cms_GA
Data source: Big Local News · About: big-local-datasette
92 rows where "filedate" is on date 2016-06-01
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Suggested facets: facility_name, address, zip, inspection_date, scope_severity, complaint, standard, inspection_date (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8126 | 8126 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2012-01-11 | 281 | D | 0 | 1 | Z8U311 | Based on observation, review of the facility policy for filing grievances and resident and staff interviews the facility failed to follow their policy of reporting grievances for one resident (1) (A) from a sample of thirty-two (32) residents. Findings include: Interview with resident A on 01/09/12 at 1:07 p.m. revealed that a staff member had been rude to her about two (2) weeks ago. The staff member had stood over the resident, spoken to her rudely, with her hands on her hips and pointed her finger in the resident's face. The resident reported the incident to the evening/night supervisor who had come to her room and taken her statement. Review of the facility policy for filing grievances revealed that to initiate a grievance and/or complaint the resident, guardian, or representative must submit an oral or written complaint to the Administrator or Director of Social Services. In the event of an oral complaint, the substance of the issue will be promptly reduced in written form for a prompt investigation. The administrator delegated the responsibility of grievance and/or complaint investigation to the social services department. Interview with the Social Worker AA on 01/11/12 at 11:59 a.m. revealed that she did not have any complaint/grievance report regarding any staff member being rude but that the unit manager might have it. Interview with the Licensed Practical Nurse (LPN) Unit Manager 3 BB on 01/11/12 at 1:43 p.m. revealed that she was not aware of this situation and had no documentation regarding this situation. Continued interview revealed that the resident could have reported this to any one (1) of three (3) people but that all reports are not necessarily written down if they can be handled and taken care of immediately, however, this one should have been documented. Interview with the Director of Nurses (DON) on 01/11/12 at 2:12 p.m. revealed that the evening/night supervisor is very good at documenting incidences that occur but sometimes the matters are taken care of rather quickly and are not placed on… | 2016-06-01 |
| 8127 | 8127 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2012-01-11 | 431 | D | 0 | 1 | Z8U311 | Based on observation, review of the facility policy for medication storage and staff interview the facility failed to secure medications in a locked area for one (1) of six (6) medication rooms. Findings include: Observation on 01/09/12 at 8:34 a.m., during initial tour, revealed that the medication storage room door was opened and unlocked on the third (3rd) Floor. There were no licensed personnel in the nurses station but there were residents and unlicensed personnel in the hallway. Interview on 1/09/12 at 8:40 a.m. with Licensed Practical Nurse (LPN) BB revealed that the door to the medication room should be locked at all times. A second interview with LPN BB at 1:04 p.m. revealed that there was a problem with the medication room door and that it had to be slammed in to order to be secured. Review of the facility Policy revealed that medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel. | 2016-06-01 |
| 8128 | 8128 | GOLDEN LIVINGCENTER - DECATUR | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2013-06-20 | 309 | D | 1 | 0 | SZIY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility record review, and resident and staff interviews, the facility failed to ensure that one (1) resident (A), of six (6) sampled residents, received medications and necessary supplies prior to a leave of absence from the facility. Findings include: Review of the progress notes dated Friday, 04/12/13 at 3:30 PM indicated Resident A left the facility with family and returned to the facility on Sunday 04/14/13 at 10:48 PM. During an interview on 04/29/13 at 4:15 PM, Resident A stated that when she went out of town with her family for a funeral, the nurses forgot to give her all of her medications. The resident said that her family had to call the facility and get the doctor to call in orders to a pharmacy so that she would have all of her medications. Review of the Medication Administration Record [REDACTED] - [MEDICATION NAME] Regular (100 unit/ milliliter (ml)) Injection Dose: 100 units/ml Order date 4/6/13. Before meals and at bedtime. Call MD if results 400 give insulin per blood sugar results. 201-250=4u 251-300= 6u 301-350= 8u 351-400= 10u. - [MEDICATION NAME] (polyethylene [MEDICATION NAME]) 17grams by mouth daily. Order dated 3/17/13 - [MEDICATION NAME] Sodium 20mg by mouth at bedtime. Order dated 3/2/13 - Famoditine 20 mgs two times daily. Order dated 3/2/13 Medications that were to be given as needed included: [MEDICATION NAME] -Sublingual dose 0.4mg for chest pain give 3 doses 5 minutes apart. For unrelieved chest pain call MD when giving 3rd dose and prepare to send patient to the ER. During a staff interview on 04/29/13 at 4:30 PM the Administrator, the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) acknowledged that Resident A did not get all of her medications to take on leave of absence. They agreed that the nurse should have checked the medication record and the physician orders [REDACTED]. During an interview on 06/20/13 at 4:45 pm the ADON stated that she called the … | 2016-06-01 |
| 8129 | 8129 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2012-03-01 | 279 | D | 0 | 1 | VJP011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined that the facility had failed to develop a plan of care to address the use of a permacath for one resident (#6) in a total sample of 38 residents. Findings include: Unit II Resident #6 had a permacath in place because of his/her need for [MEDICAL TREATMENT]. A review of the resident's care plan revealed that the interdisciplinary team had not developed a plan to address his/her use of the permacath. The resident's care plan since 10/12/11 addressed his/her [MEDICAL TREATMENT] and the potential for complications. The interventions included staff checking thrill and bruit every shift and to monitor for redness and [MEDICAL CONDITION] at the shunt site. However, there was not any evidence that the interdisciplinary team had identified the use of the permacath and planned interventions for its care. During an interview on 2/29/12 at 1:55 p.m., licensed practical nurse (LPN) BB stated that she did not assess the resident for thrill or bruit because, he/she had a permacath dressing on the right side of his/her chest. She said when the resident returned from [MEDICAL TREATMENT] that she looked at the dressing to see if it was intact and dry. In an interview on 2/29/12 at 2:16 p.m., the Minimum Data Set (MDS) nurse said that she thought the resident had a shunt but was not sure. When the resident was observed at that time, he/she had a dressing over the permacath site on his/her right chest and an old scar of his/her left arm. | 2016-06-01 |
| 8130 | 8130 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2012-03-01 | 312 | D | 0 | 1 | VJP011 | **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 nail care as planned for one resident (#6) in a total sample of 38 residents. Findings include: Unit II Resident #6 was coded on the 01/27/12 Minimum Data Set (MDS) assessment as needing. total assistance of one person for personal hygiene and care. There was a care plan intervention since 05/19/11 to the certified nursing assistants (CNAs) to ensure that all of the resident's nails were trimmed and cleaned as needed. There was also an intervention that a nurse would provide nail care. However, it was observed on 2/27/12 at 3:23 p.m., on 2/29/12 at 7:51 a.m. and 4:11 p.m., and on 3/01/12 at 8:30 a.m. that the resident's fingernails had not been trimmed or cleaned as needed. His/Her fingernails were long and had dirt underneath them. During an interview on 2/29/12 at 1:55 p.m., licensed charge nurse BB stated that she did not do the residents' nails. She said that the CNA was responsible for providing nail care to the resident. In an interview on 2/29/12 at 2:18 p.m., CNA AA said that she had not provided nail care for resident #6 for two (2) months because, the nurse did it. During an interview on 2/29/12 at 4:11 p.m., LPN CC initially said that the CNAs did nail care but then said that the podiatrist did it because the resident was a diabetic. However, the Director of Nursing provided the facility's policy on nail care which was that nail care included daily cleaning and regular trimming. It included that, unless it was otherwise permitted, staff were not supposed to trim the nails of diabetic residents or residents with circulatory impairments. There was documentation in resident #6's medical record that his/her [DIAGNOSES REDACTED]. The computerized version of the CNA flow sheet for resident #6's care indicated in bold red letters the care plan alert that all of his/her nails were (to be) trimmed and cleaned as needed in the mor… | 2016-06-01 |
| 8131 | 8131 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2012-03-01 | 323 | D | 0 | 1 | VJP011 | Based on observations, staff interview, and record review, it was determined that the facility failed to implement planned interventions to address one resident's (#6) potential risk for falls in a total sample of 38 residents. Findings include: Unit II Resident #6 had a care plan since 04/19/11 to address his/her potential risk for falls. There was a 5/19/11 care plan alert that certified nursing assistants (CNAs) were supposed to put a mat on the floor when the resident was in bed and to keep his/her call light within reach. There was documentation dated 5/19/11 on the certified nursing assistant's (CNA) flow sheet about the current care plan alert for fall prevention to have a floor mat on the floor (beside the bed) while the resident was in bed . According to the nursing notes' documentation, the resident fell seven times between 2/25/11 and 2/27/12. However, the resident was observed in bed on 2/27/12 at 3:15 p.m., 2/29/12 at 7:51 a.m., 8:20 a.m., and 8:50 a.m. but the CNAs had not put a mat on the floor or placed his/her call light in reach. The resident was in bed on 2/27/12 at 3:23 p.m. but, the CNAs had not put a floor mat on the floor. On 2/29/12 at 7:15 a.m., 8:20 a.m., and 8:50 a.m., the resident was in bed but, there was not a floor mat on the floor. The resident's call light was on the floor behind his/her bed. Later that morning, at 9:16 a.m., CNAAA said that she could not find a floor mat in the resident's room or closet. In a subsequent interview at 2:20 p.m. on 2/29/2012, she said that she had not seen a floor mat in use for the resident in at least the last two months. | 2016-06-01 |
| 8132 | 8132 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2012-03-01 | 371 | E | 0 | 1 | VJP011 | Based on observations and staff interview, it was determined that the facility failed to store refrigerated meat in a manner to prevent cross contamination and to ensure its use before its 'use by' date. Findings include: Unit II During the brief kitchen tour with the Dietary Manager on 02/27/12 beginning at 12:50 p.m., it was observed that inside of the reach in refrigerator, an open plastic bag was being stored inside of another plastic bag that was unsealed. The inner bag contained roast beef slices. The staff failed to ensure that the contents of the bag did not leak out onto other food items being stored in the refrigerator. Neither one of the bags was dated. There was also a bag of turkey slices which had not been dated. The staff's failure to date refrigerated foods prevented them from being monitored for their 'use by' date. During an interview on 02/29/12 at 12:50 p.m., the Dietary Manager confirmed that those bags should have been closed and dated. After surveyor inquiry, she removed those bags from the refrigerator. | 2016-06-01 |
| 8133 | 8133 | GOLDEN LIVINGCENTER - DUNWOODY | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2012-03-08 | 332 | E | 0 | 1 | 7H8C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations conducted during the medication pass and staff interviews, it was determined that the facility failed to ensure that it was free of a medication error rate of five (5) percent or greater. Findings include: Observations of medication pass were conducted on 3/6/12 from 8:40am thru 9:53am. Observations were made of three (3) nurses administering medications on three (3) of three (3) floors, four (4) medication errors were observed out of sixty six (66) opportunities. This resulted in a medication error rate of 6.06 percent. 1. Resident #496 was given [MEDICATION NAME] five (5) milligrams (mg). Review of physician's orders [REDACTED]. 2. Resident #423 was administered [MEDICATION NAME] capsule via inhalation. Registered Nurse BB placed the capsule into the container, punctured the capsule and laid it down on the medication cart. BB continued to prepare other medications for the resident. All medications were collected to go into the resident's room. The [MEDICATION NAME] container was waved around, laid on the bedside table, then wiped with a Kleenex, and than placed at the resident's mouth to inhale. BB also administered [MEDICATION NAME] one (1) gram by mouth to this resident. Instructions on the blister pack indicated that the medication was to be taken on an empty stomach, one (1) hour before or two (2) to three (3) hours after a meal and at least one (1) hour before, or one (1) hour after antacids, iron, or vitamins/minerals. The resident was given vitamins and [MEDICATION NAME] at the same time as the [MEDICATION NAME]. Interview with the Registered Nurse BB on 3/6/12 at 9:00am revealed he did not realize not to puncture the [MEDICATION NAME] capsule until ready to place in the resident's mouth for inhalation, because the powder was so fine it would escape the capsule with any unusual movement. He did not see the directions on the blister pack for the [MEDICATION NAME]. 3. Resident #443 was administered [MEDICATION NAM… | 2016-06-01 |
| 8134 | 8134 | GOLDEN LIVINGCENTER - DUNWOODY | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2012-03-08 | 425 | D | 0 | 1 | 7H8C11 | Based on observations, and staff interview, the facility failed to ensure that expired medications were discarded timely for one (1) of three (3) medication refrigerators, and one (1) of ten (10) medication carts. Findings include: Observations conducted on 3/7/12 at 9:30am on the third floor revealed the following medications were outdated in the medication refrigerator, and on medication cart #3. One (1) vial Novulog insulin with discard date of 12/22/11. One (1) bag of intravenous (IV) Vancomycin 1.5 grams expired 3/1/12. Two (2) bags of intravenous (IV) Cubicin, expired 2/24/12. One (1) Advair Discus that had no open date. There were thirty (32) doses left in the container. The manufacturers directions indicate the Discus should be discarded after thirty days from opening, or zero doses left, which ever comes first. Review of the facility policy/procedure on Disposal of Expired medications indicated that all discontinued or out-dated medications should be placed in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction Interview with the Assistant Director of Nursing (ADON) AA on 3/7/12 at 10:20am revealed that outdated IV medications are opened and drained in the sink, vials are discarded in the trash. When checking medication refrigerators the 11p - 7a supervisor must have overlooked these medications. | 2016-06-01 |
| 8135 | 8135 | EARLY MEMORIAL NURSING HOME | 115271 | 11740 COLUMBIA ROAD | BLAKELY | GA | 39823 | 2013-06-12 | 309 | D | 1 | 0 | YM2Q11 | Based on observations, staff interview and record reviews, the facility had failed to follow the physician's orders for the administration of a supplement to one resident (#1) of two residents with orders for a supplement, from a total sample of eleven (11) residents. Findings include: Resident #1 had an order since 12/03/12 for Ensure supplement to be served three times a day with all meals. Observations of the resident on 5/14/13 from 5:20 PM to 5:32 PM and on 6/11/13 at 6:05 PM revealed he received meals in his room. There was no Ensure on these trays during both of these meals. The diet card on the tray during both observations noted Ensure. Interview with certified nursing assistant AA on 6/12/13 at 3:00 PM revealed that the resident was not offered Ensure between meals by nursing staff. | 2016-06-01 |
| 8136 | 8136 | EARLY MEMORIAL NURSING HOME | 115271 | 11740 COLUMBIA ROAD | BLAKELY | GA | 39823 | 2013-06-12 | 363 | E | 1 | 0 | YM2Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's menus, record reviews, observations and staff interviews, the facility had failed to ensure that planned menus were followed for five (5) (#1, #3, #5, #6 and B) of nine (9) residents with orders for specialized diets, from a sample of eleven (11) residents. Findings include: Review of the current information in Section 26 of the Georgia Dietetic Manual defined the purpose of a Mechanical Diet as modified in consistency to reduce the amount of chewing required to consume food. The rational included that it was appropriate for individuals with little or no teeth, poor fitting dentures, oral [MEDICAL CONDITION] or irritated [MEDICAL CONDITION] lining. The comments included that most raw fruits and vegetables, seeds, nuts and dried foods were excluded. Review of the facility's planned menus revealed that they were in four week cycles. The four week cycle of menus for the supper meals observed on 5/14/13 and 6/11/13 were as follows: Regular menus-chicken noodle soup, crackers, turkey sandwich, chips, relish plate of tomato and lettuce, chilled peaches. Mechanical/L3 (Mechanical Soft) menus-chicken noodle soup, turkey sandwich ground, one half cup Capri vegetables and chilled peaches. It did not include crackers/chips or lettuce or tomatoes. 1. Resident #1 had an order for [REDACTED]. Observation of resident #1 on 5/14/13, from 5:20 PM to 5:32 PM, revealed that he received chicken salad on soft white bread, tomato and lettuce and peaches. On 6/11/13 at 6:05 PM, he/she received chicken salad on an onion bun, chicken noodle soup, crackers, lettuce/tomato and diced peaches. There were no Capri vegetables served on the meal trays during either meal. Lettuce/tomato or crackers were not listed on the Mechanical menu referenced above. 2. Resident #3 had an order for [REDACTED]. An observation of the resident on 5/14/13 at 4:50 PM revealed that he received a turkey sandwich with lettuce and tomato on a six inch hoagie roll… | 2016-06-01 |
