses call the hospital emergency room to info… | 2015-05-01 |
| 9770 | 9770 | BROWN'S HEALTH & REHAB CENTER | 115604 | 226 SOUTH COLLEGE STREET | STATESBORO | GA | 30458 | 2012-01-04 | 157 | D | 1 | 0 | HN5G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to immediately notify the responsible party of one (1) resident (#1), in a survey sample of six (6) residents, of significant changes in the resident's status related to the initiation of new drug therapy and a significant decline prior to the resident's death. Findings include: Record review for Resident #1 revealed a Nurse's Note of 10/26/2011 at 10:30 a.m. which documented that the resident was noted to be vomiting and that the physician extender, when notified, had given a new order for Haldoperidol 0.5 milligram by mouth every six (6) hours as needed for nausea and vomiting. However, further record review revealed no evidence to indicate that the resident's family was notified of the initiation of this [MEDICATION NAME] drug therapy. A Nurse's Note of 10/27/2011 at 10:30 a.m. documented that a new physician's orders [REDACTED]. However, further record review revealed no evidence to indicate that the resident's family was notified of the initiation of this [MEDICATION NAME] drug therapy. A Nurse's Note of 11/18/2011 at 8:45 p.m. documented that the resident had a change in vital signs, including a body temperature of 93.9 degrees Fahrenheit, and that Hospice staff was notified. A Nurse's Note of 11/18/2011 at 10:00 p.m. documented that the resident remained cold to touch and had shallow breath sounds. A Nurse's Note of 11/19/2011 at 2:00 a.m. documented that the resident's oxygen saturation was unobtainable, with oxygen continuing, and a Nurse's Note of 11/19/2011 at 7:00 a.m. documented that the resident was found unresponsive and without obtainable vital signs. This 11/19/2011, 7:00 a.m. Note documented that Hospice staff and a family member of the resident were contacted at that time regarding the resident's change in status. However, there was no evidence to indicate that the family had been notified prior to that time of the resident's significant change in stat… | 2015-05-01 |
| 9771 | 9771 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 309 | D | 0 | 1 | BHN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to administer medications as ordered by the physician for three residents (#2, #4 and #7) from a total sample of 17 residents. Findings include: 1. Resident #2 had a [DIAGNOSES REDACTED]. The resident had an abnormally low [MEDICATION NAME] level of 4.7 (normal range was between 10 and 20) on 1/6/11. The resident's attending physician changed the order on 1/7/11 for licensed nursing staff to administer 200 milligrams (8 cc) of [MEDICATION NAME] to the resident every day. However, according to nursing staff's initials on the January 2011 Medication Administration Record [REDACTED]. On 1/25/11 at 3:50 p.m., the Director of Nursing stated that licensed nursing staff had not transcribed the physician's 1/7/11 order to increase the dosage of [MEDICATION NAME] onto the resident's MAR. There was no documentation that the resident had any [MEDICAL CONDITION] activity from 1/7/11 to 1/25/11. 2. Resident #4 had a [DIAGNOSES REDACTED]. It was scheduled at 7 p.m. There was a physician's orders [REDACTED]. It was scheduled at 7 p.m. However, review of nursing staff's documentation on the December 2010 Medication Administration Record [REDACTED]. Licensed nursing staff had documented that the resident was incorrectly given both 4 mg and the 5 mg ( a total of 9 mg) of [MEDICATION NAME] from 12/1 to 12/10/10, 12/13 to 12/18/10, 12/20/10, 12/22/10 and 12/29/10. Review of the January 2011 MAR indicated [REDACTED]. Licensed nursing staff documented that the resident was incorrectly given both 4 mg and 5 mg (a total of 9 mg) of [MEDICATION NAME] on 1/2/11, 1/3/11, 1/4/11 and 1/19/11. Furthermore, there was no indication that licensed nursing staff had administered 5 mg of [MEDICATION NAME] to the resident as scheduled on 1/24/11 (Monday). On 1/25/11 at 4:20 p.m., the 5 mg [MEDICATION NAME] medication packet was reviewed with licensed nurse " ZZ." Licensed nursing staff had doc… | 2015-05-01 |
