cms_GA
Data source: Big Local News · About: big-local-datasette
161 rows where "filedate" is on date 2016-07-01
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7965 | 7965 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2012-03-15 | 157 | D | 0 | 1 | FF8U11 | **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 consult with the physician about significant eye drainage for one resident (B) from a sample of 33 residents. Findings include: It was observed on 03/13/2 at 3:50 p.m. that resident B had yellow matter in his/her eyes. During observations on 03/14/12 at 8:15 a.m. and during breakfast at 9:18 a.m. with the CNA BB, who had bathed the resident, and at 11:00 a.m., resident B had yellow matter in his/her left eye which covered the eyelashes. Both of his/her eye areas had redness and puffiness and the inner left eyelid was red. During an interview on 3/14/12 at 12:00 p.m., the charge nurse BB said that she had administered the 9:00 a.m. medications to the resident that morning. LPN BB confirmed that she had not been aware of the drainage in the resident's eyes prior surveyor inquiry. Documentation in resident B's medical record revealed the licensed nursing staff had identified that there was yellow drainage coming from the resident's left eye and at 10:30 p.m. clear drainage was running from it and it was cleaned with a warm cloth. The licensed nurse documented that she would inform the oncoming nurse of the resident's status. However, there was not any evidence that the resident's eye drainage had been reported to the oncoming nurse and that the physician had been consulted. After surveyor inquiry, the physician was consulted and ordered antibiotic eye drops for a [DIAGNOSES REDACTED]. During an interview on 3/15/12 at 8:30 a.m., the Assistant Director of Nursing stated that notifications of changes (in residents' conditions) should be immediately reported to the physician. | 2016-07-01 |
| 7966 | 7966 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2012-03-15 | 253 | E | 0 | 1 | FF8U11 | Based on observations, it was determined that the facility failed to maintain a clean shower bed in one of two common women's showers (West 1) and, one clean dryer vent of the six dryer vents located in the laundry. Findings include: Observations were made on 3/12/12 between 11:45 a.m. and 12:30 p.m., on 3/13/12 at 7:20 a.m., and on 3/14/12 from 1 p.m. to 2 p.m. 1. On 3/14/12 at 1:00 p.m., the underside of the shower bed, which was being used in the West 1 women's common shower, had unidentifiable debris from previously being used. 2. On 3/14/12 at 1:20 p.m., the fourth of six clothes dryers had a thick layer of lint on the exhaust vent. Lint had accumulated on the floor behind it. During an interview on 3/14/12 at 2:00 p.m., the Administrator stated that the vent should have been cleaned when the other vents were cleaned. The following observations were made during the initial tour on West wing on 3/12/12 between 11:45 a.m. and 12:30 p.m., and/or on 3/13/12 at 7:20 a.m 3. The edges of the floor in room 135 had a heavy build up of dirt and debris. A six inch long piece of cobase was missing next to the air conditioning unit. There was a hole in the drywall on the left side of the unit. An approximately 9 inch section of cobase had pulled away from the wall. The dry wall was bubbled and peeling on the right side of the unit. 4. The feeding pump in room 136 A was infusing at a rate of 35 cubic centimeters per hour onto the floor and the base of the feeding pump pole. The resident was not in the room. During a subsequent observation on 3/13/12 at 7:20 a.m., there was a large dried area of formula on the base of the feeding pump pole and on the floor beneath it. | 2016-07-01 |
| 7967 | 7967 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2012-03-15 | 279 | D | 0 | 1 | FF8U11 | Based on record review and interviews with a resident and staff, it was determined that the facility failed to provide the services to help one resident (A) maintain their current vision status from a total sample of 33 residents. Findings include: Resident A was assessed and coded by staff on his/her 1/23/12 annual Minimum Data Set (MDS), 10/25/11 quarterly MDS, and the 8/1/11 quarterly MDS assessments with impaired vision and having corrective lenses. Staff assessed the resident and documented his/her 1/23/12 Care Area Trigger (CAT) worksheet for Visual Function that the resident had decreased visual acuity, had glasses and wore them when he/she preferred. They also noted that a care plan would be developed for the resident's visual function. However, review of the clinical record revealed that staff had not developed a care plan to address the resident's impaired vision. During an interview on 3/14/12 at 3:15 p.m., the MDS coordinator confirmed that a care plan had not been developed that addressed the resident's impaired vision. At that time, the MDS coordinator said that she had added an intervention for staff to provide reading material with large print to the resident. See F313 for additional information regarding resident A. | 2016-07-01 |
| 7968 | 7968 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2012-03-15 | 313 | D | 0 | 1 | FF8U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with a resident and staff, it was determined that the facility failed to provide the services to help one resident (A) maintain their current vision status from a total sample of 33 residents. Findings include: Resident A had [DIAGNOSES REDACTED]. He/She was assessed and coded by staff on the 1/23/12 annual Minimum Data Set (MDS), 10/25/11 quarterly MDS, and the 8/1/11 quarterly MDS assessments to have impaired vision and not to have corrective lenses. However, staff documented on the 1/23/12 Care Area Trigger (CAT) worksheet for Visual Function that the resident had decreased visual acuity, had glasses (corrective lenses) and wore them when he/she preferred. Staff also noted that a care plan would be developed for the resident's visual function but, they did not develop one. During an interview on 3/14/12 at 3:15 p.m., the MDS coordinator confirmed that a care plan had not been developed to address the resident's impaired vision. At that time after surveyor inquiry, the MDS coordinator stated that she had added an intervention for staff to provide large print reading material for the resident. In an interview on 3/14/12 at 3:15 p.m., resident A stated that he/she was unable to read the closed captioning on his/her television because the words were too small. The resident stated that he/she wished that he/she could see (it) again. The resident said that he/she had lost his/her glasses three years ago. However, he/she did not replace them because they cost too much. During an interview on 3/14/12 at 10:45 a.m., the Social Services Director explained that social services staff assessed a resident's vision during the MDS assessments and if an impairment was noted then, they were supposed to make a referral to the eye doctor was supposed. She said that the eye doctor, who came to the facility, made reasonably priced glasses. She said that during her assessment of the resident in January, 2012, he/she had to h… | 2016-07-01 |
| 7969 | 7969 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2012-03-15 | 441 | D | 0 | 1 | FF8U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and review of the facility's Blood Sugar Monitoring policy and procedure, it was determined that the facility failed to ensure that one llicensed nurse followed standard precautions to decrease the spread of infection while obtaining one resident's (#20) blood sugar level and administering his/her insulin injection from a sample of 60 residents observed during the Medication Pass observation. Findings include: The facility's Blood Sugar Monitoring policy and procedure documented that a used lancet was to be discarded in a container of used needles. According to the Long Term Care Guide for Infection Control and a standard precaution to prevent cross contamination, staff were supposed to wear gloves in all situations where staff have the potential to come in contact with blood or body fluids. According to the Center for Disease Control guidance, this would include during blood glucose monitoring. However, a licensed nurse failed to wear gloves during an injection for resident #20. On 3/14/12 at 3:54 p.m., licensed nurse LL used a lancet to obtain a blood sample from resident #20 to check his/her blood sugar level. Although there was a container on the medication cart for staff to use to dispose of contaminated sharp items such as used needles and lancets, licensed nurse LL did not use it. After obtaining the blood sample, the licensed nurse balled up the used cotton ball, alcohol pad, glucose testing strip and lancet in his/her gloves and disposed of them in the trash can in the resident's room. The licensed nurse gave the resident an injection of [MEDICATION NAME]in his/her abdomen at 4.30 p.m. However, licensed nurse LL failed to apply gloves on his/her hands prior to administering the insulin injection. | 2016-07-01 |
| 7970 | 7970 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2012-03-15 | 455 | E | 0 | 1 | FF8U11 | Based on observations and staff interview, it was determined the facility had failed to ensure that the lighting at two (2) of five (5) the emergency exit doors was operational. Findings include: It was observed during the environmental tour on 3/14/12 between 12:30 p.m. and 12:40 p.m., and on 3/15/12 at 8:40 a.m. that there was not a light bulb in the exterior light fixture for the emergency fire doors numbered 4 and 19. During the observations on 3/14/12, the assistant administrator explained that those emergency lights were supposed to turn on when the fire alarm sounded. In an interview on 3/14/12 at 2:00 p.m., the administrator said that it was expected that the emergency lighting would be kept in workable condition. However, facility staff was not maintaining the lighting fixtures at emergency exit doors #4 and #19 in a manner that ensured the emergency power system was functional and that those exits would be lighted in case of a fire or other emergency. | 2016-07-01 |
| 7971 | 7971 | EFFINGHAM CO EXTENDED CARE FAC | 115106 | 459 HIGHWAY 119 S | SPRINGFIELD | GA | 31329 | 2012-02-02 | 328 | D | 0 | 1 | UBGT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interview the facility failed to ensure that oxygen was supplied by nasal cannula for two (2) residents (A and #81) of thirty (30) sampled residents, as prescribed by the physician's orders [REDACTED].>Findings included: 1. Resident A had multiple [DIAGNOSES REDACTED]. The resident also had a physician's orders [REDACTED]. Observation and interview with resident A on 1/31/12 at 9:00 a.m. revealed the resident had a nasal cannula, in correct placement, with tubing connected to a wall mounted oxygen flowmeter with a humidifier bottle attached. The resident had some shortness of breath and labored breathing while talking and the surveyor noted that there were no bubbles in the humidifier (water) bottle. The resident complained of having trouble breathing while eating breakfast. The respiratory therapist administered a nebulizer treatment at 7:00 a.m. that morning. At 9:15 a.m. Licensed Practical Nurse (LPN) II checked the resident's oxygen at surveyor's request. LPN II stated the oxygen was not on and she was unable to turn it on. LPN II then asked LPN DD to assist her, and LPN DD turned the oxygen on to deliver oxygen at two (2) liters per minutes. Review of respiratory Administration Records revealed the resident received a nebulizer treatment at 6:30 a.m. on 1/31/12. An interview with the Director of Rehabilation GG on 1/31/12 at 3:00 p.m. revealed that she could not account for why the resident's was without oxygen from 7:00 a.m. until 9:00 a.m. and that her expectations were that her staff would ensure that the oxygen was working properly before leaving the resident's room. 2. Review of the most recent annual Minimal Data Set assessment dated [DATE] assessed resident #81 as needing oxygen therapy. Review of the current January 2012 physician orders [REDACTED]. During observation on 1/31/12 at 10:35 a.m. and 11:05 a.m., resident #81 was sitting in the dining room with oxygen on via a na… | 2016-07-01 |
| 7972 | 7972 | EFFINGHAM CO EXTENDED CARE FAC | 115106 | 459 HIGHWAY 119 S | SPRINGFIELD | GA | 31329 | 2012-02-02 | 371 | E | 0 | 1 | UBGT11 | Based on observation and staff interview the facility failed to ensure that the temperature of foods served to residents was held at or above the level necessary to prevent potential foodborne illnesses. This affected all residents on oral alimentation (census = 105). Findings include: During a measurement of temperatures of food items held on the steamtable and being served to residents at the lunch meal on 2/01/12 at 12:15 p.m., the following items were found to be below the minimum safe temperature level of one hundred and thirty-five degrees Fahrenheit (135 F) : -Fried chicken at 128 degrees F -Baked Chicken at 113 degrees F The above observation was made using the food service department's digital thermometer and was confirmed by the facility's Food Service Director. | 2016-07-01 |
| 7973 | 7973 | EFFINGHAM CO EXTENDED CARE FAC | 115106 | 459 HIGHWAY 119 S | SPRINGFIELD | GA | 31329 | 2012-02-02 | 441 | D | 0 | 1 | UBGT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interview the facility failed to ensure that respiratory therapy oxygen concentrator filters were clean and that disposable and/or reusable equipment was stored in a sanitary manner when not in use for three (3) residents (#21, #41 and #81) of thirty (30) sampled residents. Findings include: 1. Observation 1/31/12 at 9:00 a.m. for resident #21 revealed the resident's reusable Continuous Positive Airway Pressure (C-PAP) mask was resting on top of the C-Pap machine with a heavy build up of dried debris around the inside of the mask. The mask was not in a protective bag. Observation 2/01/12 at 8:18 a.m. revealed the resident's C-PAP reusable mask was resting on top of the C-Pap machine with a heavy build up of dried debris around the inside of the mask and is not in a protective bag. 2. An observation on 2/01/12 at 10:36 a.m. of resident #41, who is on continuous oxygen, revealed the resident was not in the room and the resident's nasal cannula was lying on the resident's bed. An interview with the Chief Operating Officer, a Respiratory Therapist, BB on 2/1/12 at 1:05 p.m. revealed the facility does not have a policy for storing of nasal cannula's or C-Pap mask when not in use. 3. Review of the current January 2012 physician orders [REDACTED]. Observation in this resident's room on 2/1/12 at 7:37 am and again at 8:17 am revealed the oxygen concentrator filters were filled with lint and dust. The oxygen was tubing rolled up and hanging across the oxygen concentrator with the end that went into the nose lying on the floor. Interview with Licensed Practical Nurse AA on 2/1/12 at 8:19 am confirmed the oxygen concentrators filters were dirty and that the oxygen tubing should be secured in a plastic bag. Further interview on 2/01/12 at 12:55 p.m. with the Chief Operating Officer/Respiratory Therapist BB revealed when nasal cannulas are not in use the tubing should be stored in a plastic bag, and that the… | 2016-07-01 |
| 7974 | 7974 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2013-07-02 | 315 | D | 1 | 0 | YELP11 | **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 an indwelling urinary drainage catheter was changed as ordered for one resident (#2) of four (4) sampled residents with indwelling catheters. Findings include: Record review for Resident #2 revealed a physician's orders [REDACTED].#20 Foley catheter to be changed monthly and as needed. Review of Resident #2's record on 07/02/13 that included nurse's notes, treatment sheets, and the Medication Administration Records revealed that the last time the Foley catheter was changed was on 5/10/13, as documented on the May 2013 Medication Administration Record. An interview with the Director of Nursing (DON) on 7/2/13 at 5:55 p.m. revealed that the documentation to validate the Foley catheter had been changed should have been on the Medication Administration Record. After the DON reviewed the resident's record, she acknowledged that the resident's Foley catheter was not changed in June, as ordered and had not been changed since 5/10/13. | 2016-07-01 |
| 7975 | 7975 | PRUITTHEALTH - MARIETTA | 115276 | 50 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2013-07-08 | 315 | D | 1 | 0 | 42RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the necessary care to one (1) resident (#1), regarding an indwelling urinary drainage catheter, of five (5) sampled residents, by failing to change the catheter according to physician's orders [REDACTED]. Findings include: Record review for Resident #1 revealed Physician's Interim Orders sheets, dated 05/17/2013 and timed at 7:00 p.m., which referenced an order for [REDACTED]. However, further record review, to include review of the June 2013 Treatment Record and Skilled Daily Nurses Notes, revealed no evidence to indicate that Resident #1's catheter had been changed in June, as ordered. During interview with the DON and Administrator on 7/8/2013 at 2:00 p.m. it was acknowledged that the Nurse's Notes and Treatment Record indicated that Resident #1's indwelling urinary drainage catheter had not been changed as the physician ordered. | 2016-07-01 |
| 7976 | 7976 | BERRIEN NURSING CENTER | 115343 | 405 LAUREL AVE. | NASHVILLE | GA | 31639 | 2013-07-10 | 309 | D | 1 | 0 | XZWJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to obtain and administer medication as ordered by the physician for one resident (#2) from a total sample of twenty- three residents. Findings include: Review of the Medication Record for Resident #2 referenced a physician's orders [REDACTED]. The nursing staff documented on the Medication Record that the [MEDICATION NAME] was administered each night at 8:00 PM from April 1, 2013 until April 22, 2013 and from April 24 2013 until April 30, 2013. However, during an interview on July 9, 2013 at 3 p.m. licensed nurse AA stated the medication was not obtained and started until April 10, 2013. The [MEDICATION NAME] was initially filled by the pharmacy on April 10, 2013 for thirty (30) tablets, it was refilled on May 4, 2013 for thirty (30) tablets. If the [MEDICATION NAME] was administered each night as ordered by the Physician the sixty (60) tablets would have been completed on June 8, 2013. However, after June 8, 2013, there was no evidence the [MEDICATION NAME] was refilled. The nurses continued to document that the [MEDICATION NAME] was administered nightly at 8 PM June 9, 2013 through June 28, 2013 and June 30, 2013. The Nurses also documented on the Medication Record that [MEDICATION NAME] was administered to Resident #2 on July 1, 2013 through July 3, 2013. Interview with the Director of Nursing and Nurse AA on July 9, 2013 at 3:00 PM confirmed that the last date that the Pharmacy filled the [MEDICATION NAME] for Resident #2 was May 4, 2013. Both nurses stated that the nurses had signed the Medication Record and documented that the [MEDICATION NAME] was given though the [MEDICATION NAME] was not on the cart and was unavailable. Nurse AA added that the [MEDICATION NAME] was not a covered medication with Resident #2's insurance so his family paid for the medication. According to Nurse AA when the family did not pay for the [MEDICATION NAME] the pharmacy did not s… | 2016-07-01 |
| 7977 | 7977 | BERRIEN NURSING CENTER | 115343 | 405 LAUREL AVE. | NASHVILLE | GA | 31639 | 2013-07-10 | 514 | D | 1 | 0 | XZWJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate medication records for two residents (#2 and #5) of twenty three sampled residents. Findings include: 1. Review of the Medication Record for Resident #2 referenced a physician's orders [REDACTED]. The nursing staff documented on the Medication Record that the [MEDICATION NAME] was administered each night at 8:00 PM from April 1, 2013 until April 22, 2013 and from April 24 2013 until April 30, 2013. However, during an interview on July 9, 2013 at 3 p.m. licensed nurse AA stated the medication was not obtained and given until April 10, 2013. The [MEDICATION NAME] was initially filled by the pharmacy on April 10, 2013 for thirty (30) tablets, it was refilled on May 4, 2013 for thirty (30) tablets. If the [MEDICATION NAME] was administered each night as ordered by the Physician the sixty (60) tablets would have been completed on June 8, 2013. However, after June 8, 2013, there was no evidence the [MEDICATION NAME] was refilled. The nurses continued to document that the [MEDICATION NAME] was administered nightly at 8 PM June 9, 2013 through June 28, 2013 and June 30, 2013. The Nurses also documented on the Medication Record that [MEDICATION NAME] was administered to Resident #2 on July 1, 2013 through July 3, 2013. Interview with the Director of Nursing and Nurse AA on July 9, 2013 at 3:00 PM confirmed that the last date that the Pharmacy filled the [MEDICATION NAME] for Resident #2 was May 4, 2013. Both nurses stated that the nurses had signed the Medication Record and documented that the [MEDICATION NAME] was given though the [MEDICATION NAME] was not on the cart and was unavailable. Nurse AA added that the [MEDICATION NAME] was not a covered medication with Resident #2's insurance so his family paid for the medication. According to Nurse AA when the family did not pay for the [MEDICATION NAME] the pharmacy did not send the medication. 2. Review of the Medicatio… | 2016-07-01 |