| 8137 | 8137 | PLACE AT MARTINEZ, THE | 115308 | 409 PLEASANT HOME ROAD | AUGUSTA | GA | 30907 | 2011-12-01 | 167 | B | 0 | 1 | HMWR11 | Based on observation, staff and resident interview, the facility failed to post the availability of the State survey results in a place easily accessible to residents. The facility census was seventy-seven (77). Findings include: On 11/30/11 at 2:50 p.m., a framed sign was found on a bookcase at the front entrance to the facility that noted that 'Survey Results were Posted on A Station Bulletin Board near Door.' However, this sign was outside of locked doors so that residents would not be able to see it unless brought out the locked doors by the staff or visitors. The survey results were located in a clear plastic sleeve secured to the wall inside the locked door leading to the 'A' unit. However, there was no sign on this folder indicating what the contents were. In addition, there were no signs anywhere on the 'A' or 'B' halls to inform the residents where the survey results were located. On 12/01/11 at 7:55 a.m., resident 'A,' assessed by the facility as being cognitively intact, stated that the staff told the residents in a meeting yesterday where the survey results were located. He/she said that they did not know where the survey results were before this meeting, and would be interested in reading it. On 12/01/11 at 8:00 a.m. and 9:30 a.m., residents 'B' and 'C,' assessed by the facility as having moderate cognitive impairment, but who gave appropriate responses during interviews, both stated they did not know where the survey results were located. | 2016-06-01 |
| 8138 | 8138 | PLACE AT MARTINEZ, THE | 115308 | 409 PLEASANT HOME ROAD | AUGUSTA | GA | 30907 | 2011-12-01 | 257 | B | 0 | 1 | HMWR11 | Based on observation and staff interview, the facility failed to keep the air temperature in the halls and common area on one (1) of two (2) units ('B' unit) between 71-81 degrees Fahrenheit (F) on two (2) of four (4) days of the survey. There were thirty-three (33) residents that resided on this unit. Findings include: On 11/29/11 between 1:20 and 1:45 p.m., three residents sitting in the hall around the 'B' unit nurse's station complained that it was cold, and asked the staff to turn up the heat. A nurse was also noted to say that it sure is cold in here. The staff was not seen to adjust the temperature. At 2:51 p.m., the thermostat on the wall across from the 'B' unit nurse's station was noted to display an inside temp of 62 degrees F. The display was set to 'System-Cool,' and cold air was noted to be blowing from the ceiling vent above the thermostat. The Maintenance Director stated he normally set the temperature around 79-80 degrees when it was very cold outside, as it was that day. He verified the settings noted above, and changed the system to 'Heat.' On 11/29/11 at 4:21 p.m., the hall thermostat on 'B' unit was displaying an inside temp of 63 degrees, and the air coming from the ceiling vent was cold. The thermostat was set to 'System-Heat,' and 80 degrees. The Maintenance Director verified this observation, and said he would turn the heat up again. A resident sitting in a wheelchair by the nurse's station had on a knit cap, heavy jacket and blanket, and stated that she was cold. There were nine (9) residents in the common area across from the nurse's station at this time; most of them appeared to be dependent on staff for care and locomotion. The resident rooms had individual heating units and were warm. At 5:00 p.m., the Administrator stated that all residents would be removed from the common area and from around the nurse's station until the heat could be restored. On 11/30/11 at 7:10 a.m., the thermostat on the 'B' unit wall across from the nurse's station displayed an inside temp of 57 degrees. The … | 2016-06-01 |
| 8139 | 8139 | PLACE AT MARTINEZ, THE | 115308 | 409 PLEASANT HOME ROAD | AUGUSTA | GA | 30907 | 2011-12-01 | 282 | D | 0 | 1 | HMWR11 | Based on observation, record review and staff interview, the facility failed to follow the care plan related to weekly nail care for one (1) resident (#37), who needed extensive assistance with personal hygiene. The sample size was twenty-four (24) residents. Findings include: On 11/29/11 at 9:24 a.m. and 1:10 p.m., and 11/30/11 at 7:50 a.m., resident #37 was noted to have untrimmed nails on both hands, extending approximately 1/4 inch past the tips of their fingers. There was a dark material under and around all of the nails. The left hand was contracted, and the fingernail of left fourth (ring) finger was especially long and uneven and pressed into the palm of the resident's hand. This was verified by Licensed Practical Nurse (LPN) 'BB' on 11/30/11 at 8:10 a.m. A care plan was developed on 11/22/11 for self care deficit as evidenced by the inability to perform activities of daily living (ADL) independently. Interventions included to do nail care weekly. Review of resident #37's Nursing Care Sheet for November revealed that nail care with bath was documented as being done on 11/16/11; 11/21/11; 11/25/11; and 11/28/11. Nail care was not documented as being done in September or October. | 2016-06-01 |
| 8140 | 8140 | PLACE AT MARTINEZ, THE | 115308 | 409 PLEASANT HOME ROAD | AUGUSTA | GA | 30907 | 2011-12-01 | 312 | D | 0 | 1 | HMWR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide nail care for one (1) resident (#37), who needed extensive assistance with personal hygiene. The sample size was twenty-four (24) residents. Findings include: On 11/29/11 at 9:24 a.m. and 1:10 p.m., and 11/30/11 at 7:50 a.m., resident #37 was noted to have untrimmed nails on both hands, extending approximately 1/4 inch past the tips of their fingers. There was a dark material under and around all of the nails. The left hand was contracted, and the fingernail of left fourth (ring) finger was especially long and uneven and pressed into the palm of the hand. Review of the resident's Minimum Data Set ((MDS) dated [DATE] noted that the resident required extensive assistance with personal hygiene. A care plan was developed on 11/22/11 for self care deficit as evidenced by the inability to perform activities of daily living (ADL) independently. Interventions included to do nail care weekly. On 11/30/11 at 8:05 a.m., Certified Nursing Assistant (CNA) 'AA' stated that nails were cut on shower days, either by Restorative staff or the CNA. At 8:10 a.m., Licensed Practical Nurse (LPN) 'BB' verified that the resident's fingernails on both hands were long, that the fourth finger fingernail of the left hand was pressing into the resident's palm, and that the fingernails had dark material under and around the nails. She stated that the CNAs documented nail care in the ADL book kept at the nurses station, and that nail care was done on shower days. Review of resident #37's Nursing Care (ADL) Sheet for November revealed that nail care with bath was documented as being done on 11/16/11; 11/21/11; 11/25/11; and 11/28/11. Nail care was not documented as being done in September or October. On 11/30/11 at 10:50 a.m., the Director of Nurses stated that nail care should be done with the bath, and as needed. | 2016-06-01 |
| 8141 | 8141 | PLACE AT MARTINEZ, THE | 115308 | 409 PLEASANT HOME ROAD | AUGUSTA | GA | 30907 | 2011-12-01 | 323 | E | 0 | 1 | HMWR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure that water temperatures in two (2) of two (2) common bathing areas and resident rooms on one (1) of two (2) units ('B' unit) were below 120 degrees Fahrenheit (F); failed to lock a door to a room containing hot water heaters and electrical panels on one (1) of two (2) units ('B' unit); and failed to secure chemicals in two (2) of two (2) common bathing rooms on one (1) of two (2) units ('A' unit). There were twenty-five (25) residents in the facility that were independently mobile and cognitively impaired. Findings include: 1. During initial tour of the facility beginning at 10:45 a.m. on 11/28/11, water temperatures ranging from 111.8 degrees to 118.4 degrees F were obtained using the surveyor's thermometer in four resident rooms and two common shower rooms on the 'B' unit. Water temperatures were rechecked in the Shower Room on the front hall of 'B' unit with the Maintenance Director at 12:10 p.m.; he obtained a reading of 122 degrees F with his thermometer (it was 126.9 degrees using the surveyor's thermometer; the faucet was hot to touch and the water was steaming). He stated that a thermostat on one of two hot water heaters that supplied the 'B' wing had broken, and a plumbing service had repaired it that morning. He added that they must have adjusted the temp up after they fixed the thermostat, as the water temperature had been in the 70's. Temperatures were taken again at 1:20 p.m.; in room 14 the temperature was 124.3 using the surveyor's thermometer, and 121 degrees with the facility thermometer. 2. On 11/29/11 at 3:08 p.m., it was noted that the door to the Soiled Utility Room on the front hall on the 'B' unit had a numeric lock on it, but the door was able to be opened by turning the handle. Inside this room was another unlocked, open door that contained two large hot water heaters and several electrical panels. This was verified by the Maintena… | 2016-06-01 |
| 8142 | 8142 | PLACE AT MARTINEZ, THE | 115308 | 409 PLEASANT HOME ROAD | AUGUSTA | GA | 30907 | 2011-12-01 | 356 | B | 0 | 1 | HMWR11 | Based on observation and staff interview, the facility failed to include all of the required information on the posting of the Nurse Staffing information. The facility census was seventy-seven (77). Findings include: During the initial tour of the facility on 11/28/11 at 10:45 a.m., the posting of the Nurse Staffing information was noted at the entrance to the 'B' Unit. The only information included was the numbers of staff scheduled, and the date. On 11/29/11 at 11:08 a.m., the Staffing Coordinator verified the Nurse Staffing information did not contain the name of the facility; the census; or the number of hours worked per type of staff. | 2016-06-01 |
| 8143 | 8143 | PLACE AT MARTINEZ, THE | 115308 | 409 PLEASANT HOME ROAD | AUGUSTA | GA | 30907 | 2011-12-01 | 463 | E | 0 | 1 | HMWR11 | Based on observation and staff interview, the facility failed to ensure that all call lights in one (1) of two (2) common bathing areas on one (1) of two (2) units ('A' Unit) were functional. There were forty-four (44) residents on the 'A' Unit that may use this common bath. Findings include: On 11/30/11 at 2:07 p.m., it was noted that only one of four call lights in the Whirlpool Room on 'A' unit were functional. The call lights across from the shower stall, next to the commode, and on the hallway side of the whirlpool tub did not work. The only light that worked was in the far back corner of the room, behind the tub. This was verified by the Director of Nurses at 2:15 p.m. | 2016-06-01 |
| 8144 | 8144 | GOLDEN LIVINGCENTER - BRIARWOOD | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2012-04-05 | 281 | D | 0 | 1 | HTVV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the Georgia Practical Nurses Practice Act, the facility failed to ensure that a physician's order was written from a pharmacist recommendation for one (1) resident (#177) out of a sample of twenty-nine (29) residents. Findings include: Review of Clinical Intervention Center (CIC) Physician Recommendation from Pharmacist dated 3/22/12 revealed that the pharmacist recommended that [MEDICATION NAME] forty (40) milligrams (mg) be discontinued as the therapy was no longer needed. Continued review revealed that on 3/23/12 the physician responded to the recommendation, accepting the suggestion and requesting that a new order be written to discontinue the medication. Review of physician orders from 3/23/12 until 4/05/12 revealed no evidence that the order had been written to discontinue the medication. Review of March and April, 2012 Medication Administration Record [REDACTED]. Interview with West Wing Unit Manager AA on 4/5/12 at 10:23 a.m. revealed that there was no evidence that a physician order had been written to discontinue the [MEDICATION NAME]. Continued interview revealed that the nurses are the ones who are responsible for checking the charts that are flagged and writing any physician orders and/or recommendations. Interview with the Director of Nursing (DON) on 4/5/12 at 10:35 a.m. revealed that the night shift is responsible for a twenty-four (24) hour chart review. Review of the Georgia Practical Nurses Practice Act revealed that the practice of licensed practical nursing means the provision of care for compensation related to the maintenance of health and prevention of illness through acts which shall include but not limited to: -Implementing appropriate aspects of client care in a timely manner -Administering medications accurately | 2016-06-01 |
| 8145 | 8145 | RIDGEWOOD MANOR HEALTH AND REHABILITATION | 115341 | 1110 BURLEYSON DRIVE | DALTON | GA | 30720 | 2012-02-02 | 252 | B | 0 | 1 | OLN011 | Based on observations, the facility failed to ensure a clean and odor free environment for one (1) of two (2) common shower rooms on one (1) of two (2) units. Findings include: During the initial tour on 1/30/12 at 10:15am the Unit One common bathroom had a strong odor of urine, and feces. A bucket sitting by the tub contained a large amount of loose feces. There were no residents or staff in the bathroom. The Unit Manager AA was present during this observation. During this observation two (2) CNAs brought two (2) female residents into the shower room. Upon the CNAs entrance, AA instructed the CNAs to empty the feces and clean the bucket. A second observation of this common bath on 2/2/12 at 2:00pm revealed that the bath still had a urine odor. | 2016-06-01 |
| 8146 | 8146 | RIDGEWOOD MANOR HEALTH AND REHABILITATION | 115341 | 1110 BURLEYSON DRIVE | DALTON | GA | 30720 | 2012-02-02 | 333 | D | 0 | 1 | OLN011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Medication Administration Record [REDACTED]. This failure resulted in a significant medication error for one (1) resident (#93) from a sample of thirty three (33) residents. Findings include: Record review for resident #93 conducted 2/1/12 revealed a physician's orders [REDACTED]. Observation conducted during Medication Pass on 1/31/12 at 8:25am revealed [MEDICATION NAME] was not administered to resident #93. Review of the January MAR indicated [REDACTED]. Due to the failure to transcribe the [MEDICATION NAME] to the MAR, the resident missed approximately sixteen (16) doses. Interview with the charge nurse CC on 2/2/12 at 1:00pm revealed that the resident received the [MEDICATION NAME] from 12/7/11 through 12/21/11, but had an automatic stop order. The resident continued to complain with throat pain, swelling, and difficulty swallowing due to [MEDICAL CONDITION] treatments. Staff made a request of the Nurse Practitioner DD to re-order the medication due to the continued discomfort. The order was obtained on 1/26/12, but was not transcribed until 2/1/12. Review of the nursing notes from 1/26/12 through 1/31/12 indicated that the resident complained of throat pain six (6) times during that period. During interview with the Nurse Practitioner DD on 2/2/12 at 11:10am, she acknowledged that the [MEDICATION NAME] had not been given according to the order. | 2016-06-01 |
| 8147 | 8147 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2011-12-22 | 241 | D | 0 | 1 | BW4W11 | Based on observation and staff interviews the facility failed to provide care in a manner to maintain personal dignity during dining for one (1) randomly observed resident (Z). Findings include: Observation on 12/19/11 at 12:47 p.m. in the 400 Hall Solarium, during the lunch meal, revealed one (1) Certified Nursing Assistant (CNA) GG serving trays and setting up food for seven (7) residents at one table. After setting up the trays for each of the seven (7) residents, the CNA sat to feed one (1) resident. Five (5) other residents at the table fed themselves, while the seventh resident Z sat at the table with the food tray in front of her and her head down. When the first resident being fed had finished eating, the CNA began to feed the resident Z. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 10/27/11 assessed the resident as requiring extensive assistance with feeding and one person assist. Interview on 12/21/11 at 2:10 p.m. with CNA GG revealed she is usually without other staff members when feeding the residents in the 400 Hall Solarium. Continued interview revealed that the resident would feed herself, depending on how she is feeling. CNA GG revealed most days there are five (5) to six ( 6) residents eating lunch at the same table in the Solarium. Interview on 12/21/11 at 2:30 p.m. with Registered Nurse ( RN), Assistant Director of Nursing (ADON) concurred that any resident not being fed or receiving assistance while six (6) other residents were eating and/or being fed at the same table was a dignity issue. Continued interview revealed that the resident has days when she is very alert and other days when she is very lethargic. | 2016-06-01 |
| 8148 | 8148 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2011-12-22 | 309 | D | 0 | 1 | BW4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician orders [REDACTED].#11) from a sample of thirty-seven (37) residents. Findings include: Review of the interdisciplinary progress note dated 12/16/11 revealed resident #11 was found lying on her back, on 12/15/11 at 3:15 p.m., on the floor beside her bed. An assessment was completed and no injuries were noted. However,the Physician Assistant (PA) was in the facility, notified, and assessed the resident. Neurochecks were ordered to be done per protocol for three (3) days. Review of the neurocheck worksheet revealed that neuro checks were to be done every fifteen (15) minutes for the first hour, every thirty (30) minutes for the second hour, every hour for six (6) hours, every four (4) hours for twenty-four (24) hours and then every shift up to seventy two (72) hours. Continued review revealed that after the first hour a summary should be written in the Inter Disciplinary Team (IDT) notes of the findings during neuro checks and also at the end of each shift. Review of the neurocheck worksheet for resident #11 dated 12/15/11 revealed that after the second hour, there was no evidence that the neurochecks were completed as ordered. The level of consciousness (LOC), pupils equal, round, reactive to light and accommodation (PERRLA) and hand grip were not summarized in the IDT notes, only that neurochecks were in progress or neurochecks x twenty four (24) hours on 12/16/11. Review of the IDT notes for 12/17/11 revealed no evidence of neurochecks being done. Interview with the Director of Nursing (DON) and Nurse Consultant BB on 12/21/11 at 11:15 a.m., revealed that that there was no evidence that the neurochecks were completed as ordered. Continued interview revealed that the neuro check sheet was only a worksheet and she expected the nurses to write a summary in the interdisciplinary progress notes for the seventy-two (72) hours that the neurochecks were ordered. | 2016-06-01 |