| 9772 | 9772 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 327 | D | 0 | 1 | BHN711 | **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 provide nectar thickened fluids at the bedside for one resident (#1) with a swallowing problem and at risk for dehydration from a total sample of 17 residents. Findings include: Resident #1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Licensed nursing staff had coded the resident on the 1/18/11 initial Minimum Data Set (MDS) assessment as requiring limited assistance with eating and drinking. He/She had a physician's orders [REDACTED]. The physician documented in his 1/18/11 progress notes that the resident was not eating well and had decreased skin turgor. He ordered nursing staff to administer intravenous fluids to the resident on that day. On 1/24/11 during the Initial Tour at approximately 10:45 a.m., the resident was observed sitting in his/her wheelchair. An unopened container of nectar thickened water was on his/her bedside table. It was observed on 1/25/11 at 7:45 a.m., 9:00 a.m., 1:00 p.m., 2:00 p.m. and 5:00 p.m. that staff had failed to provide the resident with nectar thickened fluids at his/her bedside. The resident was in his/her room during those observations. On 1/25/11 at 12;10 p.m., certified nursing assistant (CNA) "VV" stated that the resident was able to drink fluids without staff assistance. However, CNA "VV" stated that he/she only provided extra fluids to the resident if the resident requested fluids. Although staff provided the resident with nectar thickened fluids at medication times, meal times and snack times ( at 10:00 a.m. and 2:00 p.m.), staff failed to provide the resident with fluids and in the ordered consistency at his/her bedside. | 2015-05-01 |
| 9773 | 9773 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 441 | E | 0 | 1 | BHN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and procedures and staff interview, it was determined that the facility failed to ensure that two of five newly hired employees had been administered the two step [MEDICATION NAME] screening test; failed to ensure that one of two nurses washed or sanitized his/her hands between residents during observation of medication administration; failed to ensure that two of two nurses placed sanitized glucometers on a protective barrier during observation of the medication administration; failed to ensure that the treatment nurse maintained a sterile field during pressure sore treatment for one resident (#1) of two residents who received pressure sore treatments; failed to ensure that the treatment nurse secured soiled linens prior to transferring them to the soiled linen cart after providing treatment for one resident (#1) of two residents who received pressure sore treatments; failed to ensure that a certified nursing assistant removed his/her soiled gloves after providing bowel incontinence care and prior to applying a clean brief and adjusting the clothing and bed linens for one resident (#2); failed to ensure that contract laundry personnel used appropriate infection control practices when he placed towels in a cabinet on the Infirmary Hall; and failed to ensure that dietary staff appropriately stored the ice scoop during observations of dietary staff providing ice to residents on three of four halls (Front Hall, Green Hall, Men's Hall). Findings include: According to the facility's "Policy and Procedure for Infection Control Practices" for wound treatment, nursing staff were supposed to open the wound dressing package and remove the dressing while maintaining sterility. However, the treatment nurse failed to maintain sterility of the dressing for resident #1 during pressure sore treatment. According to the facility's Policy and Procedure for Infection Control Practices for the appropriate disposal o… | 2015-05-01 |
| 9774 | 9774 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 502 | D | 0 | 1 | BHN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that laboratory tests were obtained as ordered by the physician for two residents (#15 and #2) of 17 sampled residents. Findings include: 1. A review of the closed record for resident #15 revealed that he/she was admitted on [DATE] with a [DIAGNOSES REDACTED]. The 10/26/10 physician's progress note documented his/her plan to have the resident's hemoglobin A1C checked on admission. However, a review of the resident's medical record revealed [REDACTED]. During an interview on 1/26/10 at 2:15 p.m., the Director of Nursing said that laboratory test was not done. 2. Resident #2 had a [DIAGNOSES REDACTED]. The resident had an abnormally low [MEDICATION NAME] level on 1/6/11 of 4.7 (normal range was between 10 and 20). On 1/7/11, the physician ordered an increase in the resident's [MEDICATION NAME] dosage and for nursing staff obtain another [MEDICATION NAME] level in 10 days. However, there was no evidence that the [MEDICATION NAME] level had been obtained until after surveyor inquiry on 1/25/11. On 1/26/11 at 10:10 a.m., the Director of Nursing stated that licensed nursing staff had failed to provide a copy of the physician's 1/7/11 order to the staff person responsible for ordering laboratory tests. | 2015-05-01 |