| 7978 | 7978 | MUSCOGEE MANOR & REHABILITATION CTR | 115351 | 7150 MANOR ROAD | COLUMBUS | GA | 31906 | 2012-05-17 | 167 | E | 0 | 1 | 1QP111 | Based on observations and interviews with four residents (A,B, C and D) and staff interviews, it was determined that the facility failed to ensure that the results of the most recent survey of the facility were readily accessible to residents and that a notice of their availability was posted. Findings include: During the Initial Tour of the facility on 5/14/12 at 9:45 a.m., the results of the most recent survey report and a notice of their availability were not observed. In an interview on 5/16/12 at 2:10 p.m., resident A stated that she/he did not know where the results of the most recent survey were located. On 5/16/12 at 2:30 p.m., resident B stated that she/he did not know where the results of the most recent survey were located. On 5/16/12 at 2:45 p.m., resident C stated that she/he did not know where the results of the most recent survey were located. On 5/17/12 at 11:30 a.m., resident D stated that she/he did not know where the results of the most recent survey were located. After surveyor inquiry on 5/16/12 at 3:10 p.m., the facility receptionist stated that the survey results were located on a shelf in the sitting room on the first floor. At that time, the notebook containing the survey results was observed on a shelf in the sitting room but, other written materials had been placed on top of it. There was not a notice of its availability posted. After surveyor inquiry on 5/16/12 at 3:10 p.m., facility staff posted a notice on a first floor bulletin board about where the survey results were located. | 2016-07-01 |
| 7979 | 7979 | MUSCOGEE MANOR & REHABILITATION CTR | 115351 | 7150 MANOR ROAD | COLUMBUS | GA | 31906 | 2012-05-17 | 253 | D | 0 | 1 | 1QP111 | Based on observations, it was determined that the facility failed to maintain an environment that was free from broken/missing toilet paper holders, holes in the ceiling, a missing thermostat control cover and missing and/or chipped paint on two of three floors (2nd and 3rd) and 3 of 4 common bathing/shower rooms. (2nd floor #1, #2 and 3rd floor #1). Findings include: Observations were made during the Environmental Tour of the facility on 5/17/12 between 10:00 a.m. and 11:30 a.m 2nd Floor 1. The paint on the metal grab bars was chipped and sections of paint were missing. The metal grab bars were in the two Arjo bathing units in the common shower room #1. 2. The toilet paper holder next to the toilet was missing in the common shower room #2. 3rd Floor 1. The toilet paper holder was broken next to the toilet in the common shower room #1. 2. There was an approximately 10 inch by 16 inch section of ceiling missing in common shower room #1. Two capped wires were exposed. 3. The plastic cover was missing off of the thermostat on the wall in common shower room #1. | 2016-07-01 |
| 7980 | 7980 | MUSCOGEE MANOR & REHABILITATION CTR | 115351 | 7150 MANOR ROAD | COLUMBUS | GA | 31906 | 2012-05-17 | 309 | D | 0 | 1 | 1QP111 | **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 follow physician's orders for one (1) resident (#138) from a sample of 39 residents. Findings include: Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Licensed staff had coded him/her as needing total assistance with bathing an personal hygiene on the Minimum Data Set (MDS) of 4/17/12. He/She had a physician's order for staff to wash his/her hair daily with [MEDICATION NAME] Shampoo 2.5%. It was observed on 5/15/12 at 9:28 a.m. that the resident's hair was greasy. According to documentation on the Nurse Aide Information Sheet, resident #138 was supposed to be given a shower on Tuesdays, Thursdays and Saturdays and required assistance with grooming. In an interview with Certified Nursing Assistant (CNA) CC on 5/17/12 at 9:23 a.m., she stated that the resident's hair was washed every other day when, he was given a shower. CC stated that she used the combination body wash/shampoo to wash the resident's hair. Approximately 10 minutes later, CNA CC reported that the resident had a special shampoo she used and that it was kept locked in the treatment cart. Observation of the resident's four (4) ounce bottle of [MEDICATION NAME] 2.5% shampoo with Licensed Practical Nurse (LPN) DD on 4/17/12 at 9:30 a.m. revealed that the bottle was almost empty. The prescription label had a handwritten note on it of need new Rx. The prescription date on that bottle of shampoo was 8/17/11. Review of the resident's Treatment Records for March, April, and May 2012 revealed staff's documentation that the resident had received a shampoo with the [MEDICATION NAME] Shampoo 2.5% only seven (7) times in March; seven (7) times in April; and five (5) times to date in May. During an interview on 5/17/12 at 12:25 p.m., LPN DD stated that the medication nurse was responsible for signing off treatments on the Treatment Record. The circles documente… | 2016-07-01 |
| 7981 | 7981 | MUSCOGEE MANOR & REHABILITATION CTR | 115351 | 7150 MANOR ROAD | COLUMBUS | GA | 31906 | 2012-05-17 | 312 | D | 0 | 1 | 1QP111 | **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 appropriate nail care for one (1) resident (#49) from a sample of 39 residents. Findings include: Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He/She had a 5/3/12 care plan intervention for staff to provide nail care with his/her bath as needed. During an observation on 5/14/12 at 3:24 p.m., and on 5/16/12 at 10:07 a.m., resident #49 had a large amount of brown material under the entire length of all 10 of his/her fingernails. In an interview on 5/16/12 at 12:45 p.m., Certified Nursing Assistant (CNA) II stated that she had given resident #49 a bed bath that morning. During an interview and observation with registered nurse (RN) FF on 5/16/12 at 12:53 p.m., she confirmed that the resident's fingernails were dirty. Although the facility had identified and provided information that a hair product for hair and scalp treatment was used on the resident's hair and that the resident would run his/her fingers through his/her hair, the facility staff failed to maintain clean fingernails as needed for the resident. | 2016-07-01 |
| 7982 | 7982 | MUSCOGEE MANOR & REHABILITATION CTR | 115351 | 7150 MANOR ROAD | COLUMBUS | GA | 31906 | 2012-05-17 | 322 | D | 0 | 1 | 1QP111 | Based on observation, record review and staff interview, it was determined that the facility failed to ensure that licensed nursing staff verified placement of a gastrostomy tube prior to medication administration for one resident (#5) with a gastrostomy tube in a total sample of 9 residents. Findings include: On 5/16/12 at 11:15 a.m., during observation of medication administration for resident #5, licensed nurse DD inserted a syringe into the resident's gastrostomy tube and pulled back the plunger to aspirate gastric contents. At that time, DD stated that he/she was verifying placement of the gastrostomy tube. However, DD did not aspirate any gastric contents and proceeded to flush the resident's gastrostomy tube with water and administer his/her medications through his/her gastrostomy tube. After failing to verify placement of the resident's gastrostomy tube by aspirating gastric contents, DD also failed to verify placement of the resident's gastrostomy tube by placing a stethoscope on the resident's abdomen, injecting air through the tube and listening for a whooshing sound. On 5/17/12 at 10:50 a.m., licensed nurse DD confirmed that the resident did not have any residual on 5/16/12 at 11:15 a.m. and stated that she/he should have verified placement by injecting air through the tube and auscultating it. On 5/17/12 at 2:20 p.m., the Director of Nursing stated that placement of a gastrostomy tube should be verified by auscultating with air. | 2016-07-01 |
| 7983 | 7983 | MUSCOGEE MANOR & REHABILITATION CTR | 115351 | 7150 MANOR ROAD | COLUMBUS | GA | 31906 | 2012-05-17 | 356 | C | 0 | 1 | 1QP111 | Based on observations, it was determined that the facility failed to post daily mandatory nurse staffing data which included the total number and the actual hours worked by the nursing staff responsible for resident care. Findings include: Although the facility was required to post the daily nurse staffing information that included the total and actual hours worked by the nursing staff directly responsible for resident care, during observation on 5/7/12 at 7:32 a.m., the form posted by the facility did not include total hours and actual hours worked by direct care staff. During an interview on 5/17/12 at 7:32 a.m., the Director of Nurses confirmed that the facility posted the daily nurse staffing information as observed. | 2016-07-01 |
| 7984 | 7984 | MUSCOGEE MANOR & REHABILITATION CTR | 115351 | 7150 MANOR ROAD | COLUMBUS | GA | 31906 | 2012-05-17 | 493 | C | 0 | 1 | 1QP111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of personnel records and staff interview, it was determined that the facility failed to ensure that the Administrator, responsible for the management of the facility, was licensed. Findings include: During a review of the personnel records on [DATE] at 1:00 p.m., the Administrator's file contained a copy of the an Administrator's license that had expired on [DATE]. The Administrator confirmed on [DATE] at 2:11 p.m., that there was no evidence that his license had been renewed. | 2016-07-01 |
| 7985 | 7985 | MUSCOGEE MANOR & REHABILITATION CTR | 115351 | 7150 MANOR ROAD | COLUMBUS | GA | 31906 | 2012-05-17 | 502 | D | 0 | 1 | 1QP111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to obtain a laboratory test as ordered for one resident (#74) from a total sample of 39 residents. Findings include: Resident #74 had [DIAGNOSES REDACTED]. He/She had a physician's orders [REDACTED]. However, there was no evidence in the clinical record that a BMP had been obtained for April. The most recent BMP panel had been obtained on 3/05/12. The Director of Nursing confirmed on 5/17/12 at 11:15 a.m. that the BMP for April had not been obtained as ordered. | 2016-07-01 |
| 7986 | 7986 | MUSCOGEE MANOR & REHABILITATION CTR | 115351 | 7150 MANOR ROAD | COLUMBUS | GA | 31906 | 2012-05-17 | 505 | D | 0 | 1 | 1QP111 | **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 promptly notify the physician about abnormal laboratory test results for one resident (#74) from a total sample of 39 residents. Findings include: Resident #74 had a Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC), Lipid Panel and [MEDICAL CONDITION] Stimulating Hormone (TSH) laboratory tests obtained on 5/07/12. There were results available on 5/07/12 with some abnormal test results. However, there was no evidence in the clinical record that facility nursing staff notified the physician about those test results until 5/16/12, after surveyor inquiry. On 5/17/12 at 11:15 a.m., the Director of Nursing (DON) confirmed that the physician had not been notified about the 5/7/12 laboratory test results until 5/16/12. She said that the resident's physician reviewed all non-critical laboratory test results every Monday but, since there was no evidence that those results had been printed out of the facility's computer until 5/16/12, she was not able to verify that he had seen those test results from 5/07/12. | 2016-07-01 |
| 7987 | 7987 | MUSCOGEE MANOR & REHABILITATION CTR | 115351 | 7150 MANOR ROAD | COLUMBUS | GA | 31906 | 2012-05-17 | 508 | D | 0 | 1 | 1QP111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and family interviews, it was determined that the facility failed to provide radiological services as ordered for one resident (Z) from a sample of 39 residents. Findings include: Resident Z had [DIAGNOSES REDACTED]. There was a 4/06/12 physician's orders [REDACTED]. However, a review of the resident's clinical record revealed no evidence that the MRI had been done. In an interview on 5/16/12 at 2:10 p.m., Licensed Practical Nurse (LPN) DD confirmed that there was no record of the resident having had a recent MRI. It was not documented in the appointment book. During an interview on 5/16/12 at 2:30 p.m., secretary/certified nursing assistant (CNA) EE said that she called for an appointment, and if the facility was closed, she left a message and then followed up on it. She stated that the 4/06/12 order for resident Z was written on a Friday, on doctor's rounds day. She said that the MRI department at the Medical Center where it would have been scheduled closed at noon on Fridays. She confirmed that there was no evidence in the appointment book of an MRI having been scheduled for the resident. She said that a family member had to go with the resident for an MRI so she had to coordinate the appointment with a family member. In an interview on 5/16/12 at 2:30 p.m., Registered Nurse (RN) FF stated that, as of 4/01/12, there was a new process for keeping track of physician's orders [REDACTED]. She said that she knew that she had a broken system. In a telephone interview on 5/16/12 at 2:57 p.m., resident Z's family member stated that he/she did not know know anything about an MRI having been ordered for the resident in April, and he/she had not been with resident Z for him/her to have an MRI. During interview on 5/17/12 at 9:55 a.m., medical records staff GG stated that she had called St. Francis, Doctor's Hospital, and the Medical Center, and neither of those facilities had any record that resident Z had an MRI at … | 2016-07-01 |
| 7988 | 7988 | DUBLINAIR HEALTH & REHAB | 115356 | 300 INDUSTRIAL BLVD | DUBLIN | GA | 31040 | 2012-04-12 | 253 | C | 0 | 1 | MIPJ11 | Based on observation, and staff interviews, the facility failed to provide housekeeping and maintenance services to maintain an orderly and sanitary environment on five (5) of six (6) halls. Findings include: Observations on 4/11/12 beginning at 8:30 a.m. revealed the following: A Hall: Room 1: The caulking around the sink in the bathroom was cracking. Room 2: The privacy curtain ceiling track for bed C was hanging four (4) inches from the ceiling, the right hand corner of the left wood window blind, sixth (6th) row up was broken and the right wood window blind on the right side was bowed on the left side corner. There was a patched, unpainted square area left of the television mount. Room 7: There was a black substance spattered on the back of the toilet seat, caulking around the right side of the toilet was brown and the caulking around the sink was soft making the sink loose. Room 9: The bathroom sink caulking is soft and cracking, causing the sink to be loose. Room 10: The privacy curtain track for bed B was hanging one (1) foot from the ceiling, at the left side of the window. Room 13: The bathroom sink caulking was cracking and the sink was loose on the right side. There was brown caulking around base of the toilet. Room 15: The wood is marred behind bed A in two (2) places and the vanilla phone box is hanging out of the wall. The microwave in the nourishment prep room had dried food on four (4) of the four (4) walls. The baseboard molding was coming loose on the right, outside room 15. B Hall: Room 2: In the left corner behind bed A there was a patched unpainted square area, half (1/2) way up the wall from the floor. Room 6: The caulking around the bathroom sink was loose and cracking. Room 9: The handle on the closet next to the bathroom was loose and the bathroom had black caulking around the toilet and cracking caulking around the sink. C Hall: Room 2: The bathroom towel bar was missing the middle piece. Room 4: The handle on the middle closet was loose. Room 7: The left corner of the metal kick plate o… | 2016-07-01 |
| 7989 | 7989 | DUBLINAIR HEALTH & REHAB | 115356 | 300 INDUSTRIAL BLVD | DUBLIN | GA | 31040 | 2012-04-12 | 309 | D | 0 | 1 | MIPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to follow the physician's order for one (1) resident (Z) of a sample of twenty three (23) residents. Findings Include: Observation on 4/11/12 at 8:47 a.m. during Medication Administration for resident Z revealed two (2) patches on the resident's back. Continued observation revealed that Registered Nurse (RN) EE went into the resident's room to apply [MEDICATION NAME] and [MEDICATION NAME]es and found the two (2) patches. The RN removed the patches before applying the new patches. Review of the physician orders revealed a current order for [MEDICATION NAME] DIS 0.4 mg/hr Apply one patch topically every morning at 9:00 a.m. and remove at bedtime, 9:00 p.m. Interview on 4/11/12 at 9:20 a.m. with RN EE verified that a [MEDICATION NAME] Patch dated 4/10/12 was one of the patches removed from the resident's back on 4/11/12. Continued interview revealed that according to the physicians's order the patch should have been removed at bedtime on 4/10/12. Review of the April, 2012 Medication Administration Record [REDACTED]. | 2016-07-01 |
| 7990 | 7990 | DUBLINAIR HEALTH & REHAB | 115356 | 300 INDUSTRIAL BLVD | DUBLIN | GA | 31040 | 2012-04-12 | 323 | D | 0 | 1 | MIPJ11 | Based on observation and staff interview, the facility failed to ensure that residents were free of hazards on three (3) of six (6) halls. Findings include: Observations on 4/11/12 between 8:30 a.m.-10:45 a.m. revealed the following: 1. Room 13, bed B on the A-hall, had two (2) small vanilla boxes with different colored wires exposed. One (1) box to the right had green, white and red wires coming out of the box and the box on the left had blue, white and orange wires coiled around. Neither box had coverings. Interview with the Plant Operation Supervisor on 4/12/12 at 8:55 a.m. revealed that these boxes were for the phone, and confirmed that the wires were hanging. 2. In the linen closet on the E-Hall there was a pair of long-handled black scissors lying on a shelf. The linen closet was unlocked. Interview with the Director of Nursing (DON) at 8:50 a.m. on 4/11/12, revealed that there were two (2) wandering residents in the building and that the door was to remain locked at all times. Interview with the Housekeeping and Laundry Manager at 8:51 a.m. on 4/11/12 revealed that she keeps the scissors in order to open boxes. 3. The mechanical room on the F-Hall, which contained a hot water tank, was unlocked. There was a sign on the door that stated that the door was to remain locked at all times. Interview with the Administrator on 4/11/12 at 9:15 a.m. confirmed that the door was unlocked. | 2016-07-01 |
| 7991 | 7991 | DUBLINAIR HEALTH & REHAB | 115356 | 300 INDUSTRIAL BLVD | DUBLIN | GA | 31040 | 2012-04-12 | 441 | F | 0 | 1 | MIPJ11 | Based on observation, staff interviews, and review of the facility policy for handwashing, the facility failed to ensure that staff maintained infection control practices to prevent the spread of infection on five (5) of six (6) halls and in the kitchen. Findings include: Observations 1. Observation of resident room E2A on 4/11/12 at 4:40 p.m. revealed the nebulizer mask wrapped around the right assist bar, uncovered. Review of the April, 2012 Physician Orders revealed that the resident receives nebulizer treatments every four (4) hours at 5:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m 2. Observation of resident room E6A on 4/9/12 at 4:35 p.m. revealed a nebulizer mask on the left corner on the nebulizer, uncovered. Review of the April, 2012 Physician Orders revealed that resident receives nebulizer treatments every four (4) hours at 1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. 3. Observation of resident room E10 at 8:40 a.m. on 4/11/12 revealed a nebulizer mask on the left corner of the nebulizer, uncovered. Review of the April, 2012 Physician Orders revealed that the resident receives nebulizer treatments every six (6) hours when needed for wheezing and/or dyspnea. Interview with resident A at 8:40 a.m. on 4/11/12, revealed that she has had the nebulizer about one (1) week and the last time she used it was 4/10/12. 4. Observation of resident room E17 on 4/10/12 at 9:15 a.m. revealed a nebulizer sitting on the nightstand, to the right of the bed, with the face mask inside the open nebulizer front and two (2) unknown vials resting behind the mask. Observation on 4/11/12 at 8:28 a.m. revealed the face mask from the nebulizer lying face down on the floor next to the right side of the bed, uncovered. Review of the April, 2012 physician orders revealed that the resident receives nebulizer treatments four (4) times a day at midnight, 6:00 a.m., noon, and 6:00 p.m. 5. Observation of resident room F1B on 4/9/12 at 4:44 p.m. revealed a nebulizer mask on the floor with the nebulizer runni… | 2016-07-01 |