| 8149 | 8149 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2011-12-22 | 425 | D | 0 | 1 | BW4W11 | Based on observations, record review, and staff interviews, the facility failed to ensure that expired medication was disposed of timely on one (1) of five (5) halls (400 Hall). Findings include: Observation on 12/20/11 at 3:15 p.m. of the Medication Cart on the 400 Hall, with Licensed Practical Nurse (LPN) EE and Consultant Registered Nurse (RN) BB revealed two (2) vials of Novolin Regular Insulin with expired disposal dates. One (1) vial was opened and dated 10/15/11 and the second vial was opened and dated 10/18/11. Labeling on both Insulin boxes revealed the Insulin should have been disposed of in forty-two (42) days. The Insulin opened 10/15/11 should have been disposed of on 11/16/11 and the Insulin opened 10/18/11 was to be disposed of 11/29/11. Interview on 12/20/11 at 3:15 p.m. with Consultant Registered Nurse concurred that the Insulins were past the disposal date. Review of the Medication Administration Record [REDACTED]. Review of the facility's policy for medication storage and disposal of Insulin revealed the Novolin Insulins had a forty-two (42) day shelf life after the first use. | 2016-06-01 |
| 8150 | 8150 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2011-12-22 | 441 | E | 0 | 1 | BW4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to maintain appropriate infection control measures to prevent the likelihood of the spread of infection for one (1) ice machine on the 200 hall and one (1) ice machine in the kitchen. Findings include: 1. Observation on 12/19/11 at 10:30 a.m. and 11:50 a.m. revealed an ice scoop in an uncovered bucket on top of the ice machine outside the chapel area at the end of the 200 hall. Interview with the Environmental Supervisor on 12/19/11 at 1:59 p.m. revealed that it is her department's responsibility to keep the ice machine by the chapel area clean and to place the ice scoop in the container in a lined bag. Continued interview revealed that the scoop should always be covered. 2. Observations on 12/19/11 at 12:00 p.m. and on 12/21/11 at 2:30 p.m. revealed an ice scoop, stored in a container with no cover, mounted on the wall next to the ice machine in the kitchen. Interview with the food service director on 12/21/11 at 2;30 p.m. revealed that the ice scoop should always be covered but that the lid to the ice scoop container was recently knocked off and a new container was ordered on [DATE] but had not arrived. | 2016-06-01 |
| 8151 | 8151 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2011-12-22 | 463 | E | 0 | 1 | BW4W11 | Based on observations, staff and resident interviews, and review of Daily Room Audit log the facility failed to maintain a functioning call light system for eleven (11) of one hundred three (103) call lights checked on four (4) of five (5) halls. Findings include: 1. Observations on 12-19-11 beginning at 3:00 p.m. revealed that ten (10) call lights were not working in the following rooms: The call light cord for bed 405B was cut and the push button at the end of the cord was missing and the call light cord for bed 408A had a damaged push button and was not working. Continued observation revealed call lights for bed 110A, 203A, 500, 502A, 502B, 502C, 510A, 510B and the bathroom call light for room 510 would not light up or sound at the nursing station. Interview with Administrator and Regional Environmental Service Manager on 12-19-11 at 3:30 p.m. confirmed that the call lights were not working. Continued interview revealed that the facility has a Daily Room Audit-Maintenance sheet and that two (2) rooms are checked for repairs weekly. Interview on 12-20-11 at 10:30 a.m. with the Regional Environmental Service Manager revealed that the wires had been cut in the overhead crawl space and that was why the call lights for room 502 were not working. Further interview revealed that it was unknown how they were cut or for how long it had been that way. Review of Daily Room Audit - Maintenance log on 12-20-11 revealed that a room audit is done on two (2) rooms a week and the call light systems are checked at that time. Continued review Daily Room Audit revealed that room 110 was checked on 10-05-11, room 203 was checked on 10-04-11, room 405 was checked on 11-15-11, room 408 was checked on 11-10-11, room 500 was checked on 10-05-11, room 502 was checked on 10-10-11, and room 510 was checked on 09-22-11. There was not a separate call light check log sheet kept by the facility. 2. Observation on 12/19/11 of the call lights on the two hundred (200) hall beginning at 3:00 p.m. with Licensed Practical Nurse (LPN) AA, revealed … | 2016-06-01 |
| 8152 | 8152 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2011-12-22 | 468 | D | 0 | 1 | BW4W11 | Based on observation and staff interview the facility failed to maintain firmly secured handrails on one (1) of five (5) halls. Findings include: Observation on 12-19-11 beginning at 10:15 a.m., during environmental tour, revealed that there was no hand rail at the end of 200 hall on the right wall in front of the Chapel. Further observation revealed that there was about a fourteen (14) foot section of the wall that did not have a handrail in place. Residents pass this area going to activities, meals and Church Services. Interview with the Regional Environmental Service Manager on 12-20-11 at 11:10 a.m. confirmed that there was a rail there at one time and that there should be one there now. | 2016-06-01 |
| 8153 | 8153 | TREUTLEN COUNTY HEALTH AND REHABILITATION | 115358 | 2249 COLLEGE STREET, NORTH | SOPERTON | GA | 30457 | 2012-04-12 | 514 | D | 0 | 1 | BOPU11 | Based on record review and staff interview the facility failed to maintain complete, detailed and timely records for residents receiving hospice care. This affected one (1) resident, #25, from a sample of twenty-two (22) residents. Findings include: A review of the clinical record of resident #25 revealed that she was receiving hospice care. A review of the contract between the facility and the hospice provider revealed that the hospice provider was responsible for preparing and maintaining complete and detailed clinical records for each resident receiving services. The agreement further stipulated that the hospice service clinical records were to provide complete, prompt and accurate documentation of services provided to, and events concerning, each resident receiving hospice care. Further record review revealed that the last documented visit made to the facility by a hospice service Registered Nurse (RN) was on 01/18/12. There were no documentation in the clinical record of visits made to the facility by a hospice service chaplain, social worker, nursing aide or volunteer. A review of the resident's Care Plan Conference Sheet dated 2/29/12 revealed that no representative for the hospice provider had attended any of the resident's recent care plan meeting. Further record review revealed that there were no interventions in the resident's care plan that were delineated between the facility and the hospice staff as stipulated by the agreement between the facility and the hospice provider. These findings were confirmed in an interview with the facility's Director of Nursing (DON) and the hospice service Director in an interview on 4/10/12 at 4:00 p.m. | 2016-06-01 |
| 8154 | 8154 | QUINTON MEM HC & REHAB CENTER | 115403 | 1115 PROFESSIONAL BLVD | DALTON | GA | 30720 | 2012-01-11 | 322 | D | 0 | 1 | 3LD711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medication pass observation, staff interview, record and care plan review, the facility failed to ensure a residual was checked prior to an enteral feeding for one (1) resident (#33) from a sample of thirty four (34) residents. Findings include: During observation of medication pass for resident #33 on 1/9/12 at 8:00am the Licensed Practical Nurse (LPN) AA was observed to check placement for the feeding tube, but failed to check for any residual. Medications and one (1) can of [MEDICATION NAME] 1.5, bolus enteral feeding, were administered. Review of the resident's care plan indicated that the resident had Dysphagia, which required enteral feedings and one (1) of the interventions included to check residual as ordered. Record review revealed signed monthly physician's orders [REDACTED]. Interview with AA on 1/9/12 at 9:20am revealed she failed to check residual prior to administering the 8:00am [MEDICATION NAME] 1.5 enteral feeding. | 2016-06-01 |
| 8155 | 8155 | THOMASVILLE HEALTH & REHAB, LLC | 115427 | 120 SKYLINE DRIVE | THOMASVILLE | GA | 31757 | 2013-06-14 | 282 | G | 1 | 0 | 9ZLW11 | Based on staff interview and record review, it was determined the facility failed to ensure that staff provided assistance, in conformance with the care plan, during the transfer of one (1) resident (#4), of four (4) residents with a history of falls, from a total sample of five (5) residents. This failure resulted in actual harm, a scalp wound, as Resident #4 experienced a fall during transfer. Findings include: Please cross refer to F323 for more information regarding Resident #4. Record review for Resident #4 revealed that the care plan identified the resident to be at risk for falls. The care plan included an intervention, originally dated 1/4/13, for nursing staff to transfer the resident with the assistance of two (2) nursing staff members. However, further record review for Resident #4 revealed a Nurse's Notes entry of 06/03/2013 at 5:45 a.m. which documented that the resident was noted on the floor, having a laceration to the right posterior scalp, and that the resident was transferred to the emergency room for treatment. A subsequent Nurse's Notes entry of 06/03/2013 documented that Resident #4 had received three (3) staples to the scalp wound. The incident report for Resident #4's 06/03/2013 fall referenced above documented that, during the transfer and subsequent fall, the appropriate number of staff were not present. The Director of Nursing (DON) acknowledged, during an interview on 6/14/13 at 1:15 p.m., that during the transfer, the CNA had transferred the resident alone, and had required additional training on providing care in accordance with the care plan. | 2016-06-01 |
| 8156 | 8156 | THOMASVILLE HEALTH & REHAB, LLC | 115427 | 120 SKYLINE DRIVE | THOMASVILLE | GA | 31757 | 2013-06-14 | 323 | G | 1 | 0 | 9ZLW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility incident report review, the facility failed to ensure that staff provided two-person assistance as required during a transfer for one (1) resident (#4), of four (4) residents with a history of falls, from a total sample of five (5) residents. This failure resulted in actual harm for Resident #4, as the resident experienced a fall during a transfer and sustained a scalp wound. Findings include: Record review for Resident #4 revealed a May 2013 Minimum Data Set (MDS) assessment which documented that the resident was admitted into the facility in October of 2006. This MDS also documented that the resident's [DIAGNOSES REDACTED]. Resident #4 had a care plan since 12/13/11 for being at risk for falls. The care plan was updated on 1/4/13 to include that she was lowered to the floor by a Certified Nursing Assistant (CNA) while being transferred from the bed to the chair. A new intervention, also dated 1/4/13, to prevent further falls instructed nursing staff to transfer Resident #4 with the assistance of two nursing staff members. The CNA Assignment Sheet also documented that Resident #4 needed the assistance of two staff for transfers. Further record review for Resident #4 revealed a Nurse's Notes entry of 06/03/2013 at 5:45 a.m. which documented that nursing staff had been called to the resident's room by a CNA, who stated that the resident was on the floor. This Notes entry documented that the resident was noted to have a laceration to the right posterior scalp. This Notes entry also documented that the physician was consulted, and an order was received for the resident to be transferred to the emergency room for evaluation and treatment. A subsequent Nurse's Notes entry of 06/03/2013, with no noted time, documented that facility staff had received a report from hospital staff indicating that Resident #4 had received 3 staples to the scalp wound, and that a Computerized Tomography scan had rev… | 2016-06-01 |
| 8157 | 8157 | CEDAR VALLEY NSG & REHAB CTR | 115436 | 225 PHILPOT STREET | CEDARTOWN | GA | 30125 | 2012-01-05 | 166 | D | 0 | 1 | I4YU11 | Based on review of the facility's Grievance Log, the Policy on Filing Grievances/Complaints, and residents' and staff interviews, the facility failed to follow the facility's policy and document grievances and ensure that residents received timely response to grievances for two residents (X and T ) from a sample of thirty three (33) residents. Findings include: 1. During an interview with resident X on 1/4/12 at 8:25am, the resident indicated had been missing bottom set of dentures for approximately 6 weeks. The resident reported it to one of the counselors and was told they would report it to the office however, has never received a response back on the missing dentures. The resident further revealed that approximately 4 to 5 weeks ago a new pair of blue jeans and 3 or 4 other pants that family had brought were missing. The resident indicated that they were aware that staff had looked for them in the laundry but no one had found them. Review of the Grievance Log revealed no evidence of the missing dentures and clothes. Interview with housekeeping/laundry staff BB on 1/5/12 at 1:00pm revealed that she could not remember every complaint of missing clothes because they receive so many but, she does remember looking for missing teeth. Interview with the Administrator on 1/5/12 at 1:04pm revealed that a form should be completed anytime a concern is voiced and the item cannot be found. Further, the facility has replaced dentures before but not for resident X. Interview on 1/5/12 at 1:55pm with the Hospitality Ambassador, FF revealed that it is part of her job to help with setting up appointments to see the Dentist. FF further revealed that resident X had not reported the missing teeth or missing clothes to her but was aware of them missing. FF was aware that staff had looked in the laundry for the clothes and the Social Worker had asked FF to see about getting the resident on the Dentist list. 2. During an interview with resident T on 1/3/12 at 11:23am, the resident revealed that one (1) pair of red satin pants and on… | 2016-06-01 |
| 8158 | 8158 | CEDAR VALLEY NSG & REHAB CTR | 115436 | 225 PHILPOT STREET | CEDARTOWN | GA | 30125 | 2012-01-05 | 278 | D | 0 | 1 | I4YU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to insure that the assessment for one (1) resident (#19) adequately reflected the resident's status from a sample of thirty-three (33) residents. Finding includes: Record review of quarterly Minimum Data Set ((MDS) dated [DATE], 8/24/11 and annual MDS dated [DATE] revealed resident #19 was assessed as having no impairment to upper extremities only to bilateral lower extremities. Review of the restorative notes for November and December 2011 revealed PROM was being done to bilateral upper extremities, which was started 11/15/11. Interview with charge nurse EE conducted 1/4/11 at 2:15pm revealed the resident has bilateral hand contractures. During interview with the MDS coordinator conducted 1/4/11 2:50pm, she revealed resident was incorrectly assessed as having no limited range of motion in the upper extremities. | 2016-06-01 |
| 8159 | 8159 | CEDAR VALLEY NSG & REHAB CTR | 115436 | 225 PHILPOT STREET | CEDARTOWN | GA | 30125 | 2012-01-05 | 282 | D | 0 | 1 | I4YU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the care plan, resident and staff interviews, the facility failed to ensure the care plan interventions were followed for one (1) resident (T) from a sample of thirty three (33) residents. Findings include: During an interview with resident T on 1/3/12 at 11:25am the resident revealed her left leg had [MEDICAL CONDITION] Arthritis, and she had taken [MEDICATION NAME] for thirty (30) years. The medication relieved some of the pain but not all and she felt she might need a different pain medication. Review of the resident's latest history/physical by the new Medical Director dated 8/9/11 indicated the resident had multiple chronic medical problems, a history of chronic pain, currently received a [MEDICATION NAME] 50mcg/hr patch with [MEDICATION NAME] for break through pain. The resident had an [MEDICATION NAME] back injection on 7/29/11 for her chronic back pain and would refer to the pain clinic if no improvement is reported. The resident received [MEDICATION NAME] 10-650 mg (1) po 5:00am, 10:30am, 4:30pm, and 9:00pm, and a [MEDICATION NAME] 50mcg every third day. Review of the Care Plan dated 11/26/11 indicated goals and interventions for risk of decline in Activities of Daily Living (ADLs) related to pain. The interventions were as follows: Pain Interventions: 1. Using a 1 to 5 pain scale assess severity/ frequency of pain before medications are given. 2. Return at thirty (30) minutes, one (1) hour and two (2) hours past medications to assess degree of pain relief. 3. Document pain relief. 4. Consult the physician if pain medications do not provide pain relief. Interview with the Licensed Practical Nurse (LPN) AA on 1/5/12 at 10:20am revealed pain was monitored by observation of the resident's involvement in ADLs, smoking, ambulation verses using a wheel chair, was the resident guarded, or rubbing pain areas. The resident never exhibited symptoms of distress except verbally. The resident had an appointment s… | 2016-06-01 |