| 9775 | 9775 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 156 | B | 0 | 1 | BHN711 | Based on a review of the facility's " Notice of Medicare Provider Non-Coverage " form, it was determined that the facility failed to issue the mandatory denial notice to two residents (#16 and #17) of their potential liability for payment of non-covered services in order to allow them to make an informed decision about whether or not they wanted to continue to receive specific items or services, knowing that they might have to pay for those items or services themselves. The facility failed to issue notices in a timely manner and failed to include the specific items or services that would be denied and the estimated cost for those services. Findings include: According to CMS' "Liability Notices/Notice of Medicare Provider Non-coverage" instructions, the "Notice of Medicare Provider Non-Coverage" form (CMS- ) was supposed to be issued when all covered services ended for coverage reasons. If the facility expected the beneficiary to remain in the facility in a non-covered stay, either the CMS- form or a Denial Letter was required to be issued to inform the beneficiary of the potential liability for the non-covered stay. The standards for use by Skilled Nursing Facilities (SNF) in implementing the CMS- form as described in the "70-Form CMS- Skilled Nursing Facility Advance Beneficiary Notice", instructed the SNF to give the specific reason(s) why it expected Medicare to deny payment. The reason(s) cited were to be in understandable lay language and sufficiently specific to allow the resident to understand the basis for the expectation that Medicare would deny payment. Estimated cost amounts could be provided either with the description of extended care items and services or on the "estimated cost" line. The facility believed that two residents' (#16 and #17) continued stay in the facility would not be paid for by Medicare Part A. However, the "Notice of Medicare Provider Non-Coverage" form issued to those residents on 4/12/10 and 8/2/10 did not conform with the notice requirements to explain to the beneficiary his/her… | 2015-05-01 |
| 9776 | 9776 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 514 | D | 0 | 1 | BHN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that licensed nursing staff accurately documented the administration of [MEDICATION NAME] as ordered by the physician for one resident (#4) of 17 sampled residents. Findings include: Resident #4 had a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. However, review of the resident's Medication Administration Records (MARs) revealed that licensed nursing staff had incorrectly documented the administration of the [MEDICATION NAME] for 21 of 29 days in December 2010 and for 6 of 23 days in January 2011. See F309 for additional information regarding resident #4. | 2015-05-01 |
| 9777 | 9777 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 428 | D | 0 | 1 | BHN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to ensure that the consultant pharmacist had identified and reported to the attending physician and director of nursing that licensed nursing staff had failed to administer Coumadin as ordered to one resident ( #4) of 17 sampled residents. Findings include: Resident #4 had a [DIAGNOSES REDACTED]. There was also a physician's orders [REDACTED]. However, a review of the resident's December 2010 Medication Administration Record [REDACTED]. According to the resident's clinical record, the consultant pharmacist had reviewed the resident's drug regime on 12/15/10. However, the consultant pharmacist had failed to identify and report to the attending physician and director of nursing that licensed nursing staff had not administered the Coumadin to the resident as ordered on those days. See F309 for additional information regarding resident #4. | 2015-05-01 |
| 9778 | 9778 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 371 | F | 0 | 1 | BHN711 | Based on observations and staff interviews, it was determined that the facility failed to maintain a sanitary dishwashing area, to serve food using sanitary techniques, and to maintain one refrigerator and two sink stands in a sanitary condition. Findings include: Observations were made on 1/25/11. 