| 7992 | 7992 | MACON REHABILITATION & HEALTHCARE CENTER | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2012-04-27 | 272 | D | 0 | 1 | GXYW11 | Based on observation, record review and staff interviews the facility failed to complete the Significant Change Minimum Data Set (MDS) for one (1) resident (# 41) from a sample of thirty (30) residents. Findings include: Observation of resident #41 on 04/25/12 at 11:00 a.m. revealed the resident lying in bed in her room with Fiber Source HN infusing at 85millilters per hour infusing per feeding tube. Review of the clinical record revealed that the resident was readmitted to the facility after a hospital stay from 02/26/12 to 03/09/12 for vomiting coffee grounds. Review of the Social Worker Progress Notes dated 03/16/12 revealed that the resident with a significant decline and now requires the assistance of Hospice Care. She has a decline in Activities of Daily Living, transfers, bed mobility and feedings. She requires total care, and has a Percutaneous Endoscopic Gastrostomy (PEG) tube for nutrition. Resident is alert but disoriented and unable to make her needs known. Review of the Minimum Data Set (MDS) assessment revealed that the last assessment was a Discharge Assessment-Return Anticipated completed 02/26/12. There was no evidence that a Significant Change MDS was completed after this resident's return from the hospital. Interview with the MDS Coordinator on 04/27/12 at 1:20 p.m. revealed that she completely overlooked resident # 41 and that she should have had a Significant Change MDS completed on 03/16/12. | 2016-07-01 |
| 7993 | 7993 | MACON REHABILITATION & HEALTHCARE CENTER | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2012-04-27 | 280 | D | 0 | 1 | GXYW11 | Based on family and staff interviews the facility failed to invite the responsible party to participate in care plan meetings for one (1) resident (XX) from a sample of thirty (30) residents. Finding includes: Interview on 4/25/12 at 11:00 a.m. with the responsible party for resident XX revealed that she was unaware of care plan meetings and had never been invited to attend one. Interview with MDS /Care Plan Coordinator conducted on 4/25/2012 at 11:30 a.m. revealed that the facility did not have a written policy regarding care plan meetings but as a standard practice, she sends out letters to family members or the responsible party once a scheduled date is set. Continued interview revealed that she did not send letters of invitation to this responsible party because she got behind in care plan meetings. She acknowledged that this resident has not had a care plan meeting since the admission care plan was developed on 5/27/2011. | 2016-07-01 |
| 7994 | 7994 | MACON REHABILITATION & HEALTHCARE CENTER | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2012-04-27 | 282 | D | 0 | 1 | GXYW11 | Based on observation, record review and staff interviews the facility failed to follow the Care Plan for one (1) resident (# 91) from a sample of thirty (30) residents. Findings include: Observation of resident # 91 on 04/26/12 at 11:35 a.m. sitting in a high back wheel chair in the solarium dining room revealed that the resident was observed self propelling by scooting his feet and upper body forward. Continued observation revealed the resident wearing white athletic socks with no shoes on his feet. A chair alarm was attached to the side of the wheelchair. There were no non skid socks on the resident's feet. Review of the care plan dated 05/26/11 and updated 04/15/12 revealed that the resident is at risk for falls related to: unsteady gait, medications, decreased safety awareness, history of falls related to dementia and behaviors. Interventions included wheelchair alarm in chair, mats at bedside, put eyeglasses in place when resident is awake, give verbal reminders not to ambulate or transfer without assistance, ensure that resident has and wears properly-fitting non skid soled shoes for ambulation, and Non skid socks Review of the Interdisciplinary Progress Notes dated 1/09/12 at 7:15 a.m. revealed that the resident was holding on to the back of another resident's wheel chair attempting to pull himself up. The resident slid to floor due to wearing slippery socks. No injuries noted. Immediate intervention - non skid socks were given and the residents shoes were placed on his feet. Interview with Licensed Practical Nurse (LPN) AA on 04/26/12 at 11:40 a.m. revealed that she concurred that resident # 91 was care planned for wearing non skid socks and that he not was wearing non skid socks at this time. | 2016-07-01 |
| 7995 | 7995 | MACON REHABILITATION & HEALTHCARE CENTER | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2012-04-27 | 323 | D | 0 | 1 | GXYW11 | Based on observation, resident and staff interview, the facility failed to ensure that residents were free of hazards in four (4) rooms on one (1) of two (2) wings. Findings Include: During initial tour of environmental rounds on 4/26/12 between 1:14 p.m.-3:05 p.m., the following areas of concerns were identified: 1. Room N-3B: An unsecured power strip was observed lying on the floor to the right of the bed with a hair dryer and telephone plugged into it. 2. Room N-17: In the bathroom there was a portable toilet seat, made from Polyvinyl Chloride (PVC) tubing, over the high toilet. It was easy to move side to side and the back legs were off the ground approximately one (1) inch. Interview with resident #Z on 4/26/12 at 1:58 p.m. revealed that the toilet has been this way since his admission. Continued interview revealed that he is the only one that uses the restroom and that when he gets on the portable toilet seat it is unsteady. Review of the medical record for resident #Z revealed he was admitted to the facility in 11/10 for skilled nursing and rehab. Review of the Minimum Data Set (MDS) 3.0 annual dated 11/13/11 and quarterly dated 2/11/12 revealed the BIMS score on both assessments was thirteen (13). 3. Room N-20: An unsecured power strip was observed lying on the floor, under a tray table, with an oxygen concentrator, television cord and a nebulizer cord plugged into it. Continued observation revealed white, black and orange wires hanging from an uncovered white panel at the entrance to the room. Interview on 4/26/12 at 3:35 p.m. with the Maintenance Director revealed that that the portable toilet seat was unsafe, the power strips should be mounted with only resident care equipment plugged into the strips and that the wires hanging from the ceiling , which are the wires to the smoke detector, should be covered. 4. Observation on 04/24/12 at 12:10 p.m. and on 4/25/12 at 8:15 a.m. revealed an unsecured power strip that was plugged into the wall outlet on the left wall in resident room N20. Further observation… | 2016-07-01 |
| 7996 | 7996 | MACON REHABILITATION & HEALTHCARE CENTER | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2012-04-27 | 502 | D | 0 | 1 | GXYW11 | Based on record review and staff interview the facility failed to follow the perform laboratory testing in a timely manner and per physician's order for one (1)resident (# 66) from a sample of thirty (30) residents. Findings include: Review of the medical record for resident resident #66 revealed a physician's order dated 3/28/12 for a Lipid panel, a Hemoglobin (Hgb) A1c, a Chemistry eight (8) panel and a complete blood count (CBC) now and every six (6) months. Continued review of the medical record with the Assistant Director of Nursing (ADON) revealed no evidence that the laboratory test had been done. Interview on 4/26/12 at 10:30 a.m. with the ADON revealed that the tests were documented in laboratory book under the wrong month therefore, they were not done. | 2016-07-01 |
| 7997 | 7997 | GOLDEN LIVINGCENTER - ROME | 115363 | 1345 REDMOND ROAD | ROME | GA | 30165 | 2013-08-06 | 203 | D | 1 | 0 | KCT611 | Based on record review and staff interview, it was determined that the facility failed to notify the resident and the family or legal representative, in writing, of the transfer/discharge information for two (2) residents (#1 and #2) of four (4) sampled residents. Findings include: 1. Record review for Resident #1 revealed a Progress Notes entry of 07/23/2013 at 2:42 p.m. which documented that an order had been received to send the resident to the hospital emergency room for evaluation, and that the resident had been transferred to the hospital at 12:00 p.m. on that date. A subsequent Progress Notes entry of 07/23/2013 at 7:04 p.m. documented that, upon calling the hospital to inquired about the resident's status, facility staff had been informed that the resident's family had taken the resident home. However, further record review revealed no evidence to indicate that Resident #1 and the resident's family had been notified in writing of the resident's transfer, of the reason for the transfer, of the date of the transfer, of the location to which the resident was transferred, of the right to appeal the action to the State, and of the specified contact information of the State long term care ombudsman. 2. Record review for Resident #2 revealed a Progress Notes entry of 07/26/2013 at 4:41 p.m. which documented that the physician ordered for the resident to be sent to the hospital emergency room . A subsequent Progress Notes entry of 07/27/2013 at 3:26 p.m. documented that the resident remained in the hospital. However, further record review revealed no evidence to indicate that Resident #2 and the resident's family had been notified in writing of the resident's transfer, of the reason for the transfer, of the date of the transfer, of the location to which the resident was transferred, of the right to appeal the action to the State, and of the specified contact information of the State long term care ombudsman. During interview with the Administrator and the Director of Nursing conducted on 08/06/2013 at 2:45 p.m., … | 2016-07-01 |
| 7998 | 7998 | MONTEZUMA HEALTH CARE CENTER | 115364 | 506 SUMTER ST | MONTEZUMA | GA | 31063 | 2012-03-29 | 156 | B | 0 | 1 | NZ6611 | Based on observation and staff interview the facility failed to post the telephone number for the State Survey and Certification Office. Census = 78 Findings include: Observation of posted signs in the facility revealed that there was no posting of the State Survey and Certification phone number. Interview on 03/28/12 at 5:50 p.m. with the Administrator and Registered Nurse Consultant BB concurred that the number was not posted on any board in the facility. | 2016-07-01 |
| 7999 | 7999 | MONTEZUMA HEALTH CARE CENTER | 115364 | 506 SUMTER ST | MONTEZUMA | GA | 31063 | 2012-03-29 | 279 | D | 0 | 1 | NZ6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive plan of care for vision for one (1) resident (#23) of a sample of thirty-five (35) residents. Findings include: Review of the annual Minimum Data Set (MDS) assessment for resident #23 dated 7/08/11 and subsequent quarterly MDS assessments revealed that the resident was assessed with [REDACTED]. Review of the Care Area Assessment (CAA) completed with the annual MDS assessment dated ,[DATE] 11 revealed that the resident was to be care planned for this care area to identify changes in vision. Review of the medical record revealed no evidence that a care plan had been developed related to vision. Interview on 3/28/12 at 2:20 p.m. with the MDS Coordinator revealed she assessed the resident's vision by taking a newspaper in the resident's room and having the resident read what he could of the newspaper. The resident indicated to her that he could only see the large print words and could not read the smaller print. Continued interview revealed that she did not develop a care plan related to vision. | 2016-07-01 |
| 8000 | 8000 | MONTEZUMA HEALTH CARE CENTER | 115364 | 506 SUMTER ST | MONTEZUMA | GA | 31063 | 2012-03-29 | 441 | D | 0 | 1 | NZ6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the facility policy for contact precautions and staff interview, the facility failed to maintain infection control measures to prevent the likelihood of the spread of infection related to proper disposal of gloves on one (1) of two (2) halls. Findings include: Observation on 3/28/12 at 9:16 a.m. revealed a Certified Nursing Assistant (CNA) put on gloves outside of room [ROOM NUMBER] and enter the room. At 9:17 a.m. the CNA exited the room with the gloves on, carrying a resident's breakfast tray. The CNA removed the gloves from her hands and held them in her right hand as she entered room [ROOM NUMBER]. When she exited room [ROOM NUMBER], she no longer had the gloves in her hand. Observation on 3/28 12 at 9:20 a.m. in room [ROOM NUMBER] revealed the gloves were in the trash can in that room. Observation on 3/28/12 at 1:48 p.m. revealed a CNA picking up the lunch tray from isolation room [ROOM NUMBER]. She put on gloves after entering the room and carried the tray out of the room to the cart with her gloves on. As she walked up the hall, the CNA threw the gloves away in the open trash receptacle on the Middle medication cart used for the lower two halls. Review of the facility policy for using gloves revealed that used gloves should be discarded into the waste receptacle inside the room. Telephone interview on 4/06/12 at 9:15 a.m. ,during the Quality Assurance process, with the Infection Control Nurse revealed that gloves should be disposed of in the resident's room prior to leaving the room. | 2016-07-01 |
| 8001 | 8001 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2012-01-26 | 441 | D | 0 | 1 | ECVV11 | Based on observation, staff and resident interview, and review of the facility policy for storing aerosol equipment, the facility failed to properly store nebulizers for one (2) random resident on one (1) of three (3) halls (200 Hall). Findings include: Observation, during initial tour, on 01-23-12 beginning at 9:30 a.m. revealed a Mabis Minicomp Nebulizer sitting on the bedside table to the left bed 216B. The Nebulizer was sitting directly on the table top, not on a protective barrier or covered and the Nebulizer mask, lying on the Nebulizer, also uncovered. The residents last treatment had been administered at 6:00 a.m. Review of facility policy for storing aerosol equipment revealed that a clean cloth should be placed under and on top of the compressor when not in use. Interview with the Director of Nursing (DON) on 1/25/12 at 3:50 p.m., revealed that the Nebulizers were to be covered with a cloth after use. Telephone interview on 2/6/12 at 10:30 a.m. with the DON revealed that the resident received Nebulizer treatments four times a day at 6:00 a.m., 12 noon, 6:00 p.m. and 12 midnight. | 2016-07-01 |
| 8002 | 8002 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2012-01-26 | 463 | D | 0 | 1 | ECVV11 | Based on observations,staff interviews and review of the facility guidelines for call lights, the facility failed to ensure that the call light system functioned appropriately in six (6) of one hundred and fifty nine (159) resident rooms on one (1) of three (3) halls (400 hall) Findings include: Observations of the resident call light system on the 400 hall on 1/23/12 beginning at 11:30 a.m revealed the following: Room 407B- the call light was attached to the side of the bed and plugged into the wall but the push button was missing from the call light making it impossible to signal for assistance;.Room 408B- the call light was attached to the side of the bed and plugged into the wall but the light failed to light up or sound in the room or at the nurses station; Room 403B-the call light failed to light up or sound in the room or at the nurses station; Rooms 416A and B, and 420A-the call lights failed to light up or sound at the nursing station. Review of the Facility Practice Guidelines for Call Lights revealed that any defective call ligh should be reported to the charge nurse and that maintenance department immediately. Interview with the Maintenance Director on 01-23-12 at 3:00 p.m. and checks of the call lights confirmed that the call lights were not working and need to be fixed. Continued interview revealed that the call lights are checked once a month and that they are fixed when they are found not to be working at that time. | 2016-07-01 |
| 8003 | 8003 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2012-05-17 | 156 | B | 0 | 1 | R15H11 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for three (3) of three (3) residents (#12, #57 and #63) discharged from Medicare Part A services, and failed to ensure that the responsible party (RP) received the Notice of Medicare Provider Non-coverage (Generic Notice) when mailed for two (2) of three (3) residents (#12 and # 63). Findings include: On 05/15/12 at 3:05 p.m., the Social Service Director (SSD)/Admissions Coordinator stated that residents #12, #57, and #63 were discharged from Medicare Part A services, and that all three (3) residents remained in the facility. He further stated that the Generic Notices were mailed to the RP's, but he could not verify that they actually received the Notice as none of them were signed and returned except for resident #57. On 5/16/12 at 8:15 a.m., the SSD stated that he stopped sending out the SNFABN months ago. | 2016-07-01 |
| 8004 | 8004 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2012-05-17 | 334 | E | 0 | 1 | R15H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer the pneumonia vaccine to seven (7) residents (#21, 39, 37, 46, 20, 52, 12), of fifteen (15) sampled resident immunization records reviewed. Findings include: Review of Resident Immunization Informed Consent Authorization forms dated 12/21/10 and 8/10/11 revealed that the responsible parties for residents #21 and #39 wanted the residents to receive the pneumococcal immunization. However, there was no documentation on the Vaccine Administration records that the vaccine was ever given. On 5/16/12 at 4:00 p.m., the Administrator stated that per pharmacy invoice records, the pneumonia vaccine had not been ordered since 2009. The facility's Procedure for Vaccine Administration noted that each resident will have the option of receiving the [MEDICATION NAME] vaccine on a one-time basis. Review of the resident's immunization informed consent authorization form dated 01/19/11 for resident #52 documented that the responsible party signed the consent indicating they wanted resident #52 to receive the pneumococcal immunization. This form had a hand written statement that the resident had never taken the pneumococcal vaccine. There was no evidence that the pneumococcal vaccine had been given to the resident. Interview with the Director of Nursing on 5/16/12 at 11:35 a.m. revealed that she was unaware that the resident's family had wanted the resident to have the pneumococcal vaccine as the family had not mentioned it to her. She was unaware if the facility would provide pneumococcal vaccines to residents. Observation of the medication room on 5/16/12 at 10:42 a.m. revealed there were no pneumococcal vaccine medications located in the medication room refrigerator. Further interview with the DON on 5/16/12 at 1:35 p.m. revealed that the Social Worker gets consents for vaccines from the responsible party or the resident on admission to the facility. Interview with the Social Worker … | 2016-07-01 |
| 8005 | 8005 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2012-05-17 | 431 | D | 0 | 1 | R15H11 | Based on observation and staff interview the facility failed to ensure that it was free of expired over-the-counter medications. Observation on 5/16/12 at 10:42 a.m. of the supply room where over-the-counter medications were stored revealed there were six (6) bottles of expired acetaminophen liquid. Two (2) of these bottles had expired in October 2011 and the other four (4) bottles expired March 2012. There were also two (2) thirty (30) ounce bottles of Prosat 101 that had expired in March 2012. Interview with a RN Supervisor (staff # AA) on 5/16/12 at 10:45 a.m. confirmed these medications were expired. Interview with the Administrator on 5/16/12 at 11:56 a.m. revealed that the receptionist in the business office was responsible for checking for expired medications in the medication supply room and should remove expired pharmaceuticals from the shelves. | 2016-07-01 |