| 8160 | 8160 | CEDAR VALLEY NSG & REHAB CTR | 115436 | 225 PHILPOT STREET | CEDARTOWN | GA | 30125 | 2012-01-05 | 318 | D | 0 | 1 | I4YU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed ensure that a decline did not occur for two (2) residents (# 19 and #100) with limited range of motion from a sample of thirty-three (33) residents. Finding includes: 1. Record review for resident #19 revealed [DIAGNOSES REDACTED]. Further record review revealed physician's orders [REDACTED]. Review of quarterly Minimum Data Set ((MDS) dated [DATE], 8/24/11 and Annual MDS dated [DATE] revealed the resident was assessed as having no impairment to upper extremities only to bilateral lower extremities (BLE) Review of the restorative notes for November and December 2011 revealed PROM was being done to BUE, which was started 11/15/11 Interview with charge nurse EE conducted 1/4/11 at 2:15pm revealed the resident has bilateral hand contractures. Joint range of motion and mobility screening conducted 11/17/11 revealed that the resident had limited joint mobility effecting hip, knee, ankle, shoulder, elbow, wrist and fingers. The form indicated that here was no change for the last screening done 8/22/11. Observation conducted 1/4/12 at 3:20pm with restorative nurse CC revealed the resident was lying quietly in bed with her arms across her chest. Bilateral extensive hand contractures were noted. CC further indicated that the resident had been feeding herself up until the last several years ago buy holding the spoon, now she cannot even hold a spoon. 2. Record review for resident #100 revealed the resident was admitted to the facility July 7, 2006 and has [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of December physician's progress note revealed this resident is bed/chair bound, and has generalized weakness. The Quarterly Minimum Data Set ((MDS) dated [DATE] assessed the resident as having impairment on both sides for upper and lower extremities. The annual MDS dated [DATE] ROM was assessed the same as 10/21/11 quarterly. Review of restorative notes… | 2016-06-01 |
| 8161 | 8161 | PRUITTHEALTH - ATHENS HERITAGE | 115509 | 960 HAWTHORNE AVENUE | ATHENS | GA | 30606 | 2012-01-05 | 170 | C | 0 | 1 | LHZ211 | Based on resident and staff interview the facility failed to ensure Saturday mail delivery for all residents in the facility based on a census of 91 residents. Findings include: Interview with the resident council representative on 01/03/12 at 11:00 a.m. revealed the facility did not provide Saturday mail delivery to the residents in the facility. The council representative stated that the mail is not delivered on Saturdays. She stated that they have been told there is no mail delivery on Saturday and some one who have to go to the post office and pick up mail. On 01/04/12 at 9:20 a.m. interview with the Administrator revealed that they had this issue last year and she had made arrangements for the nursing supervisor or weekend manager to get the mail and deliver it on Saturdays. Further interview with the Administrator on 01/04/2012 at 10:00 a.m., revealed that she had investigated the concern of no mail delivery and discovered that due to a change in postal carriers the facility had not been receiving mail delivery on Saturdays and the residents were not getting Saturday mail delivery. Interview with a US Postal Manager in Customer Service, on 01/09/12 at 11:50 a.m. revealed The rational for not delivering mail on Saturdays to the facility was that it is classified as a business and not a home address. It was her understanding that in the past there were attempts to change the delivery status, but due to a miscommunication this never occurred. | 2016-06-01 |
| 8162 | 8162 | PRUITTHEALTH - ATHENS HERITAGE | 115509 | 960 HAWTHORNE AVENUE | ATHENS | GA | 30606 | 2012-01-05 | 309 | D | 0 | 1 | LHZ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that care and services were provided in accordance with physician orders [REDACTED].#26) on a sample of twenty-eight (28) residents. Findings include: Review of the current January 2012 Physician order [REDACTED]. The Physician order [REDACTED]. Review of the December 2012 Medication Administration Record [REDACTED]. The systolic blood pressures on these days (12/11/11, 12/14/11, 12/16/11, 12/20/11, 12/24/11,12/26/110 ranged from 107 mmHg systolic to 129 mmHg systolic. Interview with the Administrator on 01/05/12 at 9:22 am confirmed that the [MEDICATION NAME] should not have been administered on the days when the systolic blood pressure was above 130 mmHg. | 2016-06-01 |
| 8163 | 8163 | PRUITTHEALTH - ATHENS HERITAGE | 115509 | 960 HAWTHORNE AVENUE | ATHENS | GA | 30606 | 2012-01-05 | 329 | D | 0 | 1 | LHZ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and pharmacist interviews, the facility failed to consistently monitor serum [MEDICATION NAME] levels to ensure the medication was within therapeutic levels for one (1) resident (#69), and failed to ensure that there was an indication for the medication [MEDICATION NAME] for one (1) resident (#27). The sample size was twenty-eight (28) residents. Findings include: 1. Review of resident #69's medical record revealed diagnosed including: [DIAGNOSES REDACTED]. On 11/29/11, a physician's orders [REDACTED]. A physician's orders [REDACTED]. In addition, a serum creatinine level (to monitor for changes in kidney status) and [MEDICATION NAME] trough level was ordered to be done before the morning dose of [MEDICATION NAME] on 12/27/11. The serum creatinine was done as ordered, but no [MEDICATION NAME] trough level was found. The resident continued to receive the [MEDICATION NAME] until it was discontinued on 01/03/12. On 01/04/12 at 4:10 p.m., the Assistant Director of Health Services (ADHS) DD verified that there was no [MEDICATION NAME] trough level on the chart for 12/27/11. She stated that [MEDICATION NAME] troughs were drawn prior to the morning dose of the antibiotic, and the results were obtained and reported to the Pharmacy prior to giving the next dose of [MEDICATION NAME]. The Pharmacy then gave the orders on dosing and subsequent monitoring labs. On 01/05/12 at 8:40 a.m., the Administrator stated that the facility had ordered the serum creatinine and [MEDICATION NAME] level for 12/27/11, but only the serum creatinine was done. She added that the Pharmacy had identified that there was no [MEDICATION NAME] levels since 12/23/11, and on 01/02/12 they ordered a [MEDICATION NAME] trough level be done prior to that evening's dose. She stated that the facility did not discover this order until the morning of 01/03/12, and the lab was not ordered to be done until 01/04/12. The [MEDICATION NAME] trough level at that tim… | 2016-06-01 |
| 8164 | 8164 | PRUITTHEALTH - ATHENS HERITAGE | 115509 | 960 HAWTHORNE AVENUE | ATHENS | GA | 30606 | 2012-01-05 | 441 | E | 0 | 1 | LHZ211 | Based on observation, and staff interview the facility failed to assure staff washed their hands after resident contact while serving and setting up meal trays on two (2) of two (2) units (Unit 1 and Unit 2) observed on two (2) shifts, 7-3 and 3-11 during both a lunch and dinner meal service. Findings include: 1. The noon meal service was observed on the 500 and 600 halls on 01/03/12. Certified Nursing Assistant (CNA) AA was observed at 12:50 p.m. serving trays on 500 hall to residents in their rooms. CNA AA did not wash her hands at anytime while serving. At 12:50 p.m. she took a tray into a room on the 500 hall. She placed the tray on the overbed table and then proceeded to pick up a fall prevention mat next to the A bed inside the door while touching the underside which was next to the bare floor. She folded the mat and put it away. She then wheeled the resident's overbed table into position across the resident's bed and set up the tray, which included taking two straws out of the paper and touching the full length of both before she placed them in the containers of liquid on the tray. She then went to another room on the 500 hall and touched the rim of the resident's ice cream cup. The resident was observed to start eating the ice cream. 2. During observation of the supper meal on 01/04/12 beginning at 5:00 p.m. on Unit One in the Activity Room CNA CC was observed passing trays. CNA CC served four (4) trays in the activity room at 5:15 p.m. After serving the first tray the CNA touched the resident's wheelchair and then patted the resident on the shoulder. She then served and set up the next three trays at the table without washing her hands using gloves or hand sanitizer. While serving the fourth tray she took the bread out of the plastic bag and cut it in half. She then assisted a resident who was coughing. She helped change the resident's clothing protector after the coughing spell. She then assisted with the feeding of two other residents without washing her hands. 3. CNA BB was observed on the 500 hall wh… | 2016-06-01 |
| 8165 | 8165 | PRUITTHEALTH - ATHENS HERITAGE | 115509 | 960 HAWTHORNE AVENUE | ATHENS | GA | 30606 | 2012-01-05 | 504 | D | 0 | 1 | LHZ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that laboratory test were done as ordered by the physician for one (1) resident (#26) on a sample of twenty-eight (28) residents. Findings include: Record review for resident #26 revealed the resident had a [DIAGNOSES REDACTED]. There was no indication in the resident's record that the lipid panel had been done as ordered. Interview with the Registered Nurse Consultant EE in the facility on 01/05/12 at 10:24 a.m. revealed the lipid panel was not done as ordered by the physician. | 2016-06-01 |
| 8166 | 8166 | BRANDON WILDE PAVILION | 115524 | 4275 OWENS ROAD | EVANS | GA | 30809 | 2011-12-01 | 225 | D | 0 | 1 | 7WO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview the facility failed to report an allegation from one (1) resident (A) from a sample of thirty-two (32) residents of verbal abuse to the State Regulatory Agency. Findings include: Record review revealed resident A had a BIMS score on the 10/03/11 MDS assessment of 14, indicating the resident was cognitive intact with no memory problems. The resident was assessed on the Quarterly Minimum Data Set (MDS) assessment dated [DATE] as needing Extensive Assist for transfer and toileting, with one (1) person assist. Interview on 11/29/11 at 9:32 a.m. with resident A revealed that approximately three (3) weeks prior, Certified Nursing Assistant (CNA) BB made an inappropriate remark and cursed at the resident while assisting her with toileting. This was reported by the resident to the Executive Director. The resident revealed that several days later CNA BB came to her room and apologized. An interview with the Director of Nursing (DON) and the Executive Director on 11/29/11 at 10:30 a.m. revealed they were aware of the resident's allegations and they did an investigation. The Executive Director revealed the facility process was for an allegation of abuse to be investigated by the Director of Nurses (DON) and to report the occurrence to the State Agency. A copy of the investigation was provided for review. Interview on 11/29/11 at 11:35 a.m. with the DON revealed the allegation was investigated but had not been reported to the State Agency. Interview with the Executive Director on 11/30/11 at 9:00 a.m. revealed the investigation should have been reported to the State Agency. | 2016-06-01 |
| 8167 | 8167 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2011-12-08 | 225 | D | 0 | 1 | GPWF11 | Based on resident, staff interviews, and review of facility policy, the facility failed to ensure that an allegation of verbal abuse from one (1) resident (RR) from a sample of forty-four (44) residents was reported to the State survey and certification agency timely. Findings include: Interview on 12/6/11 at 2:58 pm with resident RR revealed that on 12/5/11 the room was real hot and that he turned the air conditioner up to reduce the heat. He further revealed that his roommate SS became upset and came over to his bed and pulled back his curtains and stoop over him with his fist balled up threatening to hit him if he moved. Resident RR revealed that his roommate SS told him to get up and come to the door so he could knock him down. RR further revealed that roommate SS stepped away and called him white trash and said to go F___ your mother. Resident RR revealed that he reported the incident to the nurse and they did not say anything. He further revealed that he reported the incident to C2-Unit Manager, the Director of Nursing (DON) and the Social Worker. Interview on 12/7/11 at 2:30 pm with the Unit Manager on C2-Hall revealed that resident RR and his roommates can not get along. Interview on 12/8/11 at 8:00 am with the Director of Nursing ( DON) revealed that this allegation with resident RR is under investigation and the residents have been separated. Interview on 12/8/11 at 9:27 am with the Social Worker Service revealed that resident RR gave her a complaint about SS on Monday and wants resident SS moved. The social service worker provided documentation of a grievance/complaint reported dated 12/5/2011 related to this allegation. Interview on 12/8/11 at 11:30 am with the Administrator, who is the facility's Abuse Coordinator, revealed that there was no report filed with the state related to this allegation of verbal and possible physical abuse and that it should have been reported. He further revealed that it is the facility's policy to interview everyone involved and determine if the incident occurred. He also… | 2016-06-01 |
| 8168 | 8168 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2011-12-08 | 287 | E | 0 | 1 | GPWF11 | Based on review of the facility and state agency records and interview with facility staff and state agency staff, the facility failed to ensure eleven (11) Minimum Data Set (MDS) assessment information was transmitted in a timely manner. Finding includes: Review of the State survey agency records revealed that the facility had eleven (11) late or missing MDS assessments as of 12/5/2011. Interview with the MDS staff on 12/7/2011 at 11:00a.m. revealed that they were not aware that they were behind in any transmission of assessments. Staff further revealed that problems have occurred with transmitting since the 3.0 change over. Interview with State agency MDS Transmittal staff on 12/06/2011 at 10:30a.m. reveal the facility had eleven (11) current late or missing assessments. State Agency staff further revealed that the facility had not contacted the state agency regarding the eleven (11) assessments or any problems related to 3.0. | 2016-06-01 |
| 8169 | 8169 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2011-12-08 | 371 | E | 0 | 1 | GPWF11 | Based on observations, staff interview and review of facility policy, the facility failed to store food properly and under sanitary conditions in one (1) of two (2) freezers, in one (1) of two (2) refrigerators and the vent from the dishmachine. Findings include: Observation conducted during tour of the kitchen on 12/05/2011 at 8:15 a.m. with the Kitchen Manager, revealed there were cooked turkey breasts and legs stored in the freezer covered with plastic wrap. The legs had broken through the plastic wrap allowing the meat to be exposed to the cold air, and there was visible freezer burn with ice crystals and dryness on the meat. There was also a pan of sausage stored in the same freezer that was partially covered by plastic wrap that had visible freezer burn with ice crystals and dryness on the sausage. The dietary manager acknowledged that they were stored improperly. The freezer also contained a clear bag of food on a rack that was out of it's original box that had been opened. The bag was not sealed, labeled or dated. Further observations of the refrigerator revealed a carton of grape tomatoes that had visible mold growing on the tomatoes. There was a container of Hummus and cottage cheese that had been partially used with no open date. The freezer contained a clear bag of food on the rack, out of it's original box that had been opened. The bag was not sealed, and it had no label and no date on it. Staff identified it as diced turkey, and discarded it. Review of facility policy reveals that unused portions and open packages must be covered, labeled and dated. Continues observations of the kitchen on 12/05/2011 at 8:15 a.m. with the Kitchen Manager, revealed that the dishwasher had an attached steam vent coming off the machine, where the clean dishes come out of the machine, that extended up into the ceiling. The vent had peeling duct tape around it with brown grease and grime on it. This situation extended from the dishwasher to the ceiling. The vent was also covered with dust balls all the way up to the ceil… | 2016-06-01 |
| 8170 | 8170 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2011-12-08 | 431 | E | 0 | 1 | GPWF11 | Based on observation, staff interviews and review of the facility policy and procedure for Medication Emergency Boxes (E-Box), the facility failed to ensure that one (1) of five (5) refrigerated Emergency Boxes was locked and failed to ensure that medications were not expired in one (1) box located in medication refrigerator on one (1) unit (A-2) of five (5)units. Findings include: 1. Observation of the refrigerated E-Box on A-2 Unit on 12-05-11 at 2:00pm revealed the box was not locked. Review of the medication sign out slips located in the E-Box indicated one (1) of two (2) injectable vials of Ativan had been signed out on 09-19-11 at 8:30am and another one was signed out on 11-22-11 at 12:10pm. Interview with the interim Unit Manager BB on 12-05-11 at 2:00pm revealed each time the E-box was opened, it was supposed to be resealed and the pharmacy was notified to replace the box. Interview with the Director of Nursing (DON) on 12-07-11 at 8:35am revealed the refrigerated E-Box could be opened more than one time before re-ordering but should be re-sealed each time. The pharmacy checks the medication refrigerator monthly for the security of the E-Box, as well as for expired medications and she was not sure why the E-Box was not locked and medications reordered as per procedure. Interview with the Consultant Pharmacist on 12-08-11 at 12:30pm revealed the medication refrigerators were checked monthly and that the E-Boxes should only be opened once, re-sealed, and re-ordered. Review of the facility policy and procedure for Emergency Pharmacy Services and Emergency boxes indicated that after removal of a medication, the E-box was re-sealed, and re-ordered from the pharmacy. 2. Observation of the medication refrigerator on A-2 Unit on 12-05-11 at 2:00pm revealed three (3) multi-dose vials of Purified Protein Derivative (PPD) had been opened and one (1) vail of Influenza vaccine. PPD Vial # 1 was opened 07-02-11, vial # 2 was opened 07-22-11, and vial # 3 was opened 08-01-11. Vial # 2 also had a manufacturer expiration … | 2016-06-01 |