1. Dietary staff "BB" was observed washing dishes in the dishwashing area of the kitchen at 8:20 a.m. "BB" was observed removing dirty breakfast trays from a metal cart located in the middle of the dishwashing area. A tray of clean dishes was removed from the dishwasher by "BB" and put on the metal counter top, outside the dishwasher. In the same area, there were several pitchers that contained juice, dirty bowls, and diet cards on metal stands that had been placed there by dietary staff "BB" after removing them from the food cart. There was standing water on the counter. "BB" moved the tray of clean dishes across the area and placed it in a window pass that was located next to dirty dishes and the garbage disposal that was running. "BB" failed to maintain sanitary conditions for the clean dishware by handling soiled and clean dishware at the same time. She placed clean and soiled dishware in close proximity to each other. There was a potential for the garbage disposal's contents to contaminate the clean dishware. 2. At 9:00 a.m., the three compartment refrigerator had black mold on the seals of all three doors. The ends of the shelves in the double door compartment were rusty. The white covering was peeling off of the shelves. Dietary staff "AA" was observed at 9:20 a.m. breaking spaghetti pasta with his/her bare hands and putting it into a large metal bowl. "AA" picked up another bag of pasta with his/her hands and got a white handled paring knife out of a utensil holder and then used it to open the bag of spaghetti pasta. She did not wash her hands. After using the knife, the staff member picked up a white dish cloth off of the work table and used it to wipe the blade of the knife. Afterwards, "AA" inappropriately p… | 2015-05-01 |
| 9779 | 9779 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 372 | C | 0 | 1 | BHN711 | Based on observation and staff interview, it was determined that the facility failed to ensure that the top cover for one of two trash dumpsters closed properly and that the sliding side door remained closed. Findings include: The facility had two large, green dumpsters at the back of the building. Each dumpster had two, hard plastic hinged lids on the top. It was observed on 1/24/11 at 5:15 p.m. and on 1/25/11 at 11:00 a.m. that the two lids on the dumpster on the right were bent and did not completely close to cover the top of the dumpster. The sliding side door on the left side of the dumpster had not been closed. During an interview on 1/27/11 at 9:30 a.m., the maintenance supervisor stated that he had notified the company about a month ago that new dumpsters were needed. He said that they had received the dumpster on the left. He said that the company had not yet replaced the other dumpster. He stated that he had not called them again. | 2015-05-01 |
| 9780 | 9780 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 167 | C | 0 | 1 | BHN711 | Based on observation, it was determined that the facility failed to post the results of the most recent survey in a manner that was accessible to all residents. Findings include: On 1/24/11 at 4:45 p.m., the most recent survey results were observed to have been posted on the left top corner of the bulletin board. Residents, who were confined to a wheelchair, would not have been able to reach or read the survey results without having to ask for assistance. | 2015-05-01 |
| 9781 | 9781 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 456 | B | 0 | 1 | BHN711 | Based on observations, it was determined that the facility failed to maintain two of three microwaves in the hall pantries (Infirmary and Men's hall) in safe condition. Findings include: It was observed on 1/24/11 at 4:45 p.m., that there was rust inside the door under the glass window of the microwave in the pantry located on the Infirmary hall. The microwave located in the pantry on the Men's hall had rust on the inside of the door. The interior white finish was worn off in the back corner and left side of the microwave. | 2015-05-01 |
| 9782 | 9782 | LEE COUNTY HEALTH AND REHABILITATION | 115614 | 214 MAIN STREET | LEESBURG | GA | 31763 | 2010-10-28 | 328 | E | 0 | 1 | XGDS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, it was determined that the facility failed to ensure that the oxygen tubing, nasal cannulas and nebulizer masks were appropriately stored to prevent potential contamination for three randomly observed residents, and three residents (#6, #8, and #12) from four sampled residents receiving oxygen therapy, in a total sample of 17 residents. Findings include: 1. During observations on 10/26/10 at 8:00 a.m., 11:05 a.m. and 12:25 p.m., and on 10/27/10 at 9:30 a.m. and 10:20 a.m., resident #6's oxygen tubing and nasal cannula were being inappropriately stored uncovered and draped across the oxygen concentrator. His/her nebulizer mask was inappropriately stored uncovered on top of the compressor. 2. On 10/20/10 at 11:10 a.m., resident #8's nebulizer mask and tubing were being stored uncovered on top of the compressor. 