| 8006 | 8006 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2012-05-17 | 441 | F | 0 | 1 | R15H11 | Based on observation and staff interview the facility failed to serve resident meals in the main dining room under sanitary conditions for two (2) meals observed on 5/14/12 and 5/16/12. This involved random observation of six (6) staff members serving fifty-eight (58) residents meal trays without washing or sanitizing hands between resident contact. The total resident census was sixty (60). Findings include: 1. During observation of the noon meal at 12:30 p.m. in the main dining room on 5/14/12 Certified Nursing Assistant (CNA) EE served and set up multiple trays without washing or sanitizing their hands. They handled numerous drinking straws by the tip. 2. The breakfast service was observed on 5/16/12 at 7:35 a.m. CNA CC was observed serving and setting up trays for four (4) residents. She repositioned each resident's chair, and set up their trays including opening drink cartons. Between serving the second and third resident she ran the fingers of her right hand through her hair. She picked up and buttered the toast with her bare hands for the first resident. She opened each resident's milk and juice cartons and pulled out the spouts by putting her bare finger into each one. The fourth resident she made them A sandwich was made for the fourth resident with bare hands. She folded the bread over and mashed it. 3. CNA DD was observed at both meals (5/14/12, noon and 5/16/12, breakfast) serving trays to multiple residents, touching wheelchairs and assisting with feeding without washing or sanitizing their hands. 4. During observation on 5/14/12 at 12:29 p.m. in the main dinning room, revealed staff started to serve trays without first washing or using hand sanitizer. Observation at 12:46 p.m. of Certified Nursing Assistant (CNA) EE and Licensed Practical Nurse (LPN) FF while they adjusted a resident in a geri-chair by lifting the sheet beneath the resident. Both then returned to feeding or setting up lunch trays without washing or sanitizing their hands. During observations of the breakfast meal in the dining room o… | 2016-07-01 |
| 8007 | 8007 | GOLDEN LIVINGCENTER - TIFTON | 115412 | 1451 NEWTON DRIVE | TIFTON | GA | 31794 | 2013-08-21 | 166 | D | 1 | 0 | 5P6N11 | Based on observation, facility document review, staff, and resident interviews, the facility failed to ensure that resident mail was delivered to the residents unopened for one (1) resident (A) on a survey sample of six (6) residents. Findings include: Observation of mail delivered to resident A, on 8/21/13 at 11:10 a.m., revealed that the mail had been delivered to the resident with the top of the envelope and the flap sealed with tape. The top of the envelope had the appearance of being opened with an object such as a letter opener. Review of the Grievance File, dated 3/20/13 revealed the resident had expressed the concern that her mail had been opened to the social worker. The social worker documented that the business office manager was notified, however she did not indicate that she was aware of any resident mail being opened prior to delivery. This concern was documented as resolved. Interview with resident A, at 11:10 a.m., revealed all of the mail she had received of this type and from this sender, had been opened. Resident A further stated that she had notified the social worker and this practice continued on a monthly basis. Interview with the social worker and the Administrator, at 1:15 p.m., revealed that both agreed that this should not have occurred. In addition, the social worker stated that she have follow up with the resident to ensure this concern had been resolved. | 2016-07-01 |
| 8008 | 8008 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2013-08-08 | 253 | D | 0 | 1 | TZM811 | Based on observation and staff interview the facility failed to maintain the environment and equipment in appropriate condition on one (1) of two (2) short halls leading to the large dining room of five (5) halls total in the facility. Findings include: Observation on 8/6/13, at 1:30 p.m., revealed dirt and debris collected around the back and in between the three (3) vending machines, one (1) ice machine and the wall. Upon stepping onto the tile next to the soda machine, water came up between the tiles. Continued observation revealed debris and dirt behind the remaining machines and one (1) of two (2) drainage tubes leading from the ice machine to a floor drain. Observation and interview with the Administrator and the Maintenance Supervisor on 8/6/13 at 2:00 p.m revealed upon inspection that only one (1) of the two (2) drainage tubes for the ice maker was in the floor drain hole while the other was laying behind the soda machine draining water onto the floor and under the tile. An interview with the Maintenance Supervisor on 8/6/13 at 3:15 p.m. revealed that no one had reported the condition to him and that he was unaware of the problem. An interview with the housekeeping supervisor on 8/6/13 at 3:00 p.m. revealed that housekeeping is responsible for keeping the vending area clean but had not been made aware of the situation. | 2016-07-01 |
| 8009 | 8009 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2013-08-08 | 312 | D | 0 | 1 | TZM811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to provide oral hygiene and nail care for one (1) resident (A) from a total sample of twenty six (26) residents. Findings include: Review of the clinical record revealed that resident A has multiple diagnoses, including, [MEDICAL CONDITIONS] with left sided weakness, hypertension, dysphasia, and contractures of the left hand, wrist, bilateral shoulders and elbows. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed as requiring extensive assist for personal hygiene by one (1) person and total dependence for bathing by one (1) person, and assessed on the Brief Interview for Mental Status (BIMS) was fifteen (15) indicating the resident is alert and orient and reliable for interview. Observations of resident A on 8/6/13 at 10:30 a.m., 8/7/13 at 8:15 a.m. and 10:55 a.m., and on 8/7/13 at 8:15 a.m. revealed the resident's teeth had a gummy looking substance on his teeth and that the resident had long fingernails with a black substance under the nails of the right hand. Resident interview on 8/6/13 at 10:59 a.m. revealed that his teeth are not cleaned daily, rather they are cleaned weekly, but would like it done more often. Review of the resident's care plan dated 7/3/13 revealed the resident required extensive to total assistance with all activities of daily living with interventions for staff to provide grooming every day and to clean and clip the resident's nails as needed. An interview on 8/7/13 at 2:18 p,m., with Certified Nursing Assistant (CNA) EE revealed that the bath team provides nail care and should also brush the resident's teeth. An interview with the resident on 8/7/13 at 2:22 p.m. revealed that the shower team keeps his/her toothbrush in the shower room and that his/her teeth were last cleaned on 8/2/13. | 2016-07-01 |
| 8010 | 8010 | PINE KNOLL NURSING & REHAB CTR | 115443 | 156 PINE KNOLL DRIVE | CARROLLTON | GA | 30117 | 2012-03-22 | 157 | D | 0 | 1 | VN4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy, the facility failed to notify the physician of one (1) resident (#5) that the resident refused insulin from a sample of thirty one (31) residents. Findings include: Review on the March Medication Administration Sheet (MAR) for resident # 5 indicated that the resident was not given insulin her 9:00pm [MEDICATION NAME] on March 19, 20, and 21, 2012. Review of the Nurses Notes revealed the last entry was dated 3/19/2012 but there was no entry of physician being notified that the resident did not receive the night time dosage of insulin for March 19, 20 and 21, 2012. Record review revealed a physician's order for [MEDICATION NAME] 75 units subq at bedtime. The resident also had physician's orders for accuchecks before meals and at bedtime with sliding scale coverage. Review of the 9:00 pm blood glucose report revealed the following: 3/19/2012 blood glucose level was 226 mg/dl 3/20/2012 blood glucose level was 195 mg/dl 3/ 2 blood glucose level was 325 mg/dl Review of the MAR indicated [REDACTED]. Interview on 3/22/12 at 9:24 am with the Unit Manager BB revealed that the insulin that was given was for the sliding scale. BB also revealed that the Medical Doctor (MD) should have been notified that the resident did not receive any insulin on these three (3) different dates. BB also revealed that there was no evidence of a physician order or a nurses notes revealing that the physician was notified. BB further revealed that nurses have been trained to notify the physician if a resident refuses their insulin and to document this information. Interview on 3/22/12 at 9:32 am with Staff Development CC revealed the staff is suppose to notify the physician and document if the insulin is not given . CC also revealed that the Communication Physician Sheet should have been completed and she did not see one in the chart/medical record. Review of the Nurse Physician Communication Sheet d… | 2016-07-01 |
| 8011 | 8011 | PINE KNOLL NURSING & REHAB CTR | 115443 | 156 PINE KNOLL DRIVE | CARROLLTON | GA | 30117 | 2012-03-22 | 278 | D | 0 | 1 | VN4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, review of the Minimum Data Sets (MDS) and staff interviews, the facility failed to ensure accurate assessments for three (3) residents (#45, #70, and #82) from a sample of thirty-one (31) residents. Findings include: 1. Interview on 3/19/12 at 11:38am with facility staff, during the Stage I, revealed resident #82 had fallen in the past thirty (30) days. Staff further revealed that the resident had fallen on 2/20/12 and 3/1/12. Review of the medical record for resident #82 revealed the resident had fallen on 2/20/12 and was found on the floor beside the bed. Review of the current MDS Quarterly assessment dated [DATE] indicated under Section J1800 the resident has had no falls since admission or the prior assessment, whichever is more recent. The prior assessment was completed on 1/13/12. Interview with the MDS Coordinator DD on 3/21/12 at 2pm revealed the assessment completed on 2/28/12 should have reflected the fall on 2/20/12 and was just overlooked. 2. Resident #70 was admitted on [DATE] and had an physician order [REDACTED]. The nursing admission evaluation dated 11/30/11 indicated that the coccyx had a dark blue, red pressure area, not open, and does not need a dressing at this time. Noted with bilateral deep tissue injury (DTI) to both heels, skin intact, resident complains of pain to the site, Posey boots to both feet, will continue to monitor. A new order dated 12/3/11 directed staff to clean the coccyx with normal saline, pat dry, apply Duoderm and change every three (3) days or whenever necessary (prn). The admission assessment dated [DATE] indicated that the resident was not a risk for and had no pressure ulcers The care plan dated 11/29/11 indicated the resident had blue to red pressure area to coccyx that opened by 12/3/11. Interview with the MDS Coordinator DD on 11/20/12 at 3:00pm revealed the interdisciplinary team did their own individual sections of the assessment. The Treatment nurse was resp… | 2016-07-01 |
| 8012 | 8012 | PINE KNOLL NURSING & REHAB CTR | 115443 | 156 PINE KNOLL DRIVE | CARROLLTON | GA | 30117 | 2012-03-22 | 425 | D | 0 | 1 | VN4P11 | Based on observation, staff interview, and review of the facility policy, the facility failed to ensure that two (2) expired bottles of Lantus Insulin on two (2) of five (5) medication carts ( Cart #1 and Cart #2) were discarded per facility and manufacture's recommendations. Findings include. Random check on 3/22/12 at 6:50 am of medication cart #1 on the 100 hall revealed one (1) bottle of Lantus Insulin for resident #25 with an open date of 2/21/12. The Lantus bottle was one fourth (1/4) full. A random check of cart #2 revealed one (1) bottle of Lantus Insulin for resident # 5 with an open date of 2/16/12. The Lantus bottle was one fourth (1/4) full also. Interview on 3/22/12 at 7:00 am with the 11-7 nurse AA revealed that all Lantus Insulin should be discarded after twenty-eight ( 28) days. AA also revealed that both residents (#5, #25) were still being given the Lantus Insulin. Interview on 3/22/12 at 7:45 am with Staff Development Coordinator CC revealed that she has inserviced all the nursing staff on discarding all insulin's after twenty-eight (28) days . She further revealed that the staff are aware that all insulins can not be keep longer that twenty-eight (28) days. Review of the facility's Invasive Medication Administration policy indicated that all insulin must be dated when opened and replace after 28 days Review of the Medication Administration Record [REDACTED]. Review of the MAR for resident # 5 indicated that the resident received Lantus Insulin after the expiration date. Review of the manufacture's recommendation for Lantus Insulin revealed that an opened vial of LANTUS?, or LANTUS? SoloSTAR? pen, can be used for 28 days. The LANTUS? SoloSTAR? pen should not be refrigerated once opened, but should be kept at room temperature (below 86?F) and must be thrown away after 28 days. | 2016-07-01 |
| 8013 | 8013 | POWDER SPRINGS TRANSITIONAL CARE AND REHAB | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2013-07-24 | 309 | D | 1 | 0 | B03T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that laboratory tests were completed as ordered for one resident (#1) of four residents sampled. Findings include: Record review for Resident #1 revealed a Physician's Interim/Telephone Order dated 11/15/12 for urinalysis (UA) with culture and sensitivity (C&S) to rule out a urinary tract infection [MEDICAL CONDITION] because the resident complained of pain upon urination. Review of the Skilled Nursing Notes dated 11/15/12 at 9:30 p.m. indicated Resident #1 complained of pain upon urination. The nurse noted an order for [REDACTED].#1 because the resident did not have urine output. Review of the Skilled Nursing Notes dated 11/16/12 at 10:00 p.m. indicated urine for the UA with C&S was obtained at 11:45 p.m. and was left in the refrigerator for pick-up by the laboratory staff. However, there was no documented evidence that indicated the UA with C&S was collected and processed by the laboratory. Review of the Physician's Interim Telephone Orders dated 11/17/12 at 3:10 a.m. revealed a new physician's orders [REDACTED].#1. The skilled nursing notes dated 11/17/12 at 6:00 a.m. indicated all paper work for the stat UA with C&S were completed and the urine specimen was stored in the refrigerator. Again, there was no documented evidence that indicated the stat UA with C&S was collected and processed by the laboratory. During an interview with the administrator, the Director of Nurses and the Assistant Director of Nurses on 07/24/2013 at 5:30 p.m., after they consulted with the laboratory, they acknowledged that the UA with C&S laboratory tests were not done. The Director of Nurses and the Assistant Director of Nurses stated that the nurses should have obtained and sent the specimens to the laboratory in a timely manner and the stat laboratory work should have been done within one to two hours of the physician's order [REDACTED].> | 2016-07-01 |
| 8014 | 8014 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2013-07-12 | 225 | D | 1 | 0 | XR8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint document review, staff interview, record review, and review of the State complaint/facility self-reported incident database, the facility failed to immediately report to the State Survey and Certification Agency alleged sexual abuse of one (1) resident (#4), and failed to report alleged sexual abuse and misappropriation of property for one (1) resident (#6), of the seven (7) sampled residents. Findings include: 1. Review of a document of complaint dated 07/10/2013 received by the State Survey and Certification Agency revealed an allegation that Resident #4 had been impregnated by an unnamed facility staff member. Review of the State complaint/facility self-reported incident database revealed no evidence to indicate that this allegation of sexual abuse had been reported to the State as of the initiation of this complaint survey. Record review for Resident #4 revealed a Minimum Data Set assessment dated [DATE], which documented that the resident's Brief Interview for Mental Status (BIMS) Summary Score was 6, which indicated that she had severe cognitive impairment. Further record review for Resident #4 revealed no documentation regarding the allegation of sexual abuse involving this resident, as referenced above, and revealed no evidence to indicate that the facility had reported the allegation of sexual abuse to the State Survey and Certification Agency. During an interview with the Administrator and the Director Of Nursing conducted on 07/12/2013 at 2:36 p.m., the Administrator stated that he had been aware of the allegation of sexual abuse involving Resident #4 since Monday July 8, 2013, but further acknowledged that the facility had not reported the allegation to the State. 2. Review of a document of complaint dated 07/10/2013 received by the State Survey and Certification Agency revealed an allegation that Resident #6 had been sexually abused by a visitor, and that the facility had financially exploited this resident, re… | 2016-07-01 |
| 8015 | 8015 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2013-07-12 | 226 | D | 1 | 0 | XR8G11 | Based on complaint document review, review of the facility's Abuse Prevention Program policies and procedures, staff interview, and review of the State complaint/facility self-reported incident database, the facility failed to ensure that the Abuse Prevention Program policies included the immediate reporting of allegations of mistreatment, neglect, abuse, and misappropriation of resident property to the State Survey and Certification Agency. Specifically, the facility's Abuse Prevention Program policy failed to address the immediate reporting of alleged sexual abuse of one (1) resident (#4), and alleged sexual abuse and misappropriation of resident property for one (1) resident (#6), of the seven (7) sampled residents. Findings include: Please cross refer to F225, examples 1 and 2, for more information regarding Resident #4 and Resident #6, respectively. Review of a document of complaint dated 07/10/2013 received by the State Survey and Certification Agency revealed an allegation of sexual abuse involving Resident #4, and allegations that Resident #6 had been sexually abused by a visitor and financially exploited by the facility. Review of the State complaint/facility self-reported incident database revealed no evidence to indicate these allegations of sexual abuse and financial exploitation had been reported to the State as of the initiation of this complaint survey. During an interview with the Administrator conducted on 07/12/2013 at 9:00 a.m., he acknowledged having prior knowledge of these allegations of abuse and misappropriation of property involving Resident #4 and Resident #6 since Monday July 8, 2013. During a subsequent interview conducted on 07/12/2013 at 2:36 p.m., he further acknowledged that the facility had not reported the allegations to the State. Review of the facility's Abuse Prevention Program policy, dated as having been revised September 2012, revealed that the policy did specify the timely and thorough investigation of all reports and allegations of abuse. However, further review of the po… | 2016-07-01 |