| 8171 | 8171 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2011-12-08 | 463 | D | 0 | 1 | GPWF11 | Based on observations, and resident interviews, the facility failed to ensure that the call lights in resident rooms were functioning properly for two resident rooms (A119A and B120B ) on two (2) of five (5) halls. Findings include: During environmental rounds conducted with the Facility Maintenance Staff CC on 12/6/2011 from 9:00 a.m. to10:00 a.m. revealed that the call light in resident rooms A-119A and B-120B did not work. Interview with resident XX conducted on 12/6/2011 at 9:45 a.m. revealed that the call light has not worked for over a month, and that staff were aware. | 2016-06-01 |
| 8172 | 8172 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2011-11-10 | 157 | D | 0 | 1 | EU8311 | Based on record review, staff interview, and facility document review, the facility failed to immediately consult with the physician of one (1) resident (#46), of thirty-three (33) sampled residents. Findings include: Record review for Resident #46 revealed a Nurse's Notes entry of 9/18/11 at 6:30 a.m. which documented that while in the hallway, the resident had removed the lap buddy from the wheelchair, attempted to ambulate and then fell , striking her head on the wall. This Note documented that the resident had a small knot on the back of her head, and that neurological checks were implemented per protocol. During an interview with the Director of Nursing (DON) conducted on 11/09/11 at 2:28 p.m., the DON presented a copy of the Incident Report referencing this resident's 9/18/11 fall which documented that the physician's office was provided notification of the incident, by facsimile, later in the day on 9/18/11. However, review of the Nursing Home Communications sheet which was sent back to the facility from the physician, via facsimile, in response to this incident revealed that it was it was not signed by the physician until 9/19/11, and was not received by the facility until 12:48 p.m. on 9/19/11. Further review of the medical record revealed no evidence to indicate that facility staff had made any additional attempts to contact the physician for consultation about the resident's fall between the 9/18/11 facsimile to the physician's office and the 9/19/11, 12:48 p.m. facsimile back to the facility from the physician. This resulted in an approximate thirty-one (31) hour delay in physician consultation related to this incident involving the resident falling, striking her head, and sustaining an injury to the head. During an 11/10/11, 9:30 a.m. interview with the DON, the DON stated that facility procedure was to facsimile the physician a notification of a resident accident, but only if there was no injury, and then to await the response back from the physician. She stated there was no telephone call, or addit… | 2016-06-01 |
| 8173 | 8173 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2011-11-10 | 253 | E | 0 | 1 | EU8311 | Based on observation and staff interviews, the facility failed to maintain the residents environment in good repair for holes in walls, flaking ceiling paint and scuffed paint in 13 of 40 rooms, one (1)common bathing area and one (1) of three (3) water fountains. Findings include: During observation of environmental rounds on 11/9/11 at 3:00 p.m. the following was observed: The general shower room on Unit 1 revealed that the sink was loosely mounted to the wall. The soap dispenser was out of soap. No light cover was observed in the shower room for ceiling light. Four spots of small brown matter was observed on the shower floor. Room 7 revealed a hole in the wall to the right of the window at the 10 inch height. Room 9 revealed paint peeling under the wall mirror with additional peeling observed under electrical outlet across from residents beds. Room 10 revealed a scuffed wall on the lower portion beside bed A. Paint was peeling around center ceiling vent. Room 11 revealed rotten wood around the base boards next to the bathroom. Room 12 revealed no soap dispenser in the bathroom. Room 19 revealed paint peeling on the wall paper border at the lower entrance of the bathroom. Room 20 revealed an empty soap dispenser sitting on top of the non functioning paper towel dispenser. Room 30 revealed a hole in the wall where the bathroom door hits the wall. The bathroom door dragged on the floor. Room 34 revealed a hole in the wall to the left side of the window where the closet door knob hits the wall. Room 35 revealed a two inch hole in the wall at the three foot height, between the closet doors. Room 36 revealed no window blinds for the left window and the resident was lying sideways in the bed to avoid the sun coming in the blindless window. Room 38 revealed the entrance door dragged on the floor. Fire Zone 2 revealed no fire extinguisher which is marked to be located on the wall. Interview with the Maintenance Director and Nursing Home Administrator on 9/9/11 at 5:00 p.m. revealed the above items needed correction. | 2016-06-01 |
| 8174 | 8174 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2011-11-10 | 279 | D | 0 | 1 | EU8311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that care plans were developed for two (2) residents (# 71, A) on a sample of thirty three (33) residents. The facility's failure to developed a care plan for resident # 71 related to [MEDICAL CONDITION] medications and was related to physical transfer for resident A. 1. Review of the physician orders [REDACTED]. The use of the antipsychotic medications was assessed on the current annual Minimal Data Set (MDS) assessment dated [DATE] as having been used during the assessment period. Review of the Nursing Home Resident Assessment and Care Screening documentation dated 9/01/11 documented the resident was at risk for adverse effects related to the use of [MEDICAL CONDITION] medication and that a care plan would be developed for that care area, however there was no care plan to address the use of psychoactive medications. Interview with the MDS/Care Plan Coordinator on 11/10/11 at 9:05 a.m. revealed she had failed to developed a care plan that addressed the use of the resident's psychoactive medications. 2. An interview on 11/8/11 at 8:34 a.m. with resident A revealed the resident had a bruise above the left eye and that the resident had a fall earlier in the day while transferring from the bed to the chair with standby assist from two (2) Certified Nursing Assistants (CNA). Record Review reveals the resident was assessed on the Minimum Data Set (MDS) on 4/28/11, 7/9/11, 9/30/11,10/5/11 and 10/25/11 of requiring two (2) person physical assist for transfers. Record review of the resident's care plan revealed the resident was care planned to assist with transfers as needed. The Nurse Aide information sheet reveals the resident requires extensive to total care with transfers. An interview with the MDS Coordinator on 11/8/11 at 4:30 p.m. reveals that based upon the MDS assessments she agrees the care plan was not developed for the resident's transfer needs. | 2016-06-01 |
| 8175 | 8175 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2011-11-10 | 280 | D | 0 | 1 | EU8311 | Based on observation, record review, and staff interview, the facility failed to ensure that the Care Plan of one (1) resident (B), on the total survey sample of thirty-three (33) residents, was revised to reflect the use of a left hand splint. Findings include: Cross refer to F318 for more information regarding Resident B. Record review for Resident B revealed a Minimum Data Set assessment of 3/08/11 in which Section G, Functional Status, Functional Limitation in Range of Motion, indicated the resident had impairment on one side in both the upper and lower extremity, shoulder, elbow, wrist or hand. During an 11/08/11, 4:40 p.m. observation, Resident B was observed to have significant contracture of the fingers on his left hand. No splint was observed to be applied to the resident's left hand at the time of this observation. Record review revealed an Occupational Therapy (OT) note of 6/02/11 which documented that a hand splint had arrived for application to the resident's left upper extremity, and a subsequent OT Evaluation of 10/31/11 documented that after discharge from Skilled OT on 6/15/11, the resident had then been referred to the Restorative Nursing Program with hand-splinting. Additionally, a Physical Therapy (PT) Referral To Restorative Nursing form of 7/08/11 referred the resident to the Restorative Nursing Program, indicating a plan to apply a left hand/wrist splint for 6 hours daily, 3 hours in morning and 3 hours in the afternoon. Review of the resident's current Care Plan revealed an entry of 5/14/11 which identified a problem of the potential for further loss of range of motion related to contractures to resident's left side, including the wrist and fingers, with approaches having been developed to address this problem. However, there was no evidence to indicate that the Care Plan of Resident B had been updated to reflect the OT and PT plans specifying the application of the splint to the resident's left hand, per the Restorative Nursing Program. During an interview conducted on 11/10/11 at 10:11 a… | 2016-06-01 |
| 8176 | 8176 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2011-11-10 | 312 | D | 0 | 1 | EU8311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interview the facility failed to ensure that one (1) resident # 93, of thirty three (33) sampled residents, who had a history of [REDACTED]. Findings include: Observation on 11/08/11 at 9:30 a.m. of resident # 93 walking in hallway being assisted by Certified Nursing Assistant (CNA) HH to the Resident Common Area. The resident was wearing socks on their feet but no shoes. On 11/08/11 at 12:30 p.m. the resident was observed walking in the hallway to the Dinning Area. Again, staff was assisting the resident and the resident had only socks on their feet. Observation the following day, 11/09/11 at 9:00 a.m. revealed resident # 93 was being assisted by CNA HH to ambulate in the hallway. The resident wore only socks on their feet. Record review revealed resident # 93 had a history of [REDACTED]. Interview with Certified Nursing Assistant (CNA) HH on 11/09/11 at 9:35 a.m. revealed the resident had no shoes and that was why the resident was not wearing shoes. A check of the resident's closet, at that time, revealed there were shoes in the resident's closet but further examination reveals they belong to another resident. Additional interview with CNA HH revealed he had not notified the Charge Nurse or the Social Worker (SW) that the resident did not have shoes. An interview with the SW on 11/09/11 at 10:05 a.m. revealed she was not aware the resident had no shoes and that the facility did have shoes available for resident's use. | 2016-06-01 |
| 8177 | 8177 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2011-11-10 | 318 | D | 0 | 1 | EU8311 | Based on observation, record review, staff interview, and resident interview, the facility failed to ensure that one (1) resident (B) who had a limited range of motion, on the total survey sample of thirty-three (33) residents, received treatment, related to the application of a left hand splint per the Occupational Therapy and Physical Therapy plans, to prevent a further decrease in the resident's range of motion. Findings include: Record review for Resident B revealed a Minimum Data Set assessment of 3/08/11 in which Section G, Functional Status, Functional Limitation in Range of Motion, indicated the resident had impairment on one side in both the upper and lower extremity, shoulder, elbow, wrist or hand. Contracture Assessments of 02/03/11 and 8/22/11 both documented that the resident had very limited range of motion (ROM) to left shoulder, left elbow, left wrist, and fingers of the left hand. During an 11/08/11, 4:40 p.m. observation, Resident B was observed to have significant contracture of the fingers on his left hand. No splint was observed to be applied to the resident's left hand at the time of this observation. Record review revealed an Occupational Therapy (OT) assessment of 4/09/11 which indicated a Skilled OT plan to provide treatment including orthotics fitting and training, and an OT note of 6/02/11 documented that a hand splint had arrived for application to the resident's left upper extremity. A subsequent OT Evaluation of 10/31/11 documented that the resident had received therapy from 4/09/2011 to 6/15/11, and had then been referred to the Restorative Nursing Program with hand-splinting. Additionally, a Physical Therapy (PT) Evaluation of 6/16/11 indicated that PT would provide treatment 3 times weekly for 30 days, including orthotics/prosthetics training. A PT Discharge Summary of 7/14/11 documented that PT had discharged the resident, and a PT Referral To Restorative Nursing form of 7/08/11 referred the resident to the Restorative Nursing Program, indicating a plan to apply a left hand/wrist… | 2016-06-01 |
| 8178 | 8178 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2011-11-10 | 323 | E | 0 | 1 | EU8311 | Based on observation, staff and resident interviews, the facility failed to provide a safe environment, specifically, mattresses of sufficient length to accommodate bed frames, toilets securely anchored to the floor, a loose toilet seat and gerichairs with missing side panels for a census of 106 residents and to assist one (1) resident (A) with transfer resulting in a fall without injury which the staff involved failed to report to the charge nurse, DON or Administrator. Findings include: 1. During environmental rounds on 11-9-11 at 3:00 p.m. the following was revealed: Room 3 bathroom toilet seat to be loose and sliding side to side. Room 7 bed b revealed the mattress to be four to six inches shorter than bed frame. Room 9 bed b revealed the mattress was five inches shorter than the frame and footboard had up-raised brackets. Room 13 bed A revealed a mattress six inches short at the headboard. Room 21 revealed a toilet that slides side to side, two inches to each side. Room 26 bed A revealed a mattress that was five inches too short at the headboard. Room 33 bed A revealed a mattress that was short four to five inches at the headboard. Room 35 revealed a loose toilet. Room 39 revealed a loose toilet that rocks side to side and front to back. Random observation revealed two geri chairs with one chair missing the right side panel and one chair missing left and right side panels. The residents who use both chairs have some ability to move about in the chairs. Interview on 11/9/11 at 5:00 p.m. with the Maintenance Director and Nursing Home Administrator revealed the above needed correction. 2. An interview and observation with resident A on 11/08/11 at 8:34 a.m. revealed the resident had a large bruise above the left eye. The resident stated that she had fallen earlier that morning when transferring from the bed to the wheelchair. The resident revealed that Certified Nurse Assistant (CNA) AA was in the room and told the resident to get up but did not assist the resident. The resident revealed that CNA AA was told re… | 2016-06-01 |
| 8179 | 8179 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2011-11-10 | 463 | E | 0 | 1 | EU8311 | Based on observation and staff interview the facility failed to maintain a functioning call light system for one general bathing area. Findings include: During environmental rounds on 9/09/11 at 3:00 p.m. revealed that the call light system was not functioning in the toilet area or shower room in the general bath room on Unit One. The call system did not light up outside of the room nor at the nurse's station. Interview with Maintenance Director and Nursing Home Administrator on 9/09/11 at 3:00 p.m. revealed that he concurred with the above findings. | 2016-06-01 |
| 8180 | 8180 | MAPLE RIDGE HEALTH CARE CENTER | 115543 | 22 MAPLE RIDGE DRIVE S.E. | CARTERSVILLE | GA | 30120 | 2012-03-01 | 157 | D | 0 | 1 | 0W8E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and family interviews, and review of the facility's policy for Assessing Resident Condition and Notification of Change, the facility failed to notify a family member of a change in condition for one (1) resident (X) from a sample of thirty two (32) residents. Findings include: Interview with a family member of resident X on 02-27-12 at 2:45pm revealed she had not been notified when the resident developed and was treated for [REDACTED]. The family member revealed she had to find out from the resident. Review of the nurses' notes dated 02-22-12 at 7:45pm indicated the resident had a productive cough, for two (2) days, with audible wheezing. The physician was notified and ordered a chest x-ray and [MEDICATION NAME] to be given one (1) by mouth every 12 hours. The nurses' note did not reflect that the family member was notified. Review of a nurses note dated 02-23-12 at 10:00am indicated that the results of the chest x-ray was obtained and faxed to the physician. The nurses note did not reflect that the family member had been notified. Interview with the Director of Nursing (DON) on 02-28-12 at 2:00pm revealed that usually the charge nurse would notified the responsible party of any change in the resident's condition within that particular shift. Further interview with the DON on 02-29-12 at 2:45pm revealed that the nurse received the chest x-ray results at 2:30pm on 02-23-12 and thought she had notified the family. Interview with the Licensed Practical Nurse ( LPN )Charge Nurse, BB on 03-01-12 at 10:15am revealed she received the physician's orders [REDACTED]. Review of the facility's policy, Assessing Resident Condition and Notification of Change, indicated the facility staff would notify the resident's legal party or interested party when there was a significant change in the resident's physical, mental, or psychosocial status. Documentation in the medical record should include notification of the legal representa… | 2016-06-01 |