3. During the Initial Tour of the Facility on 10/26/10 at 9:00 a.m., the oxygen tubing and nasal cannula were tied to the bar on the side of resident #12's the bed. On 10/27/10 at 9:30 a.m., the oxygen tubing and nasal cannulas were being stored uncovered on top of two concentrators between the beds of resident #12 and his/her roommate. 4. During the Initial Tour of the Facility on 10/26/10 at 8:30 a.m., the nebulizer mask and tubing were stored uncovered on top of the compressor in room [ROOM NUMBER]-B. The humidifier bottle on the oxygen concentrator was not dated. 5. During the Initial Tour of the Facility on 10/26/10 at 8:35 a.m., the nebulizer mask and tubing were stored uncovered on top of the compressor in room [ROOM NUMBER]. The humidifier bottle on the oxygen concentrator was not dated. | 2015-05-01 |
| 9783 | 9783 | LEE COUNTY HEALTH AND REHABILITATION | 115614 | 214 MAIN STREET | LEESBURG | GA | 31763 | 2010-10-28 | 164 | D | 0 | 1 | XGDS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide visual privacy during incontinence care for one resident (#3) and during medication administration for one resident ("A") from a total sample of seventeen residents. Findings include: 1. During an observation of incontinence care being provided for resident #3 on 10/27/10 at 10:30 a.m., Certified Nursing Assistant (CNA) "AA" pulled the privacy curtain between the two beds but not between the resident's bed and the entrance door. A staff member knocked and immediately opened the door. The resident was exposed from the waist down to the hallway. 2. During observation of the medication pass on 10/27/10 at 10:20 a.m., while the licensed nurse was administering medication through a gastrostomy tube, a certified nursing assistant (CNA) knocked and entered room [ROOM NUMBER] without waiting for permission to enter. See F241 for additional information about staff failure to wait for permission to enter residents' rooms. | 2015-05-01 |
| 9784 | 9784 | LEE COUNTY HEALTH AND REHABILITATION | 115614 | 214 MAIN STREET | LEESBURG | GA | 31763 | 2010-10-28 | 309 | G | 0 | 1 | XGDS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to promptly assess one resident's ("B") level of pain and provide interventions to prevent an increase in pain from a total sample of 17 residents. This failure resulted in actual harm for resident "B". Findings include: During an observation of wound treatment for [REDACTED]. However, the treatment nurse asked the resident to wait outside the room until the care for resident "C" was complete. At 3:20 p.m., a staff member knocked on the door, entered and reported to the treatment nurse that resident "B" wanted to come into the room and lay down because he/she was "hurting." The treatment nurse responded by telling the staff member to ask resident "B" to wait a few more minutes. The treatment nurse also instructed the staff member to report the resident's complaints of pain to the medication nurse. However, at 3:45 p.m. (25 minutes later), as the treatment for [REDACTED]. At 3:50 p.m., resident "B" was observed sitting on his/her bed and rubbing his/her knees with a pained expression on his/her face. Licensed nurse "CC" was observed entering the room at that time to administer pain medication to the resident. The resident rated his/her pain at that time as a "10" on a scale of one to ten. Licensed nurse "CC" stated that staff had not reported the resident's pain to her. She stated that resident "B" had just reported the pain to her when she had entered the room to wash her hands before checking his/her roommate. A review of the Medication Administration Record [REDACTED]. Resident "B" stated during an interview on 10/27/10 at 12:45 p.m., that while waiting outside his/her room on 10/26/10 at 3:10 p.m., his/her pain increased from an 8 to a 10 before he/she could lay down and was given pain medication. | 2015-05-01 |
| 9785 | 9785 | LEE COUNTY HEALTH AND REHABILITATION | 115614 | 214 MAIN STREET | LEESBURG | GA | 31763 | 2010-10-28 | 368 | D | 0 | 1 | XGDS11 | Based on resident interviews it was determined that the facility failed to consistently offer snacks before bedtime for three residents ("A" and "D") and one from the Group Interview, from a total sample of 17 residents. Findings include: 1. During the Group Interview on 10/27/10 at 11:30 a.m., resident "V" stated that staff did not consistently offer him/her snacks before bedtime. 2. During the initial tour on 10/26/10 from 8:15 a.m. to 9:35 a.m. the Director of Nursing (DON) stated that resident "A" could express his/her needs. The resident stated during an interview on 10/28/10 at 9:30 a.m. that staff offered him/her a bedtime snack maybe one to two times per week. He/she asked staff for a snack when one was not offered. 3. During the initial tour on 10/26/10 from 8:15 a.m. to 9:35 a.m. the DON stated that resident "D" could express his/her needs. The resident stated during an interview on 10/27/10 at 1 p.m. that staff did not always offer him/her a bedtime snack. The resident stated it depended on which nurse was working. | 2015-05-01 |