| 8016 | 8016 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2013-07-12 | 490 | D | 1 | 0 | XR8G11 | Based on facility policy review, staff interview, complainant document review, and review of the State complaint/facility self-reported incident database, the facility failed to be administered in a manner to ensure the timely reporting to the State Survey and Certification Agency an allegation of sexual abuse involving one (1) resident (#4), and allegations of sexual abuse and misappropriation of property for one (1) resident (#6), on the survey sample of seven (7) residents. The facility also failed to ensure that the Abuse Prevention Program comprehensively addressed the immediate reporting of all allegations of mistreatment, abuse, neglect, and misappropriation, in accordance with the regulatory requirement. Findings include: Please cross refer to F225, examples 1 and 2, respectively, and F226, for more information regarding Resident #4 and Resident #6. A document of complaint dated 07/10/2013 received by the State Survey and Certification Agency alleged sexual abuse involving Resident #4 and #6, and also alleged financial exploitation involving Resident #6. However, review of the State complaint/facility self-reported incident database revealed no evidence to indicate these allegations had been reported to the State as of the initiation of this complaint survey. During an interview with the Administrator conducted on 07/12/2013 at 9:00 a.m., he acknowledged having prior knowledge of these allegations of abuse and misappropriation of property involving Resident #4 and Resident #6 since Monday July 8, 2013. During a subsequent interview conducted on 07/12/2013 at 2:36 p.m., he further acknowledged that the facility had not reported the allegations to the State. He added that if he had an inclination that any of the complaint allegations were true, he would have reported them to the State. Additionally, review of the facility's Abuse Prevention Program policy revealed that the policy failed to specify the immediate reporting of all allegations of mistreatment, neglect, abuse, and misappropriation of resident pr… | 2016-07-01 |
| 8017 | 8017 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2013-07-27 | 157 | D | 1 | 0 | 18U911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and physician interview, the facility failed to notify the physician that medications were not administered as ordered for one resident (#3) from a total sample of three (3) residents. Findings include: Please refer to F309, example 2, for additional information regarding Resident #3. Closed record review of the Resident Information sheet revealed that Resident #3 was admitted into the facility on [DATE]. On 07/27/13 at 12:33 PM, during interview with the facility assistant director of nursing (ADON) and the minimum data set (MDS) coordinator, the Medication Records, physician's order [REDACTED].#3 were reviewed. During this staff interview and record review, it was noted that the resident had physician's orders [REDACTED]. 0.9% intravenous solution (IV) on Monday, Wednesday and Friday after [MEDICAL TREATMENT]. However, further record review revealed that despite the resident's July 15, 2013 admission the facility with the physician's orders [REDACTED]. Additionally, the drugs [MEDICATION NAME] and [MEDICATION NAME] were not administered during the resident's 07/15/2013 through 07/20/2013 stay in the facility. The omission of the administration of these medications was acknowledged by both the ADON and the MDS Coordinator during the 07/27/2013, 12:33 PM interview referenced above. During a telephone interview with Resident #3's physician on 07/30/2013 at 11:07 AM regarding the facility failure to administer the medications as ordered. The physician stated that he was not notified that the pharmacy failed to deliver the medications for Resident #3 until today (7/30/13). The doctor said that it would be his expectation to be notified by the facility when medications were not available for the residents. He said that Resident #3 presented to the hospital on Friday July 19, 2013 [MEDICAL CONDITION] according to the laboratory reports. He said that the hospital discharged the resident with the abnormal lab… | 2016-07-01 |
| 8018 | 8018 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2013-07-27 | 309 | D | 1 | 0 | 18U911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, the facility failed to ensure that two residents (A and #3) of three (3) residents sampled received medications as prescribed by the physician. Findings include: 1. Resident A said that the staff at the [MEDICAL TREATMENT] Center get on him when he did not take his medications the way the doctor ordered them during an interview on 07/27/13 at 9:48 AM. Resident A communicated that the nurses did not administer the [MEDICATION NAME] Binder ([MEDICATION NAME]) before meals but gave it way after his meals. The resident said that he complained to nursing staff in the past because they did not give his medication like it was ordered but even today he had not received the binder before breakfast. Resident A confirmed that yes, at 9:48 AM hours after breakfast he had not received the binder that he should have had with his breakfast. Interview with Nurse AA on 07/27/13 at 10:25 AM revealed that she usually gave Resident A [MEDICATION NAME] Binders before or with his meals but she did not today because there was a lot going on with other residents. The nurse said that the resident received the Binder since the Resident interview was completed. Review of the July 2013 physician's orders [REDACTED]. Review of the July Medication Administration Record [REDACTED]. The nurses failed to document that the [MEDICATION NAME] was administered on 7/24/13 at 5:00 PM, 7/25/13 at 5 PM and 7/26/13 at 5 PM. The nurse documented that the [MEDICATION NAME] was given on 7/27/13 at 9:00 AM though it was not given until after 9:48 AM. Interview with the Director of Nurses by phone on 07/27/13 at 1:20 PM revealed that she was unaware of Resident 'A's grievance related to receipt of [MEDICATION NAME] Binders with his meals. 2. Closed record review of the Resident Information sheet revealed that Resident #3 was admitted into the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The physician's order [REDACTED].#3 o… | 2016-07-01 |
| 8019 | 8019 | PINEHILL NURSING CENTER | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2013-08-20 | 206 | D | 1 | 0 | D7VB11 | Based on record review, staff interview, and facility document review the facility failed to allow readmission to one (1) resident (#2), who was eligible for Medicaid nursing facility services, from a survey sample of seven (7) residents. Findings include: Review of the medical record for Resident #2 revealed a Nurse's Note dated 8/08/13 at 4:15 p.m. documenting that the resident was transported to the hospital, where he was subsequently admitted . Additional record review revealed a Pinehill Nursing Center Transfer Information Notice of Transfer form also dated 8/08/13 which documented the facility's Bed-Hold Policy. This form further documented that the resident would be placed on the facility's waiting list and readmitted to the nursing home when the next opening was available. During interview with the Administrative staff member AA on 8/20/2013 at approximately 1:56 p.m., she stated that a decision had been made that this resident would not be accepted back into this facility. At this time, Administrative staff member AA provided a letter dated 8/15/2013 which was addressed To Whom It May Concern which documented this decision. Additional interview revealed that this letter had been facsimiled to the hospital where the resident was hospitalized on the seventh day when hospital staff phoned the facility regarding his transfer back to the nursing home. AA stated that there were Medicaid beds available when Resident #2 was denied readmission into the facility. | 2016-07-01 |
| 8020 | 8020 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2011-12-16 | 280 | D | 0 | 1 | YK3P11 | Based on record review and staff interview, it was determined that the facility failed to revise the care plan and interventions to reflect the presence of actual hand contractures for one resident (#26) in a sample of 39 residents. Findings include: Resident #26 had a care plan since 10/25/10 to address his/her risk for a decline in range of motion and mobility. There were interventions for range of motion services for both of his/her upper and lower extremities and, a transfer program as indicated. There was documentation that the plan had been reviewed on 1/13/11, 6/28/11, 7/5/11, 9/15/11 and 12/9/11 but, no revisions had been done. The resident's hands were observed to be contracted into fisted positions on 12/13/11 at 2:25 p.m., on 12/14/11 at 8:20 a.m., and on 12/15/11 at 9:15 a.m. However, there was no evidence that the facility had revised the resident's care plan to address the presence of his/her actual contractures with additional interventions to be provided to address the positioning needs of his/her hands. | 2016-07-01 |
| 8021 | 8021 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2011-12-16 | 371 | F | 0 | 1 | YK3P11 | Based on observation and staff interview, it was determined that the facility failed to maintain a clean grill and clean water reservoir wells on the steamtables. Findings include: 1. During the kitchen entrance tour observations with the Dietary Manager (DM) on 12/13/11 beginning at 8:30 a.m., there was a build up of food debris that had adhered to the grill's spout to the trap. Observation of the trap beneath the grill revealed a build up of food debris along with a crumpled paper towel in the trap. During an interview at that time, the DM stated that they did not use the grill. Observations on 12/14/11 at 12:35 p.m., revealed the grill being utilized as a counter top space for cooked foods. 2. Three of the water reservoir wells of the steamtable in the kitchen had a build up of old food floating in the water and gummy surfaces adhering to the bottom of the wells. Three of the wells of the steamtable in the dining room had cloudy water and gummy residue on the inner bottom surfaces. During an interview on 12/13/11 at 9:00 a.m., the DM confirmed a build up of old residue on the bottoms and sides of the water reservoir wells of those steamtables that had not been routinely cleaned. | 2016-07-01 |
| 8022 | 8022 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2011-12-16 | 372 | F | 0 | 1 | YK3P11 | Based on observation and staff interview, it was determined that the facility failed to dispose of trash properly. Findings include: 1. During observations with the Dietary Manager (DM) on 12/13/11 at 12:50 p.m., there was not a hands-free trash can in the kitchen. The DM could not locate a trash can that could have been utilized to place trash in after washing hands without having to remove the trash can lid which would re-contaminate one's hands. During an interview on 12/15/11 at 9 a.m., the DM said that there were only large trash cans with lids in the kitchen. She said that those trash cans required that the lids be lifted with a person's hands to access the interior and dispose of trash in the kitchen. She stated that there were not any pedal operated (hands free) trash cans in the kitchen. 2. Observations of the facility's two dumpsters on 12/14/11 at 12:55 p.m. revealed that there were blue gloves scattered throughout the area adjacent to the trash dumpsters and behind the card board box recycling dumpster. There were 11 gloves on the ground adjacent to the two trash dumpsters A total of 123 blue gloves, and debris such as cellophane, were scattered over the grass next to the back drive way and fence near the cardboard recycling dumpster. There were five blue gloves next to the steps that went to the kitchen's back door. | 2016-07-01 |
| 8023 | 8023 | ALTAMAHA HEALTHCARE CENTER | 115577 | 1311 WEST CHERRY STREET | JESUP | GA | 31545 | 2012-09-13 | 241 | D | 0 | 1 | KIIQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to maintain an environment which enhanced the dignity of two residents (#40 and #46) by ensuring the privacy of confidential information about their status from a total sample of 25 residents. Findings include: There were signs posted by staff in two residents' rooms which were clearly visible to anyone entering their rooms. Those signs noted private information about the residents use of cloth diapers. One of the signs was signed by the Director of Nurses and dated 11/ 17/11. There was not any evidence of an attempt by staff to post those signs in a location to ensure the privacy of that information regarding those residents. 1. During the initial tour on 9/10/12 at 11:30 a.m. and on 9/11/2012 at 8:13 a.m., observations revealed that staff had posted instructions about the care of cloth diapers on the wall above the head of the resident #40's bed. Staff had developed a care plan to address the resident's self care deficit with an intervention for nursing staff to promptly clean him/her after each episode of incontinence. During an interview on 9/12/12 at 8:21 a.m., certified nursing assistant (CNA) JJ said that the CNAs changed resident #40's cloth diapers every two hours. She explained that if the resident had a bowel movement then, the diaper was rinsed in the hopper, placed in a clean plastic bag and taken to the laundry to be washed. The laundry returned the cleaned cloth diapers to Resident #40. In an interview on 9/12/12 at 1:00 p.m., the Social Service Director stated that the only signs that she put up in residents' rooms were the ones that noted Family will do Laundry. The Social Service Director denied having put up any signs about diapers. During an interview on 9/12/12 at 3 p.m., the Director of Nursing (DON) stated that she knew about the signs for the cloth diapers posted in Resident #40's room and they were there for a specific reason. The DO… | 2016-07-01 |
| 8024 | 8024 | ALTAMAHA HEALTHCARE CENTER | 115577 | 1311 WEST CHERRY STREET | JESUP | GA | 31545 | 2012-09-13 | 280 | B | 0 | 1 | KIIQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to review and revise care plan interventions to accurately reflect the needs for two (#32 and #79) residents in a total sample of 25 residents. Findings include: 1. Resident #79 had [DIAGNOSES REDACTED]. Staff coded him/her on the 8/23/12 comprehensive Minimum Data Set (MDS) assessment as having short and long term memory problems, moderately impaired decision making skills, as needing total assistance with activities-of-daily living (ADLs) and as having had a fall prior to admission. There was a care plan dated 8/23/12 and reviewed 8/29/12. There was a documented problem of the resident's cognitive deficit, and some short/long term memory loss related to Dementia. However, the interventions for staff to allow the resident to make his/her own choices and to orient to the facility, other residents, and activities were not appropriate based on the resident's assessed cognitive deficits. There was a care plan problem to address the resident's self care deficit. There was an intervention for nursing staff to transfer the resident as needed, to the extent required, may use lift if warrants and require one or two assess depending on the resident and situation. That intervention was not individualized to address the specific methods to use when transferring the resident. There was a care plan problem to address the resident's potential for falls and injuries. The plan documented that the potential risk factors included his/her cognitive impairment. However, the interventions for staff to encourage the resident not to attempt to transfer without calling for assistance and to keep the call bell within reach were not appropriate based on the resident's assessed cognitive deficits. 2. Resident #32 had [DIAGNOSES REDACTED]. On the 7/23/12 quarterly MDS assessment, licensed staff coded him/her as rarely understood, rarely understands, having short and long term memory problems, and severel… | 2016-07-01 |
| 8025 | 8025 | ALTAMAHA HEALTHCARE CENTER | 115577 | 1311 WEST CHERRY STREET | JESUP | GA | 31545 | 2012-09-13 | 282 | D | 0 | 1 | KIIQ11 | Based on clinical record review, observation, and interviews with staff and a resident, it was determined that the facility failed to implement planned interventions to address the visual impairment of one resident (A) in a total sample of 25 residents. Findings include: Resident A was admitted in July of 2011. Licensed staff coded resident A as having impaired vision, and able to see large print but not regular print in newspapers and books on the July, 2011 Minimum Data Set (MDS) assessment and the June, 2012 MDS assessment. There was a care plan since at least 12/01/2011 to address the resident's risk for impaired visual function. The goal was for resident A to have stable visual function and be free from injury by next review. The interventions included for staff to encourage the family of resident A to bring his/her glasses so he/she would have them as needed, and to obtain an appointment with the ophthalmologist as/if warranted. That plan was reviewed by the facility staff on 03/06/12, 06/06/12, 06/24/12, 06/29/12, 07/15/12, and 08/12/12. The updates were to continue with the plan of care. However, there was no evidence that the resident's family had brought eyeglasses for the resident or that an appointment had been obtained for the resident to see an ophthalmologist. See F313 for additional information regarding resident A. | 2016-07-01 |
| 8026 | 8026 | ALTAMAHA HEALTHCARE CENTER | 115577 | 1311 WEST CHERRY STREET | JESUP | GA | 31545 | 2012-09-13 | 313 | D | 0 | 1 | KIIQ11 | Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to implement interventions to address the assessed visual impairment for one resident (A) in a total sample of 25 residents. Findings include: Resident A was admitted in July of 2011. Licensed staff coded resident A as having impaired vision, and able to see large print but not regular print in newspapers and books on the July, 2011 Minimum Data Set (MDS) asessment and the June, 2012 MDS assessment. There was a care plan since at least 12/01/2011 to address the resident's risk for impaired visual function. The goal was for resident A to have stable visual function and be free from injury by next review. The interventions included for staff to encourage the family of resident A to bring his/her glasses so he/she would have them as needed, and to obtain an appointment with the ophthalmologist as/if warranted. That plan was reviewed six times by the facility staff on 03/06/12, 06/06/12, 06/24/12, 06/29/12, 07/15/12, and 08/12/12. The updates were to continue with the plan of care (poc). In an interview on 9/12/2012 at 1:11 p.m., the MDS coordinator stated that the Social Service Director completed the vision section of the MDS assessments. The MDS coordinator stated that she wrote the care plan for vision for resident A. The MDS coordinator stated that the Social Service Director was responsible to set up an appointment for resident A to be seen by the eye doctor. However, there was no evidence that the resident's family had brought eyeglasses for the resident or that an appointment had been obtained for the resident to see an opthamologist. In an interview on 9/12/12 at 7:35 a.m., certified nursing assistant (CNA) GG stated that she had not seen resident A with any eyeglasses. CNA GG stated that the family of resident A family did not provide him/her with glasses to her knowledge. During an interview on 9/12/2012 at 11:40 a.m., resident A said that he/she used to have glasses. Resident A stated… | 2016-07-01 |
| 8027 | 8027 | ALTAMAHA HEALTHCARE CENTER | 115577 | 1311 WEST CHERRY STREET | JESUP | GA | 31545 | 2012-09-13 | 323 | D | 0 | 1 | KIIQ11 | Based on observation and staff interview, it was determined that the facility failed to ensure that there was a secured grab bar on the wall next to the toilet in the connecting bathroom for three (3) of four (4) residents on one (C Hall) of three halls. Findings include: On 9/11/12 at 9:27 a.m., on 9/12/12 at 10:00 a.m. and on 9/13/12 at 9:40 a.m., there was not a secured grab bar on the wall next to the toilet in the connecting bath room for rooms C9 and C11. On 9/13/12 at 9:45 a.m., certified nursing assistant (CNA) AA stated that three of the four residents in rooms C9 and C11 were assisted by staff to the bathroom for toileting. On 9/13/12 at 10:00 a.m., the maintenance supervisor stated that he had refurbished the bathroom wall surrounding the toilet approximately three months ago and had failed to reinstall the grab bar. | 2016-07-01 |