| 8181 | 8181 | CUMMING NURSING CENTER | 115551 | 2775 CASTLEBERRY ROAD | CUMMING | GA | 30041 | 2012-02-02 | 156 | D | 0 | 1 | T1BV11 | Based on observation, record review and staff and resident interview the facility failed to inform two (2) of thirty-four (34) sampled residents of their right to contact the state agency with concerns and grievances. Findings include: Resident F was interviewed on 2/02/12 at 11:00 a.m. as representative for the Resident Council. She stated she had attended every meeting since her admission. A review of the Resident Council Minutes for calendar year 2011 and January 2012 revealed she was a regular participant. She further stated various facility departments are invited to the meetings to discuss relevant issues and address any concerns. She also stated resident rights were not discussed with the except a voting and the ability of the council to meet without staff if the residents so desire. Resident F was not aware of contact information for the State Agency. The Administrator was interviewed on 2/02/12 at 2:00 p.m. and stated resident rights information was provided to family members during the admission process. He further stated this was a very long process and usually does not involve the resident. The facility staff did not cover resident rights at council meetings and did not currently have another means of covering this information after admission except for posters displayed near the lobby on a bulletin board. On 02/2/12 at 1:10 p.m., resident B stated that they did not know that they could contact the State agency for care complaints, and that nobody in the facility had talked to him/her about this. The facility assessed resident B's Cognitive Status Summary Score on their most recent Minimum Data Set (MDS) as 14 (a score of 13-15 is cognitively intact). | 2016-06-01 |
| 8182 | 8182 | CUMMING NURSING CENTER | 115551 | 2775 CASTLEBERRY ROAD | CUMMING | GA | 30041 | 2012-02-02 | 172 | E | 0 | 1 | T1BV11 | Based on observation, record review and staff and resident interview the facility failed to inform four (4) residents (F, E, A and B) of thirty-four (34) sampled residents of services provided by the state Ombudsman Program including contact information. Findings include: 1. During an interview conducted 2/02/12 at 11:00 a.m. resident F stated she was not aware of services provided by the Ombudsman Program and did not know how to contact the facility Ombudsman. 2. Resident E was interviewed on 2/02/12 at 11:15 a.m. and also stated she did not remember being informed by the facility of services provided by the Ombudsman. 3 & 4. On 02/02/12 at 12:30 and 1:10 p.m., residents A and B stated they did not know who the Ombudsman was. Resident A stated they had seen the Ombudsman poster on the wall, but did not pay it any attention as they didn't know what the Ombudsman did. The residents did not recall anybody at the facility talking to them about the Ombudsman. The facility assessed both of the residents' Cognitive Status Summary Scores on their most recent Minimum Data Set (MDS) as 14 (a score of 13-15 is cognitively intact). The Administrator was interviewed on 2/02/12 at 2:00 p.m. and stated resident rights information is provided to family members during the admission process. Information regarding the Ombudsman is not covered at council meetings but posters displayed near the lobby on a bulletin board do include the information. | 2016-06-01 |
| 8183 | 8183 | CUMMING NURSING CENTER | 115551 | 2775 CASTLEBERRY ROAD | CUMMING | GA | 30041 | 2012-02-02 | 225 | D | 0 | 1 | T1BV11 | Based on record review, staff and resident interview, the facility failed to report an allegation of verbal abuse to the state agency for one (1) resident (D) from a sample of thirty four ( 34) residents. Findings include: Interview with resident D on 1/30/12 at 2:22 p.m. revealed that he/she had reported a staff member for screaming at her/him on or about 10/20/11. Allegations of abuse made by residents C and D during interviews conducted during Stage 1 of the survey revealed both residents reported this Certified Nursing Assistant (CNA) as rude and speaking harshly to them. Interview with the Director of Nursing (DON) on 2/02/12 at 11:23 a.m. revealed that she was aware of the allegation of verbal abuse toward resident D. However, she did not investigate and/or report the incident with resident D because the CNA was terminated as a result of the incident. She provided written documentation of the termination notice which revealed the staff member was observed screaming at the resident and was subsequently terminated because this type of abuse to a resident was not tolerated. When asked for written documentation of the investigation of the incident, which occurred 10/21/11, and led to the CNA's termination, she stated she did investigate it, but made no written record of her investigation. She confirmed she did not consider it abuse and did not report it to the State Agency. The DON revealed an internal investigation was conducted but the allegation was not reported to the state agency. The DON further stated she did talk with resident C on 2/01/12, but did not receive any information relevant to the resident's allegation and therefore did not continue her investigation. Review of the facility Abuse Prohibition, Identification and Response and Procedures policy revealed that the facility was to notify the State Agency of any allegations of abuse. Interview with the Administrator on 2/02/12 at 1:30 p.m. confirmed that the State agency should have been notified of the allegation of verbal abuse. | 2016-06-01 |
| 8184 | 8184 | GRACEMORE NURSING AND REHAB | 115554 | 2708 LEE STREET | BRUNSWICK | GA | 31520 | 2012-07-26 | 309 | D | 0 | 1 | K1RN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the correct amount of sliding scale insulin was given as ordered for three times in the month of July 2012 for one resident (#41) in a total sample of 25 residents. Findings include: Resident # 41 had a [DIAGNOSES REDACTED]. There was a 6/17/12 physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. On 6/19/12, the physician increased the sliding scale coverage to fifteen (15) units of [MEDICATION NAME] regular insulin for blood sugar levels over 400. On 6/24/12, the physician ordered that the [MEDICATION NAME] regular insulin dose be increased to twenty (20) units for blood sugar levels over 400. Review of the MAR for July 2012 revealed that the resident had blood sugar levels over 400 on 7/3, 7/6 and 7/14/12. However, the licensed nurse only gave 10 units of [MEDICATION NAME] regular insulin to the resident instead of the 20 units that had been ordered by the physician on 6/24/12. The physician's orders [REDACTED]. In an interview on 7/25/12 at 3:45 p.m., the Director of Nursing and the Clinical Care Coordinator AA confirmed that AA had not changed the resident's MAR (to reflect the most current physician's orders [REDACTED]. Therefore, licensed nursing staff failed to give regular [MEDICATION NAME]as ordered when the resident had blood sugar levels over 400 on 7/3, 7/6 and 7/14/12. | 2016-06-01 |
| 8185 | 8185 | BONTERRA TRANSITIONAL CARE & REHABILITATION | 115555 | 2801 FELTON DRIVE | EAST POINT | GA | 30344 | 2012-03-01 | 278 | D | 0 | 1 | DVKV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to insure that the assessment for one (1) resident (#132) adequately reflected the resident's status from a sample of thirty-three (33) residents. Findings include: Record review for resident #132 revealed a quarterly Minimum Data Set ((MDS) dated [DATE] which assessed the resident as having no impairment of the upper or lower extremities, yet the admission MDS dated [DATE] did assess the resident as having bilateral lower extremities. A nurse's noted dated 11/14/11 indicated the resident's lower extremties were very contracted. Review of the monthly nursing summary dated 11/10/11 revealed bilateral leg contractures. Observation conducted 3/1/12 at 10:00 a.m. revealed the resident lying in bed with bilateral contractures of lower extremties and a pillow was between legs. Interview with Nursing Supervisor AA conducted 02/29/2012 at 11:00 a.m., revealed the resident does have bilateral lower extremity contractures. Interview with the MDS Coordinator BB conducted 03/01/12 at 10:20am, revealed that the MDS dated [DATE] was inaccurate and should have included bilateral lower extremity contractures. | 2016-06-01 |
| 8186 | 8186 | BONTERRA TRANSITIONAL CARE & REHABILITATION | 115555 | 2801 FELTON DRIVE | EAST POINT | GA | 30344 | 2012-03-01 | 279 | D | 0 | 1 | DVKV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the care plan, and staff interviews, the facility failed to develop a comprehensive care plan for Care Area Assessment (CAA) that triggered related to [MEDICAL CONDITION] drug use for one (1) resident (#65) from a sample of thirty-three (33) residents. Findings include: Record review revealed a Minimum Data Set (MDS) for resident #65 dated 01/30/12 which assessed the resident as receiving antipsychotic medications. Review of physician's orders [REDACTED]. The Care Area Assessment (CAA) dated 02/13/2012 indicates that [MEDICAL CONDITION] drug use was triggered and would be addressed in the Care Plan. Review of the care plan dated 02/21/12 revealed no care plan for [MEDICAL CONDITION] medications. Interview with MDS Coordinator CC conducted 02/29/12 at 10:50am. revealed, that after reviewing the CAA, a care plan should have been developed for [MEDICAL CONDITION] drug use. Interview with Nursing Supervisor AA conducted 02/29/2012 at 11:00am revealed the resident is receiving [MEDICAL CONDITION] medications and should have been included in the care plan. | 2016-06-01 |
| 8187 | 8187 | BONTERRA TRANSITIONAL CARE & REHABILITATION | 115555 | 2801 FELTON DRIVE | EAST POINT | GA | 30344 | 2012-03-01 | 318 | D | 0 | 1 | DVKV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed ensure that a decline did not occur for one (1) residents (# 132) with limited range of motion from a sample of thirty- three (33) residents. Findings include: Record review revealed that resident #132 was admitted to the facility 10/22/11 and Minimum Data Set ((MDS) dated [DATE] assessed the resident as having bilateral contractures of lower extremities. Review of the care plan dated 10/22/11 for resident #132 revealed the resident was care planned for limited mobility of lower extremities and requires extensive to total assistance with Activities of Daily Living. Observation conducted 3/1/12 at 10:00 a.m. revealed the resident lying in bed with bilateral contractures of lower extremities and a pillow was between her legs. Review of monthly nursing summary dated 11/10/11 reveals resident has bilateral leg contractures. A nurses' note dated 11/14/11 revealed the resident's lower extremities were very contracted. Interview with Nursing Supervisor AA conducted 02/27/2012 at 11:00 a.m. revealed the resident does have bilateral lower extremity contractures but does not receive Occupational Therapy (OT), Physical Therapy (PT) or Restorative nursing care. Interview with Certified Nursing Assistant (CNA) EE conducted 02/29/2012 at 9:30am revealed the resident does have bilateral lower leg contractures, and remains in bed. EE revealed that the resident is not on the Restorative nursing program. Further interview with Nursing Supervisor AA on 03/01/12 at 10:30am revealed that the resident has not been receiving any therapy that would prevent further decline of her contractures. AA indicated a screening would be conducted and the resident would be place on the Restorative nursing program. | 2016-06-01 |
| 8188 | 8188 | BONTERRA TRANSITIONAL CARE & REHABILITATION | 115555 | 2801 FELTON DRIVE | EAST POINT | GA | 30344 | 2012-03-01 | 371 | D | 0 | 1 | DVKV11 | Based on observations, and review of facility policy, the facility failed to store and discard food properly in the refrigerator and freezer. Findings include: Initial tour of the kitchen was conducted on 2/27/12 at 8:30 a.m. with the Dietary Director, and the Assistant Dietary Director. Observations revealed the following: 1. There was a case of chocolate milk in the refrigerator that was out of date. The use by date was 02/25/2012, staff acknowledged it was out of date and discarded the milk. 2. The freezer contained a large pot covered with plastic wrap that contained mixed vegetables and was dated 01/24/2012. The vegetables had obvious freezer burn with ice crystals, and the contents were dry and cracked. Staff acknowledged that the vegetables had freezer burn and should be discarded. Review of the facility's policy for refrigerator/freezer maintenance indicated that all leftovers must be labeled, dated and discarded after thirty (30) days. | 2016-06-01 |
| 8189 | 8189 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2013-06-06 | 309 | D | 1 | 0 | A7MV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide medications as ordered by the physician to one (1) resident (#1) of four (4) sampled residents. Findings include: The admission orders [REDACTED]. On 4/25/2013 there was an order to discontinue the [MEDICATION NAME] 1 mg at bedtime and start [MEDICATION NAME] 25 mg orally at bedtime for hallucinations. An additional order dated 5/17/2013 documented to discontinue the [MEDICATION NAME] 1 mg orally at bedtime when the supply was depleted and start [MEDICATION NAME] 0.5 mg orally at bedtime for dementia. Review of the Medication Administration Record [REDACTED]. However, review of the May Medication Administration Record [REDACTED]. The [MEDICATION NAME] 1 mg was changed to 0.5 mg as directed by the 5/17/2013 order. Interview with the administrative nursing staff on 6/6/2013 at 3:00 pm revealed that the 5/17/2013 order was the result of a pharmacy recommendation. The pharmacist was not aware of the 4/25/2013 order to discontinue the [MEDICATION NAME] and administer [MEDICATION NAME] because the resident was still receiving the [MEDICATION NAME] 1 mg. The nurse also stated at 4:00 pm that the order written on 4/25/2013 to discontinue [MEDICATION NAME] and administer [MEDICATION NAME] was the order that should have been followed from 4/25/2013 to the present. A new physician's orders [REDACTED]. | 2016-06-01 |
| 8190 | 8190 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 167 | C | 0 | 1 | O3X711 | Based on observation and interviews with a resident and a staff, it was determined that the facility had failed to post a notice of the location and availability of the results of the most recent state inspection. Findings include: During an interview on 1/24/12 at 10:20 a.m., resident A stated that he/she did not know where the most recent state inspection results were posted. On 1/26/12 at 9:30 a.m., the Assistant Director of Nursing (ADON) stated that the results of the most recent state inspection were posted in the activity room. She stated that the notices about their location and availability had been posted on the walls but, someone had taken them down. On 1/26/12 at 9:45 a.m., the results of the most recent state inspection were observed to have been posted on a wall in the activity room. | 2016-06-01 |
| 8191 | 8191 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 225 | E | 0 | 1 | O3X711 | Based on record review and staff interview, it was determined that the facility failed to ensure that the results of the pre-employment background checks were obtained within an appropriate timeframe to use for screening two (2) of the eight (8) employees hired in the last 12 months. Findings include: 1. The facility had obtained the criminal background check results for one certified nursing assistant (CNA) on 11/29/11. However, the CNA did not begin employment at the facility until 1/17/12, 49 days after the results of his/her background check were obtained. 2. The facility had obtained the criminal background check results for one certified nursing assistant (CNA) on 6/28/11. However, the CNA did not begin employment at the facility until 9/12/11, 76 days after the results of his/her background check were obtained. During an interview on 1/26/12 at 1:06 p.m., the Assistant Director of Nursing (ADON) stated that she did not know why the criminal background check results for those employees were not obtained timely. | 2016-06-01 |
| 8192 | 8192 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 241 | B | 0 | 1 | O3X711 | Based on random observations and a staff interview, it was determined that the facility failed to provide five to eight of the residents with non-disposable spoons during lunch. Findings include: During observations of lunch having been served in the main dining room on 1/23/12 at 12:40 p.m., on 1/24/2 at 12:45 p.m. and 1/25/12 at 12:45 p.m., five (5 ) to eight ( 8) residents were observed eating with plastic spoons. In an interview on 1/26/12 at 9:55 a.m., the Dietary Manager stated that the kitchen staff had just told him that they had run out of metal spoons. After surveyor inquiry at that time, the Dietary Manager stated that he was going to buy more eating utensils. | 2016-06-01 |
| 8193 | 8193 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 253 | D | 0 | 1 | O3X711 | Based on observations, it was determined that the facility failed to maintain an environment free of worn wooden finishes on a table and chairs, holes in/or torn vinyl chairs and dusty light fixtures in two day rooms (South and Wing 2), a dining room, and the main entrance. Findings include: Observations were made on 1/25/12 at 3:30 p.m. and on 1/26/12 at 3:26 p.m. South Hall Day Room 1. The finish had been worn off of the arms of seven wooden chairs so, the bare wood was exposed. 2. There were two holes in the seat cushion of an overstuffed, vinyl chair. Both of the vinyl covered arms were torn. There was food debris beneath the seat cushion. 3. Two beds, three wheelchairs and a mechanical lift were being stored in that room. Dining Room 4. Dust and dead bugs were on the inside wall of the fluorescent light fixture that was directly above a dining room table. The light fixture did not have a cover on it. Wing 2 Day Room 5. A bed, a recliner, two mechanical lifts, walk-on scale, and two overbed tables were stored stored in that room. Main Entrance 6. The sections of the finish on the top of the decorative, wooden table had been worn off in so that the bare wood was exposed. | 2016-06-01 |