| 9786 | 9786 | LEE COUNTY HEALTH AND REHABILITATION | 115614 | 214 MAIN STREET | LEESBURG | GA | 31763 | 2010-10-28 | 253 | E | 0 | 1 | XGDS11 | Based on observation, it was determined that the facility failed to provide an environment free from dust on two of four halls (100 and 300), the activity room and the common bath. Findings include: The following were observed during the General Observation Tour of the Facility on 10/28/10 from 2:15 p.m. to 2:50 p.m. 100 Hall: There was dust around the two ceiling vents in the hall 300 Hall: There was dust around the ceiling vent at the beginning of the hall. Common Bath: The ceiling vents above the sink and commode areas were dusty Activity Room: There was dust around the two ceiling vents. | 2015-05-01 |
| 9787 | 9787 | LEE COUNTY HEALTH AND REHABILITATION | 115614 | 214 MAIN STREET | LEESBURG | GA | 31763 | 2010-10-28 | 441 | D | 0 | 1 | XGDS11 | Based on observations, it was determined that the facility failed to provide care in a manner to prevent the spread of infection for one resident (#1) and failed to store respiratory equipment during transfer in a manner to prevent contamination for one resident (#6), from a total sample of 17 residents. Findings include: 1. On 10/27/10 at 9:40 a.m., while certified nursing assistant (CNA) "XX" was pushing resident #6 in his/her wheelchair and pushing the oxygen concentrator from the resident's room to the Activity Room. The resident's oxygen tubing and nasal cannula were observed dragging along on the floor behind the wheelchair. The "Hand Hygiene and Gloves" section of the Center for Disease Control (CDC) "Recommended Infection Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens," explaines the standard precaution section that gloves were supposed to be worn during any procedure that involved the potential exposure to blood or body fluids. Handwashing was required between every resident care activity. However, nursing staff failed to handwash and use gloves appropriately when assisting with care for two residents. 2. During an observation of wound treatment on 10/26/10 at 3:10 p.m., CNA "BB" failed to wash or disinfect her hands after entering the resident's room or use gloves while assisting the treatment nurse. The CNA touched the resident's soiled brief and then the clean brief with her bare hands. | 2015-05-01 |
| 9788 | 9788 | LEE COUNTY HEALTH AND REHABILITATION | 115614 | 214 MAIN STREET | LEESBURG | GA | 31763 | 2010-10-28 | 322 | E | 0 | 1 | XGDS11 | Based on observation, staff interview and record review, it was determined that the facility failed to ensure that a water flush flowed by gravity for one resident (#6) and that medications were infused by gravity for one resident (#13), of three residents in the facility with gastrostomy tubes, from a total sample of 17 residents. Findings include: The "Medication Guide for the Long Term Care Nurse, Sixth Edition" by the American Society of Consultant Pharmacists' documented that liquids should be allowed to flow by gravity into a feeding tube and fluids never forced into the tube. The facility's Enteral Tube Medication Administration policy instructed the nurse to allow medications to flow down the tube via gravity, to give gentle boosts with the syringe plunger if the medication would not flow by gravity, and not to push medication through the tube with force. However, licensed nursing staff failed to allow liquids to flow by gravity in the feeding tubes for residents #6 and #13. 1. During observation of the Medication Pass on 10/27/10 at 10:20 a.m. for resident #6, licensed nurse " UU " failed to allow the 100 milliliter (ml) water flush to infuse by gravity. Licensed nurse " UU " used the plunger on the syringe to push the water into the resident's gastrostomy tube. 2. During observation on 10/28/10 at 9 a.m. of medications being administered via the gastrostomy tube for resident #13, licensed nurse " WW " used the plunger of the syringe to push the medications through the tube rather than allowing the medications to infuse by gravity. During an interview on 10/28/10 at 3:45 p.m. the Director of Nursing stated that licensed nurses should have allowed the water flush to flow by gravity, and only provided a gentle push on the plunger if the tube was clogged. | 2015-05-01 |
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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 );