| 8028 | 8028 | ALTAMAHA HEALTHCARE CENTER | 115577 | 1311 WEST CHERRY STREET | JESUP | GA | 31545 | 2012-09-13 | 514 | D | 0 | 1 | KIIQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and physician interview, it was determined that the facility failed to maintain a complete clinical record that reflected the urinary status for one resident (#1) from a sample of 25 residents. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was coded on the 8/7/12 annual Minimum Data Set (MDS) as being incontinent of bladder and bowel, as being totally dependent on staff for toileting and as not having had a UTI in the last 7 days. On 9/10/12 at 1:44 p.m., licensed nursing staff BB stated that the resident had an indwelling catheter due to urinary incontinence. BB stated that the resident had a Stage II pressure sore on his/her buttocks and that the indwelling catheter had been inserted to promote healing. On 9/10/12 at 3:44 p.m., resident #1 was lying in bed. The resident had an indwelling catheter that was draining clear yellow urine to the bedside bag. review of the resident's medical record revealed [REDACTED]. Review of the nurses' notes for 8/12-8/21/12 revealed that licensed nursing staff had documented that the resident had a soft, non-distended abdomen, was incontinent of bladder and bowel and was kept clean and dry by staff. Review of the Total Intake and Output Record for 8/1-8/21/12 revealed that the resident had voided 2-3 times per each 8 hour shift for those days. On 8/21/12, licensed nursing staff had documented in the nurses' notes that the resident had open areas on his/her right buttock and that a Foley catheter was inserted due to [MEDICAL CONDITION]. The [DIAGNOSES REDACTED]. However, there was no documentation in the resident's clinical record to support the [DIAGNOSES REDACTED]. On the Total Intake and Output Record for 8/24/12, licensed nursing staff had documented that the resident's indwelling catheter was leaking and had to be changed. On the Total Intake and Output Record for 8/25/12, licensed nursing staff had documented that the reside… | 2016-07-01 |
| 8029 | 8029 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2012-03-15 | 157 | D | 0 | 1 | 40V811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the family and/or responsible party of changes in condition requiring medical intervention for two (2) residents (#20 and # 67) from a sample of forty (40) residents. Findings include: 1. Review of a nurses note for resident #67 dated 02/09/12 at 1:30 p.m revealed that the physician was notified of the results of a urine culture and sensitivity that had been collected 2/7/12. An order was obtained to begin antibiotic therapy for a Urinary Tract Infection [MEDICAL CONDITION]. Continued review revealed a nurses note dated 03/05/12 at 10:45 a.m. that the physician was again notified about a positive urine culture and the resident was placed on antibiotics again. There was no evidence that the family/responsible party had been notified of the recurrent UTI 2. Review of a Hospice Nurses Note dated 12/13/11 for resident #20 revealed that the resident had increased confusion and hallucinations in the past thirty-six (36) hours with complaint of urgency and frequency with urination. The physician was notified and an order was obtained for antibiotic therapy. Continued review revealed that the resident had a strong odor to the urine and an order was received for a urinalysis and culture and sensitivity. The physician visited in the facility on 1/16/12 and an order for [REDACTED]. There was no evidence that the family/responsible party was notified of the recurrent UTI. Interview with Licensed Practical Nurse (LPN) CC on 03/14/12 at 4:10 p.m. revealed that they do make the physician aware if there are changes in the resident's care and document that they do, however they may not document that they make the resident's family aware of changes. If the resident family comes to the facility, they will just tell them when they are in the building. Interview on 03/14/12 at 4:26 p.m. with the Administrator revealed that they do have a notification policy and the staff are to document in t… | 2016-07-01 |
| 8030 | 8030 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2012-03-15 | 244 | E | 0 | 1 | 40V811 | Based on record review and staff interview the facility failed to make Resident Council meetings open and available to all residents. Census ninety-six (96). Findings include: Review of the resident council meeting minutes dated July 19, 2011 revealed a discussion was held to nominate additional members to the resident council. Some of the present members have declining health and no longer desire to be on the council. Resolution: Discuss issue with administration for permission and input. Review of resident council meeting minutes from August 16, 2011 revealed residents were asked to nominate names of residents to serve on resident council. Resolution: Names presented to administration for consideration. Review of resident council meeting minutes from September 19, 2011 revealed residents nominated to serve on resident council were presented and approved by administration. Interview with the Activities Director on 3/14/12 at 1:28 p.m. revealed there are specific resident council members who are nominated and come to all the meetings, but the meetings are open to any resident that wants to come; anybody who has a complaint or concern can come. The Activity Director revealed she did not understand the purpose of nominating members but that this system was in place when she took this position. She further revealed that members are nominated and approved by administration. She continued that members had to be approved by the administrator and assistant administrator. When asked how residents are told about the resident council, the AD revealed that when residents are admitted they are told that there is a council where they can come and make complaints. She conceded that the resident council is presented as if a resident does not have a problem, that resident does not need to come to the meetings. She further revealed that the resident council meetings are posted on the activities calendar. Interview with the administrator and assistant administrator on 3/14/12 at 2:30 p.m. revealed the residents usually elect the r… | 2016-07-01 |
| 8031 | 8031 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2012-03-15 | 248 | D | 0 | 1 | 40V811 | Based on observation and staff interview the facility failed to provide an activity program to meet the needs for one (1) resident (#20) from a sample of forty (40) residents. Findings include: Observation of resident #20 on 03/12/12 during initial tour of facility at 11:30 a.m. revealed the resident to be sitting up in her geri-chair in her room. The resident was very hard of hearing, even when leaning down next to her and speaking loudly into her ear. Review of the resident activities care plan revealed that the resident would participate in weekly activities and that the facility would provide one to one visits in a quiet location when resident was unable to tolerate group activities. The care plan further revealed that the facility would provide structured activity programs for intellectual stimulation for the resident. Review of the Social & Acitivities Progress Note dated 11/17/11 revealed that the resident enjoys one on one visits. Review of the Daily activities Log for January, 2012 revealed that in room visits were conducted on January 2, 5, 10, 12, 19, 23, 26, and 30, 2012. Review of the Daily Activities Log for February, 2012 revealed that in room activities were conducted February 2, 9, 13, 21,and 23, 2012. Review of the March, 2012 Daily Activities Log from march 1 through March 12 revealed that in room visits were conducted March 1, 5, and 8, 2012. There was no evidence that resident #20 had been included in these one to one activities and there was no indication, in the medical record, that the resident refused to participate in activities. During the three (3) days of the survey, the resident was never observed participating in any activities or being encouraged to attend activities by the staff. Review of the Activities Calendar for March, 2012 revealed that a scheduled activities for March 13, 2012 at 10:00 a.m. was Dynamic Mobile Dentist and at 2:00 p.m. Shopping. Interview with the Activities Director (AD) on 03/13/12 at 3:37 p.m. revealed that Shopping involves going to the residents to obtai… | 2016-07-01 |
| 8032 | 8032 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2012-03-15 | 281 | D | 0 | 1 | 40V811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to integrate the facility and hospice care plans for one (1) resident (#20) and failed to write a physician's verbal order for an antibiotic for one (1) resident (#91) from a sample of forty (40) residents. Findings include: 1. Review of the medical record for resident #20 revealed that the resident was admitted to Hospice on 07/19/11. Continued review revealed that the resident has two (2) separate care plans, one (1) for Hospice and one (1) for the facility. The care plans have not been integrated to reveal responsibilities for provision of care by which service. The facility care plan only reveals that the resident is under the care of hospice. Interview with the Administrator on 03/14/12 at 4:10 p.m. revealed that there are two (2) separate care plans for this resident with no integration of services for provision of care. 2. Review of the medical record for resident #91 revealed a physician's orders [REDACTED]. Review of nurses' note dated 3/6/12 at 3:45 p.m. revealed: New orders received for antibiotics for positive urine culture/sensitivity received on 3/5/12 and faxed to MD office. Review of results for the urine culture revealed a notation: 3/6/12 New orders. Review of the physician's orders [REDACTED]. Interview with the DON on 3/15/12 at 1:50 p.m. revealed Licensed Practical Nurse (LPN) CC took the order verbally from someone in the doctor's office and ordered the antibiotics from the drug store. She documented in nurse's notes and on the Medication Administration Record [REDACTED]. Interview with LPN CC on 3/15/12 at 1:55 p.m. revealed that there was no order written for the [MEDICATION NAME] 100 milligrams by mouth twice a day for fourteen (14) days. | 2016-07-01 |
| 8033 | 8033 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2012-03-15 | 309 | D | 0 | 1 | 40V811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to follow physician's orders for a urinalysis for one (1) resident #91 from a sample of forty (40) residents. Findings include: Review of physician's orders for resident #91 revealed that a urinalysis was ordered to be collected on 3/01/12. Review of the laboratory requisition with date specimen to be collected 3/01/12 revealed the urine tests that had been ordered were urine culture/culture vial; urine [MEDICATION NAME]; and urine creatinine. Review of the specimen log record revealed that a urine [MEDICATION NAME] and urine creatinine were the only urine tests requested to be collected on 3/01/12. Interview with Licensed Practical Nurse CC on 3/15/12 at 2:40 p.m. revealed that the order slip for Clinical Laboratory Services requested a Urine Culture/Culture Vial and that the incorrect laboratory test was requested. | 2016-07-01 |
| 8034 | 8034 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2012-03-15 | 314 | D | 0 | 1 | 40V811 | Based on observation, record review, family interview and staff interview the facility failed to provide care for skin breakdown in a timely manner for one (1) resident (#67) from a sample of forty (40) residents. Finding include: Observation of resident #67 on 3/14/12 at 10:13 a.m. during skin assessment revealed a small bump with a small opened circular area with a red base on the resident's left buttocks. Continued observation revealed that the treatment nurse cleaned the area with normal saline, patted the area dry and applied a skin barrier paste. Review of the medical record revealed no evidence that this open area had been identified prior to this observation. Review of the treatment nurse's note dated 03/14/12 revealed the following: Pressure ulcer to left buttock measuring .6 centimeters (cm) by 1cm x less than .1 cm depth; stage 2 red granulation tissue to wound bed with open wound edges with scant to light serous exudate with no odor or signs/symptoms of infection. Surrounding tissue normal and intact. She is up daily to geri chair. Air mattress to be placed to bed. Physician notified with order noted for the area. She is non-ambulating and dependent for activities of daily living. Physician and family aware. Family has previously refused to have a mattress on bed. Pressure relief device to geri chair. Interview on 03/14/12 at 10:51 a.m. with Certified Nursing Assistant (CNA) AA revealed that she did see the area when she bathed the resident this morning but did not report it because she assumed it had already been reported. Continued interview revealed that she assumed it had been reported because the resident had skin barrier paste on the area on Monday morning, 3/12/12, when she provided care therefore, she continued to apply the paste. Interview with CNA BB on 03/14/12 at 11:50 a.m. revealed that she worked Sunday, 03/11/12 and cared for resident #67. Continued interview revealed that the resident received a bath and she noticed the open area to her bottom and reported it to the nurse. Interview wi… | 2016-07-01 |
| 8035 | 8035 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2012-03-15 | 463 | D | 0 | 1 | 40V811 | Based on observations and staff interviews the facility failed to maintain a functioning call light system for four (4) resident rooms of fifty-two (52) rooms checked on two (2) of two (2) halls. Findings include: 1. Observation on 3/12/12 at 11:00 a.m. revealed that the call light in the bathroom between rooms 4 and 5, that is used by three (3) residents, was not working, the call lights in room 5 for both bed A and bed B were not working and the call lights in room 7 for bed A and bed B were not working properly, the button on the call light had to held down in order for the light to work. 2. Observation on 3/12/12 at 10:30 a.m. revealed that the call light in room 31 for bed A and bed B were not working Interview with administrator on 3/13/12 at 7:59 a.m. revealed that maintenance checks the call lights monthly. Interview with the maintenance director, on 3/13/12 at 10:00 a.m. revealed that he usually checks the call lights monthly and more often if there is a problem. He revealed that the last time he checked the call lights was in February, 2012 but he does not keep a log of when he checks the call lights and what problems he finds. Observation on 3/13/12 at 11:59 a.m. of the call lights in room 52, formerly the treatment room, where two (2) residents live revealed that neither of the two call lights in the room work. There is no light above the door. Interview with a Certified Nursing Assistant on 3/13/12 at 12:01 p.m. revealed the call lights for this room make a noise at the nurses' station; she confirmed that neither call light in the treatment room was working. Interview with the administrator on 3/13/12 at 12:10 p.m. confirmed that neither call light in the treatment room where two (2) residents live was working | 2016-07-01 |
| 8036 | 8036 | GRACE HEALTHCARE OF TUCKER | 115596 | 2165 IDLEWOOD ROAD | TUCKER | GA | 30084 | 2011-09-15 | 504 | D | 0 | 1 | 5BV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to obtain labs according to the physician orders resulting in unnecessary lab draw for one (1) resident (#142) from a sample of twenty-four (24) residents. Findings include: Review of resident #142 medical record revealed a physician order dated 05/06/11 for a [MEDICATION NAME] with International Ratio (PT w/INR) to be obtained via venipuncture in one (1) week. However, there is another physician's order dated 05/08/11 for PT w/INR monthly. The facility obtained the lab in one (1) week on 05/13/11 instead of waiting until 6/08/11. Continued review of the medical record revealed that the facility obtained the laboratory study on 06/08/11 but also drew the PT w/INR 06/13/11 without a physician's order. Further review of the medical record revealed a physician's order dated 07/08/11 for a PT w/INR to be obtained in one (1) week, 07/15/11. The facility obtained the laboratory work on 07/15/11, but on 07/11/11 with no physician's order. An order dated 07/15/11 revealed that the lab work should be repeated in one (1) month, however the facility obtained the lab 08/08/11. The facility obtained labs four (4) times unnecessarily without orders (05/13, 06/08, 07/11 and 08/08/11). Interview with the Director of Nursing (DON) on 09/14/11 at 1:09 p.m. revealed that she was not sure why the labs were done like they were. She did concur that the physician's order on 05/08/11 should have overridden the order on 05/06/11, therefore only obtaining the [MEDICATION NAME] w/INR monthly instead of in one week. Interview with the DON and Unit Manager of North Hall on 09/14/11 at 2:19 p.m. revealed that they felt they had orders for all of the labs but were unable to provide evidence of these physician's orders. Continued interview revealed that the DON indicated that the problem originated with the lab manifest, which revealed that the lab was to be drawn monthly and no matter how many times the physici… | 2016-07-01 |
| 8037 | 8037 | WARM SPRINGS MEDICAL CENTER NURSING HOME | 115603 | 5995 SPRING STREET | WARM SPRINGS | GA | 31830 | 2012-03-29 | 323 | E | 0 | 1 | D6G711 | Based on observations, record review, staff interviews and review of facility policy, the facility failed to ensure that resident's environment remained free of accident hazards related to hot water temperature of 120 degrees Fahrenheit (F) in two (2) resident rooms and one (1) common bath; and the inappropriate application of a wheelchair tray for one (1) resident (#82) from a sample of twenty-seven (27) residents. Findings include: 1. Observation of water temperatures during the general environmental tour conducted with the Facility Maintenance Director on 03/28/12 starting at 1:00 pm revealed water temperatures of 120 degrees F. in the following areas: Ground floor: Water temperature in the common shower room was 120 degrees F The facility reported that all twenty (20) ground floor residents were bathed in this shower room. Resident room Water temperature at the hand sink in room 65 was 120 degrees F Two (2) residents in this room that had access to the sink. Interview with the Maintenance Director on 03/28/12 at 1:15pm, revealed that there have been water temperature issues, especially in the rooms next to the boiler on both floors. He further indicated that he is always tweaking the boiler to maintain proper temperatures. Interview with the Chief Nursing Officer on 03/28/12 at 2:30pm, revealed that she is aware of problems related to water temperature, and that the facility has purchased new parts for the boiler to keep temperatures in range. Review of facility policy reveals that the water temperatures for bathing and handwashing shall be maintained between the temperature range of 95 degrees F. and 110 degrees F. 2. Observation of resident (#82) on 03-28-2012 at 10:45am revealed the resident sitting in a wheel chair with a clear, plastic tray attached to both sides of the chair arms with velcro straps that were tied in knots. The resident was unable to release the tray due to straps being tied in knots. A previous observation conducted 3/28/12 at 8:30am revealed the resident was up in the wheelchair with t… | 2016-07-01 |
| 8038 | 8038 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2012-08-09 | 252 | D | 0 | 1 | FUE711 | Based on observation and staff interviews, it was determined that the facility failed to maintain an environment free from pervasive odors in one bathroom (M21) in a sample of rooms checked for a total sample of 22 residents. Findings include: The bathroom in room M21 had a mixture of air freshener and urine or, a strong pervasive urine odor on 8/07/12 at 11:18 am and 1:50 p.m., on 8/08/12 at 10:15 a.m. and 1:25 p.m., and on 8/09/12 at 12 p.m. and 1:45 p.m. Housekeeping staff LL stated on 8/09/12 at 9:35 a.m., that the resident's room was mopped daily but, the urine odor always returned. The administrator stated during an interview on 8/9/12 at 11:50 a.m., that it would probably take stripping the wax off of the floor to remove the odor from the resident's room. She said that the facility was in the process of using a new company to provide training for the floor technicians and new floor cleaning products. However, a review of documentation provided by the facility revealed that training for the floor technicians and use of any new products would not occur until 8/21/12. | 2016-07-01 |