| 8194 | 8194 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 273 | D | 0 | 1 | O3X711 | **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 complete an initial Minimum Data Set (MDS) for a comprehensive assessment for two (2) residents from a sample of 17 residents. Findings include: The State Agency generated report of the facility's Missing/Late MDS assessments was reviewed with MDS coordinator BB on 1/24/12 at 3 p.m. and on 1/25/12 at 1:15 p.m. The facility failed to complete two residents' required MDS for their comprehensive admission assessments. 1. One resident was admitted to the facility on [DATE]. Staff should have completed his/her MDS within 14 days of the admission (9/13/11), however, staff did not complete it. 2. The admission MDS was due to have been completed for one resident prior to his/her death in the facility on 10/29/10 but, staff did not do it. | 2016-06-01 |
| 8195 | 8195 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 275 | D | 0 | 1 | O3X711 | Based on record review and staff interview, it was determined that the facility failed to complete a comprehensive assessment at least every 366 days for one resident from a sample of 17 residents. Findings include: The State Agency generated report of Missing/Late MDS assessments was reviewed with MDS coordinator BB on 1/24/12 at 3 p.m. and on 1/25/12 at 1:15 p.m. One of the seventeen residents listed in the report did not have his/her comprehensive assessment completed timely as required. One resident had an annual comprehensive MDS completed by staff on 4/24/10. The staff should have completed the next required annual comprehensive assessment in April 2011 but, they did not do it. The facility did not complete a comprehensive assessment of the resident until 5/23/11, when there had been a significant change in his/her condition. | 2016-06-01 |
| 8196 | 8196 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 279 | D | 0 | 1 | O3X711 | **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 develop a comprehensive plan of care to address the level of assistance needed to ensure continence as possible for one resident (B) resident from a sample of 32 residents. Findings include: Resident B was admitted with [DIAGNOSES REDACTED]. According to his/her most recent Minimum Data Set (MDS) assessment dated [DATE], staff had coded him/her as having been continent and requiring the assistance of two people for transfers. They coded the resident as having had diminished cognition and was never understood. His/Her care plan since 11/10/11 addressed the resident's impaired mobility as well as interventions for nursing staff to assist him/her with activities of daily living (ADLs) as needed, and to observe his/her skin during incontinence care as well as to check him/her for incontinence every two hours and as needed. However, the facility failed to develop a comprehensive care plan which addressed the fact that the resident was continent and should be offered the opportunity to go to the bathroom. | 2016-06-01 |
| 8197 | 8197 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 282 | D | 0 | 1 | O3X711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, it was determined that the facility failed to implement the plan of care for one resident (#47) who was at high risk for developing pressure ulcers and to administer pain medication as ordered for one resident (#2) from a total sample of 33 residents. Findings include: 1. Resident #47 was assessed and coded by the facility on the 1/6/12 quarterly Minimum Data Set assessment as at risk for pressure sores and as having a history of pressure sores. The resident had a care plan since 1/11/12 with interventions for nursing staff to apply heel protectors and to float his/her heels as needed, to turn and reposition him/her every two hours and, for a pressure relieving mattress to be on the resident's bed. However, it was observed that the resident remained positioned in the bed positioned on his/her right side and laying on a deflated air mattress on 1/24/12 at 8:15 a.m., 9:05 a.m., 10:20 a.m. and at 11:15 a.m. There were not any pressure relieving device between the resident's knees or feet. Also during those observations, the resident was not wearing any heel protectors and his/her heels were not floated as instructed in the plan of care. Additional observations were made of the resident laying in the bed on a deflated air mattress with his/her heels resting directly on the mattress without wearing any heel protectors on 1/23/12 at 2:45 p.m. and 4:00 p.m., 1/25/12 at 10:00 a.m. and 10:30 p.m. and on 1/26/12 at 9:00 a.m. and 11:20 a.m. During an observation and interview with licensed staff AA on 1/26/12 at 11:20 a.m., he/she confirmed that the air mattress was deflated because it was unplugged from the wall. He/she also stated that the mattress that was underneath the air overlay was not a pressure relieving mattress. See F314 for additional information regarding resident #47. 2. Resident #2 had a care plan since 8/17/11 to address his/her risk for pain and discomfort related to peripheral… | 2016-06-01 |
| 8198 | 8198 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 287 | C | 0 | 1 | O3X711 | **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 complete a Discharge or Death in facility Minimum Data Set (MDS) assessment for 9 residents and failed to electronically transmit a completed 5 day Medicare part A, 14 day Medicare part A and admission MDS for 1 resident, and Discharge or Death in facility MDS assessments to the State for 7 residents from a total sample of 17 residents. Findings include: The State Survey Agency generated report about Missing/Late MDS was reviewed with MDS coordinator BB on [DATE] at 3 p.m. and on [DATE] at 1:15 p.m. Sixteen of the seventeen residents listed in the report did not have Discharge or Death in facility MDS assessments completed within seven days or electronically transmitted to the State as required at least monthly. 1. One resident was discharged from the facility on [DATE]. However, a Discharge assessment was not completed. 2. One resident expired in the facility on [DATE]. However, the Death in facility assessment was not completed and electronically transmitted to the State until [DATE]. 3. One resident was discharged from the facility on [DATE]. However, a Discharge assessment was not completed. 4. One resident expired in the facility on [DATE]. The Death in facility assessment was completed on [DATE] but not electronically transmitted to the State. 5. One resident expired in the facility on [DATE]. However, the Death in facility assessment was not completed and electronically transmitted to the State until [DATE]. 6. One resident was discharged from the facility on [DATE]. However, a Discharge assessment was not completed. 7. One resident had a 5 day Medicare part A assessment completed on [DATE], and a 14 day Medicare part A and admission assessment completed on [DATE]. However, the assessments were not electronically transmitted to the State until after surveyor inquiry on [DATE]. In addition, this resident was discharged from the facility on [DATE]. … | 2016-06-01 |
| 8199 | 8199 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 309 | D | 0 | 1 | O3X711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined that the facility failed to administer a pain relief medication as ordered for one resident (#2) from a total sample of 33 residents. Findings include: Resident #2 had a care plan since 8/17/11 to address his/her pain and discomfort related to his/her [DIAGNOSES REDACTED]. The interventions included that licensed nursing staff were supposed to medicate the resident as his/her physician ordered. The resident had a physician's orders [REDACTED].#3 three times a day as well as a as needed order for [MEDICATION NAME]. Although, there was nursing staff's documentation on the resident's January 2012 Medication Administration Record [REDACTED]. Nursing staff documented on the back of the MAR indicated [REDACTED]. A licensed nurse documented in the 1/20/12 at 7:30 a.m. nurses notes that the pharmacy and (facility) staff had tried to contact the resident's doctor because, the resident had been out of Tylenol #3 since 1/8/12. During an interview on 1/26/12 at 1:45 p.m., the Director of Nursing stated that the resident's attending physician had been unavailable during that time so, the order to refill the prescription for the Tylenol #3 was not signed. Tylenol #3 was not given as ordered from 1/8/12 until the 1/20/12 order to discontinue it. | 2016-06-01 |
| 8200 | 8200 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 314 | D | 0 | 1 | O3X711 | Based on observations, record review, and staff interview, it was determined that the facility failed to ensure that interventions to promote healing and prevent pressure sore development were implemented for one resident (#47), who was at high risk for developing pressure ulcers from a total sample of 33 residents. Findings include: Resident #47 was assessed and coded by the facility on the 1/6/12 quarterly Minimum Data Set assessment as at risk for developing pressure sores and as having a history of pressure sores. The resident had a 1/11/12 care plan with interventions to attempt to prevent pressure sores from developing which included the use of heel protectors and to float heels as needed, for staff to turn and reposition him/her every two hours and for the use of a pressure relieving mattress on his/her bed. When the resident was observed in the bed on 1/24/2012 at 8:15 a.m., 9:05 a.m., 10:20 a.m. and at 11:15 a.m., the right side of the air mattress was not inflated and the resident had been positioned on his/her right side. There was not any pressure relieving device between the resident's knees or feet. Also during those observations, the resident was not wearing heel protectors and his/her the heels were not floated. The resident was observed laying in the bed on a deflated air mattress with his/her heels resting directly on the mattress and without any heel protectors in use on 1/23/12 at 2:45 p.m. and 4:00 p.m., 1/25/12 at 10:00 a.m. and 10:30 p.m. and on 1/26/12 at 9:00 a.m. and 11:20 a.m. During an observation and interview on 1/26/12 at 11:20 a.m., licensed nurse AA confirmed that the air mattress was deflated and said that it was unplugged. He/she stated that the mattress that was underneath the air overlay was not a pressure relieving mattress. | 2016-06-01 |
| 8201 | 8201 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 371 | F | 0 | 1 | O3X711 | Based on observations, staff interview and record review, it was determined that the facility failed to ensure that the temperature in the ice cream freezer was maintained at a level to keep the ice cream frozen. Findings include: On 1/26/12 at 9:45 a.m. and at 1:35 p.m., the temperature in the ice cream freezer was 20 degrees Fahrenheit. The tubs of ice cream and sherbet were soft to touch. Some of the melted ice cream and sherbet had leaked out of their cardboard containers. Four cases of Magic Cup ice cream (dietary) supplement were soft. Inside the case that staff had opened, it was observed that several individual cups had busted and the Magic Cup ice cream was exposed. At that time, the Dietary Manager stated that the box of Magic Cup should have been removed. Review of the staff's documentation on the facility's Refrigeration Temperature log form revealed that the freezer temperature that morning had been a negative 10 degrees Fahrenheit. Staff's documentation of the freezer temperatures for January 2012 ranged from a negative 20 degrees to zero degrees. The Dietary Manager stated at that time that they had not had any problems with the ice cream freezer. | 2016-06-01 |
| 8202 | 8202 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2012-01-26 | 463 | E | 0 | 1 | O3X711 | Based on observation and staff interview, it was determined that the facility failed to maintain a functioning call system in one of four common baths (Wing I Women's Bath) and in the common bathroom for rooms 11 and 12. Findings include: 1. During the tour on 1/23/12 at 11:30 a.m., the call light next to the toilet in the Wing I women's bath would not stay pressed in when pushed and the light did not work. A certified nursing assistant (CNA) verified that the call light did not function properly. It was observed on 1/23/12 at 4:00 p.m., 1/24/12 at 8:00 a.m., 9:40 a.m., 12:05 p.m., 2:00 p.m., and 4:45 p.m., 1/25/12 at 7:15 a.m., 9:50 a.m., 11:30 a.m. and 2:00 p.m., that the light did not turn on when the call light button was pushed. During an interview on 1/25/12 at 2:05 p.m., the maintenance supervisor was unaware of the call light not functioning properly. 2. On 1/23/12 at 4:37 p.m. and on 1/6/12 at 12:05 p.m., the call light in the common bathroom for rooms 11 and 12 did not work. On 1/26/12 at 12:10 p.m., the unit manager for Wing I stated that three of the four residents in those rooms were capable of using the call light in the bathroom. On 1/26/12 at 12:40 p.m., the maintenance supervisor stated that he was unaware that the call light did not work. He stated that he randomly checked the call lights in the residents' rooms once a month but, he did not document which rooms he checked. He stated that he did not know the last time that the all light for the bathroom for rooms 11 and 12 was checked. | 2016-06-01 |
| 8203 | 8203 | SAVANNAH BEACH HEALTH & REHAB | 115633 | 26 VAN HORNE STREET | TYBEE ISLAND | GA | 31328 | 2012-04-19 | 253 | E | 0 | 1 | R4E311 | Based on observation and staff interview the facility failed to maintain the facility in a sanitary, orderly and comfortable manner on two of three (2 of 3) halls and on the smoking patio. Findings include: During observations of resident living areas and common areas of the facility the following items were noted: 1. Several ceiling tiles on the hallways were mismatched, some were cracked and/or sagging, some were stained and some of the support frames were discolored and/or rusty. 2. Air return vent near room 26 was dusty/discolored. 3. Broken cracked light covers noted near room 13 and near the dining room entrance. 4. Several fluorescent lights through the building were of different brightness levels and color spectrum, and some were burned out. 5. There was a cracked toilet seat in room 26. 6. The smoking patio floor had warped, raised boards and protruding screws. 7. One (1) of two (2) patio umbrellas was broken. 8. Both fans on the smoking patio were not working. 9. The fire extinguisher #4 by room 13 did not have a wall sign that was visible to These items were confirmed by the Director of Maintenance and the Director of Housekeeping during a tour made at 8:45 a.m. on 4/19/12. | 2016-06-01 |
| 8204 | 8204 | SAVANNAH BEACH HEALTH & REHAB | 115633 | 26 VAN HORNE STREET | TYBEE ISLAND | GA | 31328 | 2012-04-19 | 280 | D | 0 | 1 | R4E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that a care plan was updated related to hospice care for one (1) resident (# 41) on a sample of twenty-three (23) residents. Findings include: Review of the most recent annual Minimal Data Set (MDS) assessment dated [DATE] assessed resident # 41 as currently being a hospice resident. The record revealed the resident was admitted to hospice on 10/21/11. Review of the record revealed the resident had two (2) sets of care plans, one that was done by the facility that was initiate in August 2011 and the other that was done by hospice and initiated 4/17/2012. The two (2) care plans included some of the same problems but each had different goals and interventions. The facility's care plan did not address the psychosocial and spiritual needs for the resident. The hospice care plan addressed the spiritual needs of the resident but not the care needs. Interview with MDS Coordinator 4/18/12 at 1:29 p.m. confirmed that the care had not been updated to coordinate the care of the resident since he/she was admitted to hospice care. | 2016-06-01 |
| 8205 | 8205 | SAVANNAH BEACH HEALTH & REHAB | 115633 | 26 VAN HORNE STREET | TYBEE ISLAND | GA | 31328 | 2012-04-19 | 282 | D | 0 | 1 | R4E311 | Based on observations and record review, it was determined that the facility failed to implement care plan intervention to measure and document the condition of pressure ulcer for one (1) resident (#27) and to use of a bed alarm for one (1) resident (#17) from a total sample of twenty-three residents. Findings include: 1. Record review revealed resident #27 had a care plan dated 3/15/12 to address an existing pressure ulcer with an intervention for nursing staff to measure and document the condition of skin weekly. Review of the resident's Skin Notes and Nurses Notes revealed no wound measurements documented from 3/14/12 through 4/03/12. 2. Record review for resident #17 revealed that she had fallen out of bed on 3/12/12 but did not sustain any injuries as a result of the fall. Further record review revealed that her attending physician wrote an order on 3/12/12 for the resident to have a bed alarm in place. This was also added as an intervention on the resident's Plan of Care. An observation made on 4/18/12 at 9:30 a.m. revealed that a Certified Nursing Assistant (CNA) assisted the resident to bed. An observation of the resident later at 9:40 a.m. revealed that she was asleep in bed but there was no bed alarm in place. This observation was confirmed at the time of the observation by Licensed Practical Nurses (LPNs) AA and BB. | 2016-06-01 |
| 8206 | 8206 | SAVANNAH BEACH HEALTH & REHAB | 115633 | 26 VAN HORNE STREET | TYBEE ISLAND | GA | 31328 | 2012-04-19 | 314 | D | 0 | 1 | R4E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review the facility failed to ensure that the treatment nurse thoroughly assessed and document the findings of a pressure ulcer weekly to include date, stage, length and width, depth, drainage, odor and progress, failed to provide treatment as ordered and failed to observe proper infection control precautions for one resident (#27) during a dressing change from a sample of twenty- three residents. Findings include: Record review for resident #27 revealed that on 3/14/12 a stage III pressure ulcer to the left heel was identified. Documentation from 3/14/12 through 4/03/12 failed to include assessment and the condition of the pressure ulcer. The Treatment Record recorded treatment as being conducted every other day for the period of time from 3/23/12 through 3/31/12. Review of the physician orders, for that period of time, revealed treatments were ordered to be conducted daily. Review of the Skin Notes revealed documentation on 4/03/12 of ulcer measurements, 5 centimeters (cms) by 7.5 cms by 0.1 cms, but in the Nurses Notes the size was documented as 4 cms by 7.7 cms by 0.1 cms. Skin Notes dated 4/11/12, included documentation of the resident's left heel as having 80% eschar and 5% slough. Nurses Notes for this date documented 80% eschar and 10% slough. Observation of resident #27's treatment to the left heel pressure ulcer on 4/18/12 revealed licensed nursing staff assisting with the treatment to picked up a foam wedge off of the floor and placed it under the resident's legs. The Treatment Nurse (TN) provided the treatment as ordered, but while securing the dressing in place dropped the roll of tape on to the floor. TN picked tape up off the floor and continued to use the same roll of tape to secure the dressing. TN then placed the roll of tape back on the clean field next to the 4x4s used later to cleanse an open area on this resident's buttock. Review of the facility's policy and procedure fo… | 2016-06-01 |
| 8207 | 8207 | RETREAT, THE | 115675 | 898 COLLEGE ST | MONTICELLO | GA | 31064 | 2012-03-29 | 441 | D | 0 | 1 | MV1G11 | Based on observation, staff interviews and record review the facility failed to ensure that appropriate infection control practices were followed related to medication administration for one (1) resident (#31) from a sample of twenty-eight (28) residents. Findings include: Observation on 3/27/12 at 2:34 p.m. during medication administration for resident #31 revealed Licensed Practical Nurse (LPN) BB disconnected the tube feeding and placed the uncovered connector onto the resident's brief while checking placement then reconnected the tubing to the connector. Continued observation revealed that the nurse then prepared the medication and water flushes, disconnected the connector from the feeding tube, allowed the connector to drop onto the resident's brief and the reconnected the feeding tube to the connector after the medication was administered. Interview with LPN BB on 3/27/12 at 11:50 a.m. revealed that the tubing connector should have been covered and not allowed to drop on the resident's brief. Interview with the Director of Nursing (DON) on 3/27/12 at 3:30 p.m. revealed it is poor technique to allow the tubing connector to rest on the resident's brief. | 2016-06-01 |
| 8208 | 8208 | RETREAT, THE | 115675 | 898 COLLEGE ST | MONTICELLO | GA | 31064 | 2012-03-29 | 514 | D | 0 | 1 | MV1G11 | Based on record review and staff interview, the facility failed to ensure that pressure sore documentation accurately reflected residents current medical condition for one (1) resident (#30) out of a sample of twenty-eight (28) residents Findings include: Review of the Wound/Skin Healing Record for resident #30 dated 12/30/11 revealed that the resident had a stage two (2) sacral and coccyx pressure ulcer with a red wound bed measuring 7 centimeters (cms) by 6.2 (cms). Continued review revealed that on 1/6/12, the wound bed was described as eschar, measured at 8cms by 7cms and was still considered a stage 2 pressure ulcer Review of the Minimum Data Set 3.0 dated 1/10/12 revealed that resident was admitted with an unstageable pressure sore. Interview with Licensed Practical Nurse (LPN) AA, on 3/28/12 at 11:10 a.m.,revealed that a pressure ulcer that has eschar, is an unstageable ulcer and you measure only the eschar. Continued interview revealed that on admission the physician said that the pressure sore was a stage two (2) and believed it was a blood blister; however, according to her training, she would have called the pressure sore unstageable, but did not question the physician. Interview with the Director of Nursing (DON) on 3/28/12 at 11:45 a.m., she concurred that the treatment nurse should have documented the pressure sore on 1/6/12 as unstageable due to the wound bed being eschar. | 2016-06-01 |
| 8209 | 8209 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2012-11-01 | 279 | D | 0 | 1 | GCPU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interview, it was determined that the facility failed to develop a care plan for one resident (#68) with a limited range of motion and for one resident (A) with impaired vision from a total sample of 39 residents. Findings include: 1. Resident # 68 had [DIAGNOSES REDACTED]. Licensed nursing staff coded the resident on the 5/21/12 and 8/17/12 quarterly Minimum Data Set (MDS) assessments as having functional limitations to both of his/her upper and lower extremities. Staff coding on those MDS forms indicated that the resident was not being provided range of motion exercises or restorative nursing services. During an interview on 10/29/12 at 3:05 p.m., licensed nurse DD stated that resident #68 had contractures of his/her upper and lower extremities. The resident was observed lying in bed in a fetal position with both legs drawn up on 10/30/12 at 10:44 a.m. However, staff did not include the resident's identified problem of limited range of motion on his/her care plan. See F318 for additional information regarding resident #68. 2. Resident A had [DIAGNOSES REDACTED]. The nursing staff coded the resident on his/her 8/15/12 annual Minimum Data Set ( MDS) assessment as having moderately impaired vision and no corrective lenses. Staff documented on the Care Area Assessment (CAA) Summary form that the resident's visual function triggered being care planned to address the problem. However, a review of the resident's care plan revealed that, as of 10/30/12, the staff had not developed a care plan to address the resident's vision needs. Staff developed a care plan to address the resident's vision problem after surveyor inquiry on 10/31/12. See F 313 for additional information regarding resident A. | 2016-06-01 |
| 8210 | 8210 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2012-11-01 | 313 | D | 0 | 1 | GCPU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with a resident and staff, and record reviews, it was determined that the facility failed to provide assistance for one resident (A) to obtain services needed to maintain his/her vision. Findings include: During an interview on 10/31/12 at 11:30 a.m., resident A stated that he/she had a problem with vision in his/her right eye which had gotten worse. Resident A said that he/she had not been to the eye doctor for a long time. He/she stated that he/she had to quit playing Bingo because, he/she could not see. Resident A had [DIAGNOSES REDACTED]. Staff coded the resident on the 8/15/12 Minimum Data Set ( MDS) for his/her annual comprehensive assessment as having moderately impaired vision and no corrective lenses. Staff documented on the Care Area Assessment (CAA) summary form that the resident's visual function triggered being care planned and would be addressed in the care plan. However, a review of the resident's care plan revealed that as of 10/30/12 it did not address his/her vision needs. Staff developed a care plan to address the resident's visual needs after surveyor inquiry on 10/31/12. According to the 5/16/12 Social Service Director's (SSD) progress notes, the resident's vision had declined so, he/she was unable to see large print letters, words or pictures. There was a 5/17/12 activity note that the resident could not play Bingo anymore and had gotten upset because he/she could not get the numbers right. During an interview on 10/31/12 at 12:45 p.m., the SSD stated that the resident was last seen by an ophthalmologist in May, 2011 for the treatment of [REDACTED]. She provided a progress note about that visit with documentation that the ophthalmologist would return as needed. She said that she did not know why the resident no longer played bingo but, she thought that it was because he/she needed assistance with the cards and numbers. She said that there were not enough volunteers available to help the … | 2016-06-01 |
| 8211 | 8211 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2012-11-01 | 318 | D | 0 | 1 | GCPU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record reviews, it was determined that the facility failed to provide range of motion exercises for two residents (#68 and #2) from a sample of six residents with limitations in range of motion from a total sample of 39 residents. Findings include: 1. Resident # 68 had [DIAGNOSES REDACTED]. The nursing staff coded the resident on his/her 5/21/12 and 8/17/12 quarterly Minimum Data Set (MDS) assessments as having functional limitations in both of his/her upper and lower extremities (arms and legs). However, staff did not develop a care plan for the resident which included his/her problem of having limited range of motion. During an interview on 10/29/12 at 3:05 p.m., licensed nurse DD said the resident had contractures of his/her upper and lower extremities. The resident was observed on 10/30/12 at 10:44 a.m. to have been lying in bed in the fetal position. On 10/31/12 at 1:20 p.m., while the resident was lying in bed, Certified Nursing Assistant (CNA) AA attempted to extend the resident's legs but was not able to extend them more than 90 degrees. Although the CNA extended the resident's right arm to almost 180 degrees, the resident grimaced when she attempted to extend the resident's left arm. Licensed nurse DD stated that the CNAs, who were assigned to give residents' their care, had each resident's care information documented in the Activity of Daily Living (ADL) notebook . She said that the CNAs signed off in that notebook to record the care provided each day for that resident. There was an entry printed on resident's October ADL form ADL Information: Range of motion (ROM) - splint application. See Restorative book. There was no documentation for any day in October, 2012 to indicate that a CNA had signed off to record having provided ROM or splint application for the resident. There was not an assignment sheet for resident #68 in the restorative nursing services notebook to indicate that restorati… | 2016-06-01 |
| 8212 | 8212 | CARLYLE PLACE | 115680 | 5300 ZEBULON ROAD | MACON | GA | 31210 | 2012-07-31 | 314 | D | 0 | 1 | DIQL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record reviews it was determined that the facility failed to adequately assess a pressure ulcer for one resident (#25) from a sample of twenty seven (27) residents. Findings Include: Review of the clinical record for resident # 25 revealed that the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 6/21/12 the nurses's notes revealed that a Certified Nursing Assistant (CNA) identified a dark area on the right heel and a skin assessment completed on 6/21/12 recorded the area as a stage 1 pressure ulcer on the right heel. However, there were no measurements of the wound noted. Continued review revealed that skin assessments were completed on 6/27/12 and 7/8/12 and continued to identify the area on the right heel as a stage 1 pressure ulcer but there were no measurements of the wound. Review of the thirty (30) day Minimum Data Set (MDS) assessment dated [DATE], assessed the resident as having a deep tissue wound to the right heel, however the computerized 7/21/12 skin assessment noted that the resident had a stage 1 wound to the right heel. There were no measurements of the wound. Interview with the Director of Nurses (DON) on 7/31/12 at 9:15 a.m. revealed that she usually stages the pressure ulcers and that the nurses complete a paper weekly skin assessment of all wounds that include the measurements. Review of the wound notebook with the DON revealed there were no completed skin assessments in the notebook for resident #25. Continued interview revealed that she had identified the resident's wound as a deep tissue wound with the Minimum Data Set nurse, prior to the completion of the 7/12/12, thirty (30) day assessment and that the computerized skin assessment was incorrect. According to the U.S. Department of Health and Human Services Clinical Practice Guideline, Number 15: treatment of [REDACTED]. Pressure sores should be reassessed at least weekly in order to monitor the progress or deterioration of t… | 2016-06-01 |
| 8213 | 8213 | HEARDMONT NURSING HOME | 115685 | 1043 LONGSTREET ROAD | ELBERTON | GA | 30635 | 2012-05-03 | 272 | D | 0 | 1 | OM7011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and family interview the facility failed to accurately assess the dental status for one (1) resident, A of twenty-eight (28) sampled residents. Findings include: Observation of resident A on 4/30/12 at 3:51 p.m. revealed the resident's front teeth were broken and chipped. Interview with a family member on 5/01/12 at 8:45 a.m. revealed the resident had broken teeth when admitted to the facility. Review of the Annual MDS dated [DATE] revealed the resident had no dental concerns identified, including no broken teeth. Interview with the MDS Coordinator on 5/03/12 at 10:15 a.m. revealed she was not aware that resident A had broken teeth. | 2016-06-01 |
| 8214 | 8214 | HEARDMONT NURSING HOME | 115685 | 1043 LONGSTREET ROAD | ELBERTON | GA | 30635 | 2012-05-03 | 412 | D | 0 | 1 | OM7011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and family interview the facility failed to accurately assess the dental status and provide available dental services for one (1) resident A of twenty-eight (28) sampled residents. Findings include: Resident A was observed on 04/30/12 at 3:51 p.m. The resident's two front teeth were broken and noticeably shorter than the remaining upper teeth. A family member was interviewed on 5/01/2012 at 8:45 a.m. and stated the resident's teeth had gradually worn away or become chipped and broken over a period of years Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed no dental issues were identified. Review of the current Care Plan revealed the resident had a history of [REDACTED]. The broken teeth were not documented on the Care Plan. Licensed Practical Nurse (LPN) AA was interviewed on 5/03/12 at 12 noon. She has cared for the resident since admission. She stated his teeth have been broken since admission. The MDS Coordinator was interviewed on 5/03/12 at 10:15 a.m. revealed she was not aware of the resident's dental status. She included information that the facility did not perform annual dental assessments and although a dental service did come routinely, resident A had not been seen. Licensed Practical Nurse (LPN) CC was interviewed on 5/03/12 at 10:45 a.m. and stated the resident has not had a dental assessment done. | 2016-06-01 |
| 8215 | 8215 | MEDICAL MANAGEMENT HEALTH AND REHAB CENTER | 115692 | 1509 CEDAR AVE | MACON | GA | 31204 | 2013-06-05 | 469 | D | 1 | 0 | W7H011 | Based on resident and staff interview, observation, record review the facility failed to ensure that the residents lived in a pest free environment in two (2) resident rooms (A and B) on one (1) of four (4) Halls (B Hall) . Findings include: Resident interviews with two of four interviewable residents (A, B) revealed that Resident A stated that he heard other residents talk about mice running around the facility. Resident Bstated that he saw a small mouse about three weeks ago come across the hall into his room that he shared with resident A. Residents A and B lived on the B Hall. During an observation at 6/5/13 at 3:15 p.m., with the Maintenance Supervisor and Director of Nursing, mouse droppings were noted on top of a white blanket in resident A's personal bag During an observation on 6/5/13 at 3::25 p.m. with the Maintenance Supervisor, a mouse trap was noted in the closet of Resident B. An interview with the Maintenance Supervisor on 6/5/13 at 3:15 p.m., revealed that he set out mouse traps in different closets in the facility and that the facility's exterminator came out monthly to treat the facility for pests, etc. Record review of the last two month's pest control service records (April and May 2013) revealed the facility had been checked for pests in the facility and had a monthly contract with a local pest control company. | 2016-06-01 |
| 8216 | 8216 | TWIN FOUNTAINS HOME | 115709 | 1400 HOGANSVILLE ROAD | LAGRANGE | GA | 30240 | 2012-02-16 | 252 | B | 0 | 1 | H9NQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews the facility failed to ensure that the environment was free of odors for one (1) of two (2) resident day area, the main lobby and main hallway outside the main dining room, visitors bathroom and administrator's office for four (4) of four (4) days of the survey. Finding includes: Upon entrance into the facility on [DATE] at 9:30 a.m. a strong urine odor was noted in the lobby, main hallway and the North Wing. Further observations on 2/13/12 at 12:30 p.m., during lunch, revealed pervasive odor of urine and feces in the day area of North Wing. Continued observations on 2/13/12 at 1:30 p.m., 2:30 p.m.and 3:30 p.m. and 4:30 p.m. revealed this odor remained on the North Wing day area, the lobby and main hallway near the Administrator's office, visitor's bathrooms and main dining room. On 2/14/2012 at 7:30 a.m. strong urine odor was noted upon entering the building in the lobby, hallway near the visitor's bathrooms and Administrator's office. Further observations at 8:00 a.m., 8:30a.m., 9:00 a.m., 9:30a.m, 11:30 a.m., 2:00 p.m., and 4:00 p.m. revealed a strong urine odor on the North Wing, the main hallway near visitor's bathrooms, Administrator's office and main dining room. Observation on 2/15/12 at 8:00 a.m., 10:15 a.m., 12:30 p.m. and 4:00 p.m. revealed a strong foul odor in the main lobby, the main hall near the administrator's office, the visitor's bathroom and near the resident's dining room. Observation on 2/16/12 at 8:00 a.m. revealed a strong foul odor in the main lobby, main hall near the administrator's office, in front of the visitor's bathroom and near the resident's dining room. Interview with the Administrator on 02-16-12 at 9:30am revealed she had spoken with the plant engineer and arranged to have a moisture test performed on Monday 02-20-12. | 2016-06-01 |
| 8217 | 8217 | TWIN FOUNTAINS HOME | 115709 | 1400 HOGANSVILLE ROAD | LAGRANGE | GA | 30240 | 2012-02-16 | 253 | B | 0 | 1 | H9NQ11 | Based on observations and staff interviews, the facility failed to ensure orderly interior for one (1) resident room (room 47) and one (1) of two (2) common baths. Finding Includes: 1. Observation conducted 2/16/12 at 9:10 a.m. with the Housekeeping Supervisor revealed that in room 47 the resident in the A bed was laying on a low bed. The bed was against the wall with a hole appropriately three (3) inch wide and six (6) inch long under the light with the sheet rock exposed. 2. Observation conducted on 2/16/2012 at 9:30 a.m. with Maintenance Director in the North Wing common shower revealed a missing wall tile at the bottom corner of the shower. Interview with Maintenance Director during this observation revealed he will immediately replace the tile before any other resident uses the shower. | 2016-06-01 |
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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 );