| 8039 | 8039 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2012-08-09 | 281 | D | 0 | 1 | FUE711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, it was determined that the facility failed to monitor and assess one resident's (#56) aftercare of a urethral stent placement from a total sample of 22 residents. Findings include: According to the Georgia Practical Nurses Practice Act 43-26-32, the practice of licensed practical nursing means the provision of care that includes the participation in the assessment, planning, implementation and evaluation of health care services. However, licensed nursing staff failed to assess and evaluate resident #56 following urinary stent placement. According to Drugs.com, Urethral Stent Placement information, a resident who had had the procedure was to contact a caregiver if there was pain in the lower abdomen (stomach); if there was a feeling of needing to urinate more often than usual and; if there was pain in the area between the anus and genitals. The resident was to seek care immediately if there was a high body temperature and shaking chills; if there was blood or discharge in the urine; if there was severe flank or low back pain and; if having trouble urinating or pain when urinating. However, there was no evidence that resident #56 was monitored for the symptoms listed above that had the potential to require physician intervention. Resident # 56 had [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE] at 4:30 p.m. after having a urethral stent placement at the hospital. The resident returned with the 'patient discharge instructions' sheet for the nursing staff to follow. The instruction sheet included directions for the resident to limit activities, drink plenty of fluids, stay hydrated, and follow all of the instructions given by the physician. The instructions also included that the resident receive 500 milligram (1/2 tablet) [MEDICATION NAME] a day. There were further instructions to return to the emergency room if the resident's temperature was over 101 degrees, if pai… | 2016-07-01 |
| 8040 | 8040 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2012-08-09 | 282 | D | 0 | 1 | FUE711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and record review, it was determined that the facility failed to implement the care plan for one resident (#15 ), who had a history of [REDACTED].#15 and # 3) while receiving antipsychotic medications from a total sample of 22 residents. Findings include: 1. Resident #15 had [DIAGNOSES REDACTED]. There was a care plan since 1/30/07 to address the resident's risk for potential injury because of limited mobility and leg amputation. The 7/18/12 nurses' notes documented that the resident had been found on the floor on 7/18/12 with a hematoma on his/her head. The care plan was revised on 7/18/12 to include interventions for staff to keep the bed in the low position and to place a fall mat on the floor. However, during observations on 8/8/12 at 5:30 p.m. and 6:45 p.m. and on 8/9/12 at 9:20 a.m., the resident was observed in the bed but, staff had not placed a fall mat on the floor. The fall mat was rolled up and propped against the wall. See F323 for additional information regarding resident #15 Resident #15 was receiving one 0.5 milligrams (mg) of [MEDICATION NAME] at bedtime. There was a care plan since 1/26/09 with interventions for nursing staff to monitor the resident for side effects of the medication and for behavior monitoring. However, there was no evidence on the resident's July and August Medication Administration Records (MAR) that the nursing staff had monitored the resident as planned. 2. Resident #3 had [DIAGNOSES REDACTED]. The resident was receiving 12.5 mg of [MEDICATION NAME] (one half of a 25 mg tablet) every night. The resident had a care plan since 5/28/02 with interventions for the nursing staff to monitor the resident for possible side effects of the medication and for behaviors. However, there was no evidence on the resident's July and August MARs that nursing staff had monitored the resident as planned. See F329 for additional information regarding residents # 3 and #15. | 2016-07-01 |
| 8041 | 8041 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2012-08-09 | 309 | D | 0 | 1 | FUE711 | **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 follow the physician's orders for administration of a drug to one resident (# 3) from a total sample of 22 residents. Findings include: Resident # 3 had [DIAGNOSES REDACTED]. The resident had a physician's order since 6/5/12 for nursing staff to give him/her 1 milligram (mg) of Glimepride every morning. The order included that the nursing staff was supposed to hold the Glimepride if the resident's finger stick blood sugar level results were less than or equal to 100. However, a review of the resident's medical record revealed [REDACTED]. Since the nursing staff could not determine if the resident's blood sugar level was less than or equal to 100, they could not follow the physician's order for administration of 1 mg of Glimepride during that period. However, licensed nursing staff signed the MAR each day to indicate that Glimepride had been given every day. During an interview on 8/9/12 at 2:45 p.m., the Director of Nurses was unable to provide any evidence that nursing staff had obtained the resident's the fingerstick blood sugar levels from 6/6/12 through 6/30/12. Licensed nursing staff documented the resident's fingerstick blood sugar level results on the July and August, 2012 MAR. Although nursing staff documented on the MARs that the resident's blood sugar level was below 100 for seven days in July (7/8, 7/16, 7/18, 7/20, 7/28, 7/29, and 7/30) and three days in August (8/01, 8/06, and 8/07), nursing staff did not hold the Glimepride as ordered. | 2016-07-01 |
| 8042 | 8042 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2012-08-09 | 323 | D | 0 | 1 | FUE711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, it determined that the facility failed to provide a fall mat beside the bed for one resident (#15) with a history of a falls from a total sample of 22 residents. Findings include: Resident #15 had [DIAGNOSES REDACTED]. There was a care plan since 1/30/07 to address the resident's risk for potential injury because of limited mobility and leg amputation. The 7/18/12 nurses' notes documented that the resident had been found on the floor on 7/18/12 with a hematoma on his/her head. The care plan was revised on 7/18/12 to include interventions for staff to keep the bed in the low position and to place a fall mat on the floor. However, during observations on 8/8/12 at 5:30 p.m. and 6:45 p.m. and on 8/9/12 at 9:20 a.m., the resident was observed in the bed but, staff had not placed a fall mat on the floor. The fall mat was rolled up and propped against the wall. Staff had failed to consistently implement the intervention for the floor mat to be beside the bed when the resident was in the bed. | 2016-07-01 |
| 8043 | 8043 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2012-08-09 | 329 | D | 0 | 1 | FUE711 | **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 monitor two residents (#3 and #15) who were receiving antipsychotic medications for potential side effects and behaviors in a total sample of 22 residents. Findings include: 1. Resident # 3 had [DIAGNOSES REDACTED]. The resident was receiving 12.5 mg of [MEDICATION NAME], one half of a 25mg tablet, every night. A review of the Medication Administration Record [REDACTED]. However, a review of the July and August MARs had no evidence that the monitoring had been done. 2. Resident # 15 had a [DIAGNOSES REDACTED]. The resident was receiving 0.5mg of [MEDICATION NAME] one tablet at bedtime. A review of the resident's July and August MARs revealed no evidence that nursing staff had monitored for side effects and behaviors related to the use of [MEDICATION NAME]. During an interview on 8/09/12 at 2:45 p.m., the Director of Nurses stated that the facility had undergone changes in management which included the printing of physician's orders [REDACTED]. Therefore, there was no evidence that the monitoring had been done. | 2016-07-01 |
| 8044 | 8044 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2012-08-09 | 333 | D | 0 | 1 | FUE711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined that the facility failed to assure one resident (#19) was administered an extended release pain medication in the manner intended to provide twelve hour relief in a sample of 10 residents observed during medication administration. Findings include: Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. On 8/7/12 at 4:20 p.m. during observation of the medication administration, licensed nurse RR crushed two [MEDICATION NAME] sulfate extended release pills (one 30 milligrams (mg) and one 15 mg) and mixed the resulting powder in pudding. Nurse RR said that the (extended release) medication was crushed because the resident swallowed it better. According to the Geriatric Medication Handbook, 12th edition, that medication had a warning that extended or sustained release dosage forms should not be crushed or chewed. There was documentation that there was no maximum dose for chronic pain but, the action taken by nurse RR contraindicated the extended release mechanism for that medication. In an interview on 8/8/12 at approximately 1:30 p.m. and on 8/9/12 at approximately 10 a.m., the Director of Nursing (DON) stated that the medication should have been given whole. After surveyor inquiry, the DON notified the resident's physician about the nurse crushing and adminsitering the exgtended release [MEDICATION NAME]. The physician had no further orders or changes to the resident's existing orders. | 2016-07-01 |
| 8045 | 8045 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2012-08-09 | 505 | D | 0 | 1 | FUE711 | **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 report an abnormal laboratory test result to the physician in a timely manner for one resident (#3) in a total sample of 22 residents. Findings include: Resident #3 had [DIAGNOSES REDACTED]. history of [MEDICAL CONDITIONS] and chronic [MEDICAL CONDITION]. The resident was receiving [MEDICATION NAME] therapy and having a [MEDICATION NAME] time (PT) and international normalized ratio (INR) checked as ordered by the physician. The resident had a Pt/INR drawn on Friday, 6/15/12, with the the report having been faxed to the facility at 20:36 (10:36 p.m.) on the same day. The results were abnormal, the PT was high at 38.9 (11.8-13.3) and the INR was high at 3.15 (0.9-1.2). However, nursing staff did not notify the MD about those abnormal test results until Monday, 6/18/12. During an interview on 8/9/12 at 2:45 p.m., the Assistant Director of Nursing (ADON) stated that the facility received all laboratory reports on a printer in her office and that no staff had access to her office on the weekends. She said that the laboratory always notified the nursing staff by phone if a resident had a critical high laboratory test result. Therefore, the weekend nursing staff were not able to promptly notify physicians about any laboratory test results. Although the facility provided documentation that the 6/18/12 Performance Improvement committee's plan was to have a daily checklist and for the unit managers to monitor daily that the physicians were notified about laboratory test results, there were no approaches to address the problem of a lack of access to those results on the weekends by the licensed nursing staff and unit managers. | 2016-07-01 |
| 8046 | 8046 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2012-08-09 | 514 | D | 0 | 1 | FUE711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, it was determined the facility failed to maintain accurate and complete Physician's Order Forms for one resident (#85) from a total sample of 22 residents. Findings include: Resident #85 was admitted to the facility on [DATE] with a stage four pressure ulcer on his/her sacrum and an indwelling urinary catheter. On 6/15/12, the physician ordered nursing staff to start a wound vac to the sacrum wound (pressure ulcer). The physician ordered that the wound vac settings be continuous and vac pressure be set at 100. The pressure ulcer/ wound treatment order included for nursing staff to cleanse the wound with saline wound wash, apply saline moistened 4x4's to the wound bed, and cover it with a [MEDICATION NAME] dressing every Monday and Thursday and as needed. Nursing staff NN confirmed on 8/7/12 at 11:30 a.m. that the resident continued to have an indwelling urinary catheter and stage four pressure ulcer on his/her sacrum. However, a review of the current August 2012 Physician's Order Forms revealed that the order for the resident's continued use of an indwelling urinary catheter and the pressure ulcer/wound treatment orders had not been printed on the current order sheet. | 2016-07-01 |
| 8047 | 8047 | PRUITTHEALTH - FRANKLIN | 115616 | 360 SOUTH RIVER ROAD | FRANKLIN | GA | 30217 | 2012-04-18 | 272 | D | 0 | 1 | ZEWT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Sets (MDS) assessment, Physician's orders, Medication Administration Record [REDACTED]. Findings include: Record review for resident #81 revealed an admission MDS dated [DATE] that did not indicate use of [MEDICAL CONDITION]/antianxiety medications. The resident had a physician's order for [MEDICATION NAME] one (1) milligram (mg) by mouth (po) every eight (8) hours as needed (prn). Review of the January 2012 MAR indicated [REDACTED]. Interview with with the MDS Coordinator AA on 4/18/12 at 9:00am revealed that [MEDICATION NAME] should have been addressed on the MDS dated [DATE]. | 2016-07-01 |
| 8048 | 8048 | PRUITTHEALTH - FRANKLIN | 115616 | 360 SOUTH RIVER ROAD | FRANKLIN | GA | 30217 | 2012-04-18 | 274 | D | 0 | 1 | ZEWT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Sets (MDS) assessments, Physicians orders, care plans, and staff interviews, the facility failed to complete a significant change assessment for one (1) resident ( #57) from a sample of twenty-seven (27) residents. Findings include: Record review for resident #57 revealed the resident was admitted to Hospice care on 03/21/2012. Further record review revealed a physician's orders [REDACTED]. Review of the resident's care plan dated 03/21/12 included Hospice care. Review of Social Services notes dated 04/09/12, revealed that the resident had a significant change this quarter and was admitted to hospice on 03/21/2012. Interview with the Social Worker on 04/17/2012 at 2:20 p.m. revealed the resident had a decline in condition, and Hospice was consulted for an assessment which resulted in the resident being placed on Hospice care on 03/21/2012. This was a significant change, which requires a significant change assessment within fourteen (14) days of the resident being placed on Hospice care. Interview with the Assistant Director of Nursing (ADON) on 04/17/2012 at 2:50 p.m. revealed that a significant change assessment should be performed immediately when a resident is placed on Hospice. Interview with the Minimum Data Set Coordinator on 04/17/2012 at 3:05 p.m. revealed there was not a significant change assessment performed on this resident when placed on Hospice care. Interview with the Clinical Reimbursement Consultant on 04/17/2012 at 3:15 .pm. revealed the resident was placed on Hospice on 03/21/2012 and a significant change assessment should have been performed by 04/04/12. | 2016-07-01 |
| 8049 | 8049 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2012-04-05 | 246 | D | 0 | 1 | NEGU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to consistently provide services to address the positioning needs of one resident (#48) in a wheelchair in a total sample of 31 residents. Findings include: Resident #48 had [DIAGNOSES REDACTED]. Observations on 4/03/12 at 9:14 a.m. revealed the resident seated in a wheelchair in the dining room but, his/her upper body was leaning to the right and bent down from the waist. During an observation and interview with the Assistant Director of Nursing (ADON) on 4/03/12 at 3:47 p.m., the resident sat in the wheelchair. He/She was leaning to the right and bent at the waist. There was a Velcro seat belt on the resident during that observation. The ADON stated that the Velcro seat belt was used to keep the resident from falling forward. She stated that the resident could not get up by himself/herself. During an observation with the Director of Nursing (DON) on 4/04/12 at 9:44 a.m., the resident was sitting in the wheelchair. He/She was leaning forward and to the right. There was a 3/24/12 Request for Therapy Screen Due to Change of Status form with documentation that the change in the resident's status was falls. Staff noted on that form that the therapy department had recommended the use of a Velcro seat belt to address the resident's falls. However, there was not any evidence that nursing staff had identified the resident's positioning needs and/or that the therapist had addressed that the resident was leaning over and to the right when in the wheelchair. After surveyor inquiry, on 4/04/12, the therapists assessed the resident as having kyphosis, scoliosis and as leaning to the right and forward with hip rotation. The therapist recommended a different type of wheelchair, one with lateral wings for upper torso support for the resident. | 2016-07-01 |
| 8050 | 8050 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2012-04-05 | 278 | D | 0 | 1 | NEGU11 | Based on observations, staff interview, and record review, it was determined that the facility failed to accurately assess one resident's (#48) functional range of motion from a total sample of 31 residents. Findings include: Review of the staff coding of resident #48 on the Minimum Data Set (MDS) assessments completed on the 10/22/11 (annual comprehensive assessment) and the 01/17/12 (quarterly assessments ) revealed that they had coded his/her as not having had any impairments in his/her functional range of motion abilities. However, those MDS assessments had been inaccurately coded by staff and did not reflect the resident's limitations in range of motion in his/her left hand which had previously been identified by the occupational therapist (OT). The occupational therapist noted on the 4/27/11 Initial Evaluation and Plan of Treatment form that the resident had a flexion contracture of digits 3 to 5 in his/her left hand. The OT had noted on 12/8/11 that the resident would benefit from skilled OT to increase his/her passive range of motion and decrease his/her contracture. | 2016-07-01 |
| 8051 | 8051 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2012-04-05 | 309 | D | 0 | 1 | NEGU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to ensure that nursing staff had followed up with attending physicians in a timely manner about one abnormal laboratory test result reported for one resident (#9) from a total sample of 31 residents. Findings include: Resident #9 had [DIAGNOSES REDACTED]. According to the Drug Information Handbook for Nursing, 8th Edition, recommended daily allowances of vitamin D have not been developed to persons over [AGE] years of age. Elderly persons consume less vitamin D, their absorption of it may be decreased and they many have decreased exposure to the sun. The warnings and/or precautions included that vitamin D should be administered with extreme caution in residents with impaired renal function and [MEDICAL CONDITION]. Nursing actions included monitoring laboratory tests. However after documenting that the 10/24/11 report had been faxed to the resident's attending physician, there was not any evidence that nursing staff had follow-followed up with the attending physician in a timely manner about those abnormal vitamin D level test results for resident #9. Resident #9 had a Vitamin D level (laboratory test) obtained on 9/07/11. The test results were available to the facility on [DATE]. The laboratory reported that the test results were abnormally low with a value of 26 from a range of 30-100 ng/ml. The facility staff documented on the laboratory report that the physician was faxed the results on 9/12/11. On 9/13/11, the physician ordered that 50,000 units of Vitamin D be administered to the resident once a week for six weeks and then recheck the resident's Vitamin D level. A Vitamin D level (laboratory test) was obtained on 10/21/11 as ordered. The test results were available to the facility on [DATE]. The test results were reported as abnormally low with a value of 27.9 from a range of 32-100 ng/ml. Nursing staff documented having faxed the report on 10/24/11. Despite the lack of a… | 2016-07-01 |
| 8052 | 8052 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2012-04-05 | 371 | F | 0 | 1 | NEGU11 | Based on observation and staff interview, it was determined that the facility failed to ensure that the kitchen was free from dust and food debris in the food preparation and utensil and dish cleaning areas. Findings include: During an interview on 4/4/12 at 11:45 a.m., the Dietary Manager said that the kitchen staff had a routine cleaning schedule which was posted in the kitchen. The Dietary Manager said that they cleaned the stove every week on Thursdays. The following on 4/2/12 at 11:45 a.m. and on 4/4/12 at 1 p.m. 1. There was a build-up of dust around the temperature knobs on the stove. 2. The artificial plant hanging over the three compartment sink was dusty. 3. There was food debris on the shelf beside the dishwasher. The plastic dishwasher crates were stored on that shelf. 4. A dome lidded trash can, which was not completely covered, was positioned near the sink where kitchen staff washed their hands and near the dishwasher. One side of the domed lid was open. | 2016-07-01 |
| 8053 | 8053 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 156 | B | 0 | 1 | VJEI11 | Based on observation and staff interview the facility failed to post contact numbers for reporting abuse to the State Agency for residents on one hall, (1) West Wing Hall, of three (3) halls in the facility. Findings include: Observation on 12/08/11 at 11:55 a.m. revealed that there was not an Abuse Hotline poster on the West Unit that explains how to report suspected abuse to the state agency. A tour of the West Wing Unit with Licensed Practical Nurse (LPN) CC at this same time revealed that there was no Abuse Hotline poster prominently displayed for residents, staff or family to utilize. The poster was prominently displayed on the East Wing Unit. | 2016-07-01 |
| 8054 | 8054 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 157 | D | 0 | 1 | VJEI11 | Based on observation, record review and staff and resident interview the facility failed to provide timely notification to the physician and/or family for two (2) residents on a sample of thirty-nine (39). The family of one resident (# 127), was not provided timely notification of significant weight loss and the physician was not notified timely of pain and concerns with a indwelling Foley catheter for one (1) resident (#117). 1. Review of the Clinical Record of resident #127 revealed the resident had a significant weight loss of seven (7) pounds or of 5.83 percent (5.83%) from October 2011 to November 2011. Review of a dietary note dated 11/11/11 revealed the facility identified the weight loss and interventions were put in place to address the weight loss. Further review of the record revealed no evidence the resident's family was notified of the significant weight loss. During an interview on 12/06/11 at 11:00 a.m Licensed Practical Nurse (LPN) NN confirmed she could find no evidence the family was notified of the significant weight loss. 2. Resident A was observed on 12/06/11 at 2:00 p.m. in his wheelchair at the nurses' station requesting that Licensed Practical Nurse (LPN) AA call an ambulance and send him to the emergency room . He pointed to his lower abdomen and complained of pain and burning in the bladder region related to an indwelling urinary catheter. He further stated he felt something was wrong with the catheter and had complained of this since 12/05/11. LPN AA stated she had called the physician's office on 12/05/11 regarding the resident's discomfort and had not received a return call. She further stated she had not attempted to call the physician again. The nurse also explained to the resident that it was normal for him to have discomfort after surgery. The resident continued to complain of discomfort and requesting to go to the emergency room . LPN AA stated she would call the Physician's office again and arrange an office visit if possible. Review of the Nurses' Notes dated 12/05/11 at 5:00 p… | 2016-07-01 |
| 8055 | 8055 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 161 | E | 0 | 1 | VJEI11 | Based on record review and staff interview the facility failed to provide a surety bond with a penal sum sufficient to assure the security of personal funds of residents that were deposited with the facility. This affected all residents with personal funds held by the facility in a trust fund account (number = 103). Findings include: Record review revealed that the facility's surety bond penal sum was currently limited to $45,000 dollars. Further record review revealed that the trust fund's ending bank balance on 9/30/11 was $48,521 and on 10/31/11 it was $46,250. A review of trial fund balance on 12/08/11 revealed that the current total balance was $61,234. This information was verified by the facility's Administrator in an interview on 12/8/11 at 10:00 a.m. | 2016-07-01 |
| 8056 | 8056 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 252 | E | 0 | 1 | VJEI11 | Based on record review and interview the facility failed to provide a homelike atmosphere in dining rooms. This affected all residents who visit the rooms for meals or for recreational activities (census = 131). Findings include: During an observation of the facility's main dining room on 12/05/11 at 12:30 p.m. eleven of eighteen (11 of 18) windows on the west side of the Main Dining Room were noted to have sills and/or sashes that are in various stages of substantial deterioration. This information was confirmed by the facility's Administrator in an interview on 12/05/11 at 2:30 p.m. During the dining experience on 12/05/11 at 11:30 a.m. in the Special Care Unit the following was observed: There were eleven dining (11) chairs in the dining room. All of the chairs were scuffed, with the finish peeling off the arms and legs, there were food particles noted in the crevices of the chairs with dried substances on the chairs. The right arm of one chair was loose. One set of twelve (1 of 12) blinds in the dining room was noted to have bent and broken blades. This was confirmed by the Administrator during an interview on 12/07/11 at 3:00 p.m. | 2016-07-01 |
| 8057 | 8057 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 253 | E | 0 | 1 | VJEI11 | Based on observation and staff interview the facility failed to maintain a clean, organized environment on both the East and West Wings related to worn, or broken furniture, loose baseboards and accumulation of dirt and cobwebs in doorways, furniture and windowsills. Findings include: The following were observed on the West Wing during initial tour on 12/05/11 which began at 8:30 a.m. and again during environmental tour on 12/07/11 at 4:00 p.m: 1. A common room used for dining and activities at the end of Twelve Oaks Hall had a long table with chipped or missing veneer. Molding along the baseboard to the left of back door was loose. A maroon colored sofa along the window area on the left side of the room had a tear in the upholstery one and a half to two inches (1-1/2 to 2 ) long with stuffing exposed. cobwebs under two (2) chairs to the left of the sofa. 2. The lower foot board on the side nearest the window in room 220-2 had a large piece that had broken away. 3. The windows of each resident room on the 300 Hall were dusty and streaked with a white film. Each room had double panes and the white film on one of the panes covered the window, blocking the view to the outside. 4. The common area at end of Twelve Oaks Hall had two (2) large windows, one along the back wall in the right corner, and in the far corner to the left along the side that had loose, ill fitting screens and a heavy accumulation of cobwebs. During environmental tour of the East Wing on 12/08/11 at 10:20 a.m. the following concerns were noted: 1. In the hallway outside of rooms 101 and 102 the baseboard was pulled away from the wall. The wallpaper that was below the chair rail in this same area also was pulled away from the wall above the baseboard. 2. In room 111 there was patched unpainted drywall next to the bathroom door. The drywall at the head of the bed and on the right side of the bed had been gouged and scuffed removing the paint from these areas. 3. In rooms 102, 103, 106, 110, 114, 115, 116, 117, 118, 119, 121 and 123 the wallpaper bo… | 2016-07-01 |
| 8058 | 8058 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 274 | D | 0 | 1 | VJEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to perform a comprehensive assessment for one resident (#26) on a sample of thirty-nine (39) residents who experienced a decline in physical condition after a fall. Findings include: Review of the Quarterly Minimum Data Set Assessment (MDS) for resident #26 dated 6/25/11 revealed the resident required supervision with transfers and ambulation, limited assistance with dressing and supervision with her personal hygiene and was only occasionally incontinent. The resident experienced a fall on 7/11/11 and was hospitalized . The resident returned from the hospital on [DATE] and had an order to receive Physical Therapy (PT). Review of the PT evaluation dated 7/18/11 indicated the resident required maximum assistance with ambulation and transfers. Interview on 12/07/11 at 12:20 p.m, the Registered Physical Therapist (RPT) revealed the resident's current condition was unchanged from the time she returned the facility following the fall. The resident received Physical Therapy (PT) after the fall and made very little progress. She further stated the resident was fully ambulatory and wandered on the unit prior to the fall, and when receiving therapy the resident required maximum assistance with transfers and ambulation. During observations on 12/07/11 at 9:00 a.m. the resident was sitting in a wheelchair in the day room, was constantly chattering and speech was unintelligible. During and interview on 12/07/11 11:30 a.m. the MDS coordinator stated the resident was ambulatory and was taking herself to the bathroom and was only occasionally incontinent before her fall. She further stated since she came back to the facility after the fall her condition had severely declined. Review of the quarterly MDS dated [DATE] revealed the resident required extensive assistance with transfers and dressing, was totally dependent with personal hygiene and was always incontinent. The resident did … | 2016-07-01 |
| 8059 | 8059 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 279 | D | 0 | 1 | VJEI11 | Based on observation, record review and staff interview with facility failed to develop a comprehensive care plan to address dental concerns for one (1) resident (#119) on a sample of thirty-nine (39) residents. Observation of the teeth of resident #119 on 12/07/11 at 10:00 a.m. revealed the resident had missing teeth in the front along with a broken tooth. Review of the annual Minimum Data Set (MDS) assessment completed on 10/25/11 revealed the resident was assessed as having missing and broken natural teeth. The Care Area Assessment (CAA) worksheet dated 10/25/11 indicated the resident had missing and broken natural teeth. The worksheet further indicated the resident had cognitive impairments and decreased mobility limiting his ability to perform personal hygiene. Care planning considerations on the worksheet indicated the resident's dental concerns would be addressed in the care plan Review of the comprehensive care plan revealed no evidence of a care plan to address the resident's dental needs. During an Interview on 12/07/11 at 3:00 p.m. the MDS coordinator confirmed a care plan to address the resident's dental needs had not been developed. | 2016-07-01 |
| 8060 | 8060 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 282 | D | 0 | 1 | VJEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident and staff interview the facility failed to follow the Comprehensive Care Plan for two (2) residents, # 129 and C of thirty-nine (39) sampled residents by not correctly applying a restraint device for resident # 129 and not providing oral care to resident C. Findings include: Resident # 129 was observed sitting in his wheelchair at an activity on 12/05/11 at 10:30 a.m. A soft waist belt was observed around his waist but it was not secured correctly in the back of the wheelchair. The ties were not crisscrossed and were very loosely looped over the back legs. The resident was observed on 12/06/11 at 9:00 a.m. in his room sitting in his wheelchair with the soft waist belt again not crisscrossed and the tie on the right side not looped around the back leg of the chair. Review of Fall Risk Assessments for each quarter dating back to the resident's admission on 9/3/2011 revealed he was assessed a high risk for falls. Review of the current Comprehensive Care Plan revealed an intervention to apply the soft belt correctly. It was added on 3/18/11 when the resident sustained [REDACTED]. The Director of Nursing (DON) was interviewed on 12/08/11 at 11:10 a.m. and stated the ties for the soft waist belt should be crisscrossed in the back of the wheelchair and looped securely over the bottom back legs of the wheelchair. She further stated an inservice would have to be done to make sure all staff knew the correct way to apply the belt. 2. During resident interview on 12/06/11 at 8:41 a.m. resident C revealed staff did not brush the resident's teeth as needed. Observation of the resident's teeth at that time revealed there was dried food particles present and they needed brushing. Record review revealed the resident had her own teeth. Review of the care plan for resident C dated 10/19/10 and reviewed quarterly revealed an intervention to provide total assistance for oral care daily. Review of the clinical recor… | 2016-07-01 |
| 8061 | 8061 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 309 | D | 0 | 1 | VJEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to follow physician orders [REDACTED].#115 and #175) of the sampled of thirty-nine (39) residents. Findings include: 1. Review of the November 2011 physician orders [REDACTED]. On two (2) days, 11/1/11 and 11/3/11, the residents B/P was above 175 mmHg. On 11/1/11 the B/P measured 176/71 mmHg and on 11/3/11 the B/P was 188/78 mmHg. Review of the November 2011 Medication Administration Record [REDACTED]. On 11/10/11, review of the MAR indicated [REDACTED]. Interview on 12/7/11 at 10:50 a.m. with Licensed Practical Nurse (LPN) OO revealed she needed to clarify the physician order. She confirmed the resident should have received the [MEDICATION NAME] on 11/01/11 and 11/03/11 and she should not have given the medication on 11/10/11. 2. Record review of resident #175 revealed a physician order [REDACTED]. Review of weight records dated 9/11/11 through 11/15/11 revealed a ten (10) pound weight loss. Review of a physician's dated 11/17/11 revealed an order to serve the resident whole milk three (3) times a day. Observation on 12/07/11 at 7:30 a.m. revealed the resident was served and consumed two percent (2%) milk. Observation on 12/07/11 at 12:40 p.m revealed the resident received and consumed 2% milk. Interview on 12/07/11 at 12:40 p.m. the Dietary Supervisor confirmed the resident was to receive whole milk not the 2% milk that was served. | 2016-07-01 |
| 8062 | 8062 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 312 | D | 0 | 1 | VJEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide the necessary services to maintain good oral hygiene for one (1) dependent resident, resident C on a sample of thirty-nine (39) residents. Findings include: Interview on 12/06/2011 at 8:41 a.m. with resident C revealed no one regularly brushed her teeth. The resident stated she did not know if she even had a toothbrush. The surveyor looked in resident's bedside table and observed a toothbrush and toothpaste in the drawer. Observation of the resident's teeth at this time revealed that they were dirty with food dried to the base of her teeth. The resident has her own teeth. Record review of the annual MDS assessment dated [DATE] revealed that resident C was assessed as being alert and oriented. Her BIMS score was 14 out of 15. Interview with Licensed Practical Nurse (LPN) NN on 12/06/2011 at 9:00 a.m. revealed that resident C was considered oriented and credible. Resident C was assessed as being dependent for ADL care and needing the assistance of one staff member. She was assessed as no problems with her teeth. Observation of the resident on 12/07/2011 at 2:30 p.m. revealed that her teeth were still dirty with food and plaque visible. She stated her teeth had not been brushed today. Interview with the unit clerk for the East Wing at this same time revealed that the Certified Nursing Assistants (CNAs) chart in the Activities of Daily Living ( ADL) book resident's care. Review of the ADL sheet for resident C revealed assessment that she needed total care for hygiene but there was no documentation to support that dental care had been provided for this resident. Review of the care plan for resident C dated 10/19/10 and reviewed quarterly revealed that staff were to provide total assistance for oral care daily. There was no documentation in the of the resident refusing oral care. | 2016-07-01 |
| 8063 | 8063 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 323 | E | 0 | 1 | VJEI11 | Based on observation, record review and staff interview the facility failed to provide an environment free from accident hazards for one resident, # 129 of thirty-nine (39) sampled residents and for one resident bathroom on the Secured Unit on the West Wing, and for one common area on one of four (4) halls on the West Wing. This was related to improperly tying a restraint for resident # 129, a loose toilet seat on the secured unit, cleaning chemicals in an unlocked closet on the West wing and a table with a loose leg used for activities in a common area on the West Wing. Findings include: 1. During initial tour of the facility, which began on 12/05/11 at 8:00 a.m., a janitor's closet on Atlanta Avenue on the West Wing was unlocked and contained a chemical dispensing system affixed to the back wall. Housekeeper II was interviewed at 8:18 a.m. stated the closet contained a chemical dispensing center that was used by housekeeping staff to refill their cleaning bottles and that it should definitely be locked. She locked it at 8:20 a.m. 2. A game table in the common area at the end of Twelve Oaks Hall had one (1) very loose and wobbly leg. This was reported 12/05/11 at 8:37 a.m. to the Marketing and Admission Coordinator who immediately removed it. 3. Resident # 129 was observed sitting in his wheelchair at an activity on 12/05/11 at 10:30 a.m. A soft waist belt was observed around his waist but it was not secured correctly in the back of the wheelchair. The ties were not crisscrossed and were very loosely looped over the back legs. The resident was observed on 12/06/11 at 9:00 a.m. in his room sitting in his wheelchair with the soft waist belt again not crisscrossed and the tie on the right side not looped around the back leg of the chair. Review of Fall Risk Assessments for each quarter beginning with the resident's admission on 9/3/2011 revealed he was a high risk for falls. The Director of Nursing (DON) was interviewed on 12/08/11 at 11:10 a.m. and stated the ties for the soft waist belt should be crisscrossed in … | 2016-07-01 |
| 8064 | 8064 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 325 | D | 0 | 1 | VJEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure appropriate interventions to address a significant weight loss were put in place for one (1) resident (# 42) on a sample of thirty-nine (39) residents. Findings include: Review of the clinical record for resident #42 revealed the resident had a weight of 137 pounds on 10/06/11 and a weight of 130 pounds on 11/11/11 resulting in a 6 pound weight loss or a loss of 5.11 percent (%) in one month. Review of the Nutrition Progress note dated 11/11/11 identified the weight loss and noted a nutritional supplement was already in place and the resident had no pressure sores. The note further states the facility would continue to monitor the weights. There were no new interventions noted to address the weight loss. Review of the Medication Administration Record [REDACTED]. The resident was also receiving a multivitamin which was ordered on [DATE]. Further review of the MAR for September and October 2011 revealed the resident would consume 50% to 100% of the supplement and in November 2011 the resident refused the supplement thirty (30) times. Further review of the clinical record indicated the resident developed a stage two (2) pressure sore on his right buttock on 11/28/11, measuring 1.5 centimeters (cm) by 1.5 cm. Review of the Weight Record revealed the resident lost an additional 1.2 pounds on 11/29/11. The Weight Loss Weekly notes from the weekly weight and would meetings were reviewed, and a note was made on 11/29/11 indicating only to continue to monitor. There was no documentation to address the continued weight loss or the development of the pressure sore. During an Interview 12/8/11 at 10:30 a.m. the Director of Nursing (DON) stated the resident had been reviewed at the weekly weight and wound meeting. She confirmed the resident developed a Stage II pressure sore on the right buttocks on 11/28/11. She also confirmed there were no new interventions put into place after the… | 2016-07-01 |
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CREATE TABLE [cms_GA] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );