cms_GA
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131 rows where "filedate" is on date 2018-09-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5372 | 5372 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2014-12-11 | 157 | G | 0 | 1 | FNVB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital Emergency Department Physician's Documentation form review, hospital Emergency Department Order Results Final Report review, staff interview, and physician interview, the facility failed to immediately consult with the physician of one (1) resident (#115), upon the resident's return to the nursing facility after the resident was transferred to the hospital due to a fall, diagnosed with [REDACTED]. The survey sample size was fifty-six (56) residents. Resident #115 subsequently developed a Deep Tissue Injury (DTI) to the right outer ankle measuring 8 cms by 1.5 cm, a DTI on the top of the right foot measuring 8 cms by 2 cms, a DTI to the outside of the right foot measuring 7 cms by 2 cms, a DTI to the right inner ankle measuring 6.5 cms by 4.5 cms, a 7 cm by 7 cm by 1 cm pressure sore to the right foot Achilles Tendon, and an unstageable area to the top of the right foot measuring 6 cms by 5 cms. Findings include: Resident #115's Quarterly Minimum Data Set assessment of 08/01/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Hypertension, [MEDICAL CONDITION], and Dementia. A 10/20/2014, 4:00 p.m. Nurses Notes (NN) entry documented Resident #115 was lying on the floor and a bump to the back the head was noted. This NN documented that when notified, the physician gave an order to send Resident #115 to the hospital. A 10/20/2014 hospital Emergency Department (ED) Physician's Documentation form documented Resident #115 reported he hit his head and injured his right ankle during a fall, and physician's orders [REDACTED]. A 10/20/2014 hospital ED Order Results Final Report documented Resident #115's right ankle X-ray revealed no fracture. However, a hospital ED Physician Documentation form documented that Resident #115 was discharged from the hospital on [DATE] with Discharge Instructions identifying that he did have an ankle sprain, with Velcro Splint application, an… | 2018-09-01 |
| 5373 | 5373 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2014-12-11 | 167 | B | 0 | 1 | FNVB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to ensure survey results were accessible to residents and failed to post a notice of their availability in one (1) building (Building B) of two (2) buildings observed. Findings include: 1. An observation conducted 12/08/2014 at 11:15 A.M. in the B building revealed the survey results were in a red binder located in the glassed area of the nurses' station and not visible or accessible to visitors and residents. 2. Interview conducted with the Administrator on 12/11/2014 at 9:37 A.M. confirmed there was no sign posted to inform residents or visitors of the location of the survey results. She further confirmed the current location of the survey results was only accessible to staff. 3. Record review for Resident C revealed an Annual Minimum Data Set assessment having an Assessment Reference Date of 10/23/2014 documented, in Section C - Cognitive Patterns, that the resident had a Brief Interview for Mental Status Summary Score of 15, thus indicating the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. Interview conducted on 12/11/2014 at 6:49 P.M. with Resident C revealed that he was aware that residents had the right to see survey results, but he was not aware of where the survey results were located. | 2018-09-01 |
| 5374 | 5374 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2014-12-11 | 242 | D | 0 | 1 | FNVB11 | Based on record review, resident interview, and staff interview, the facility failed to honor choices related to the frequency and method of bathing for one (1) resident (B) from a survey sample of fifty-six (56) residents. Findings Include: Record review for Resident B revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 08/14/2014 which documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Hypertension, Diabetes Mellitus, and Dementia. This MDS also documented, in Section C - Cognitive Patterns, that Resident B had a Brief Interview for Mental Status Summary Score of 12, indicating the resident had moderate cognitive impairment. Section G - Functional Status documented that Resident B required supervision/oversight with walking, and set-up and physical help in part of the bathing activity. The Care Plan for Resident B, up-dated on 12/14/14, indicated that staff were to assist with bath or showers as needed, and to allow the resident to make choices and assist in care. During an interview with Resident 'B' conducted on 12/08/2014 at 1:22 p.m., the resident stated she would like to have more than one (1) shower per week. The Hall Shower List indicated that Resident B was to have a shower twice per week, on Monday and Friday. However, review of the (MONTH) 2014 Activity of Daily Living (ADL) Tracking Form for Resident B revealed the resident had only three (3) documented showers for the month, with no documented refusals. Resident B's (MONTH) 2014 ADL Tracking Form indicated no showers for the period extending from 12/01/2014 to 12/11/2014, with no documented refusals. During an interview with the Certified Nursing Assistant (CNA) Shower Aide HH conducted on 12/11/2014 at 12:01 p.m., this CNA stated she showered all ambulatory residents. CNA HH acknowledged that Resident B's shower schedule was for showers on Mondays and Fridays, stating that if a shower was missed, HH either stayed late to finish or the shower was performed the nex… | 2018-09-01 |
| 5375 | 5375 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2014-12-11 | 281 | G | 0 | 1 | FNVB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, physician interview, hospital Emergency Department Nurses Notes review, hospital Emergency Department Physician Documentation form review, facility Policy and Procedure for Casts/Splints review, and National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, the facility failed to ensure that care was provided in accordance with professional standards of quality regarding the ongoing assessment for one (1) resident (#115) who was at risk for altered skin integrity after the application of an ankle splint, and regarding the administration of [MEDICATION NAME] drug therapy as ordered for two (2) residents (#58 and #101). The total survey sample was fifty-six (56) residents. This resulted in harm for Resident #115 who, after the failure of staff to monitor the resident's right foot and ankle after splint application, subsequently developed a Deep Tissue Injury (DTI) to the right outer ankle measuring 8 centimeters (cms) by 1.5 cm, a DTI of the right foot measuring 8 cms by 2 cms, a DTI to the outside of the right foot measuring 7 cms by 2 cms, a DTI to the right inner ankle measuring 6.5 cms by 4.5 cms, a 7 cm by 7 cm by 1 cm pressure sore to the right foot Achilles Tendon, and an unstageable area to the top of the right foot measuring 6 cms by 5 cms. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice, Section 2.3.2(c) - Standards Related to Licensed Practical Nurse/Vocational Nurse Responsibilities for Nursing Practice Implementation, specified the nurse demonstrates attentiveness and provides resident surveillance and monitoring. In addition, Section 2.3.2.(i)(3) of Chapter 2 of these Model Nursing Administrative Rules specified that the nurse administers… | 2018-09-01 |
| 5376 | 5376 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2014-12-11 | 282 | G | 0 | 1 | FNVB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, hospital Emergency Department Physician Documentation form review, and Policy and Procedure for Casts/Splints review, the facility failed to provide skin assessments, in accordance with the Care Plan, to monitor the skin integrity of one (1) resident (#115) after the application of a right ankle splint, and failed to administer [MEDICATION NAME] anticoagulant drug therapy as ordered, as specified by the Care Plans of two (2) residents (#58 and #101). The total survey sample was fifty-six (56) residents. The facility's failure to monitor the skin integrity of Resident #115 as specified by the resident's Care Plan resulted in actual harm, in that Resident #115 developed a Deep Tissue Injury (DTI) to the right outer ankle measuring 8 centimeters (cms) by 1.5 cm, a DTI on the top of the right foot measuring 8 cms by 2 cms, a DTI to the outside of the right foot measuring 7 cms by 2 cms, a DTI to the right inner ankle measuring 6.5 cms by 4.5 cms, a 7 cm by 7 cm by 1 cm pressure sore to the right foot Achilles Tendon, and an unstageable area to the top of the right foot measuring 6 cms by 5 cms. Findings include: 1. Resident #115's Significant Change Minimum Data Set (MDS) assessment of 02/01/2014 documented [DIAGNOSES REDACTED]. Section M - Skin Conditions documented that Resident #115 had no pressure sores at that time, but was at risk of pressure sore development. The Care Plan of Resident #115 identified a Problem, originally dated 02/22/2014, indicating that the resident was at risk for an alteration in skin integrity related to reasons which included, but were not limited to, fragile and thin skin and limited mobility, with a [DIAGNOSES REDACTED].#115's Care Plan to address the resident's risk for an alteration in skin integrity included, but were not limited to, skin audits to be conducted both weekly and, in addition, on an as-needed basis, and to report any open areas or areas of redness to… | 2018-09-01 |
| 5377 | 5377 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2014-12-11 | 287 | B | 0 | 1 | FNVB11 | Based on review of the State Agency (SA) Minimum Data Set (MDS) Missing OBRA Assessment Report and staff interview, the facility failed to ensure that seven (7) MDS assessments were transmitted to the SA in a timely manner. Findings include: Review of the SA MDS Missing OBRA Assessment Report having a Run Date of 12/04/2014 revealed that as of that date, the facility had seven (7) missing MDS assessments. During an interview conducted on 12/11/2014 at 12:32 P.M. with the MDS Coordinator, she acknowledged that some resident MDS assessments were late or missing. She stated that transmission problems one (1) year ago caused a two (2) month delay in assessments, and the facility is still trying to reduce the number of late or missing assessments. | 2018-09-01 |
| 5378 | 5378 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2014-12-11 | 309 | D | 0 | 1 | FNVB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Medication Administration Record [REDACTED]. The total survey sample size was fifty-six (56) residents. Findings include: 1. Record review for Resident #101 revealed Quarterly Minimum Data Set (MDS) assessment having an Assessment Referenced Date of 09/12/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Further record review for Resident #101 revealed a 10/27/2014 physician's orders [REDACTED]. An 11/10/2014 Physician's Telephone Orders (PTO) form for Resident #101 specified to hold [MEDICATION NAME] for two (2) days, and then to restart [MEDICATION NAME] at a dose of five (5) mg by mouth at bedtime. Review of Resident #101's (MONTH) 2014 MAR indicated [REDACTED]. However, this (MONTH) 2014 MAR indicated [REDACTED]. Resident #101's (MONTH) 2014 MAR indicated [REDACTED]. During interview conducted on 12/11/2014 at 8:32 A.M. with the Director Of Nursing (DON), the DON acknowledged that Resident #101 received an incorrect dose of [MEDICATION NAME] on 11/12/2014 and 11/13/2014 due to the order not being transcribed on the MAR indicated [REDACTED] 2. Record review for Resident #58 revealed a Quarterly MDS assessment having an Assessment Reference Date of 09/09/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Resident #58 had a physician's orders [REDACTED]. Resident #58's [MEDICATION NAME] Dosage Tracking form documented a laboratory test result of 11/12/2014 which revealed an International Ratio of 3.4. A Daily Skilled Nurses Notes entry dated 11/12/2014, timed at 3:00 p.m., for Resident #58 documented the physician was notified of the laboratory result and gave a new order, and a PTO dated 11/12/2014 specified to hold Resident #58's [MEDICATION NAME] for two (2) days, then to give [MEDICATION NAME] six (6) mgs daily. However, review of Resident #58's (MONTH) 2014 MAR indicated [REDACTED]. This MAR indicated [REDACTED]. During an interview conducted 12/12/2014 at 10:50 A.M. with Licensed P… | 2018-09-01 |
| 5379 | 5379 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2014-12-11 | 314 | G | 0 | 1 | FNVB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, physician interview, hospital Emergency Department form review, hospital Emergency Department Order Results Final Report review, hospital Emergency Department Physician Documentation form review, Policy and Procedure for Casts/Splints review, the facility failed to perform skin assessments and monitoring of the right lower extremity, per facility policy, of one (1) resident (#115) after the application of an ankle splint. The survey sample size was fifty-six (56) residents. This failure resulted in actual harm to Resident #115, who developed a Deep Tissue Injury (DTI) to the right outer ankle measuring 8 centimeters (cms) by 1.5 cm, a DTI on the top of the right foot measuring 8 cms by 2 cms, a DTI to the outside of the right foot measuring 7 cms by 2 cms, a DTI to the right inner ankle measuring 6.5 cms by 4.5 cms, a 7 cm by 7 cm by 1 cm pressure sore to the right foot Achilles Tendon, and an unstageable area to the top of the right foot measuring 6 cms by 5 cms. Findings include: Review of the facility's Policy and Procedure (P&P) for Casts/Splints, having an Effective Date of 02/2011, revealed the documented Purpose of the P&P was to outline management in the care of a resident with a cast/splint. This P&P specified, in the Assessment section, that after cast/splint application, staff were to assess a resident's finger/toes of the involved extremity every two (2) hours for the first 24 hours or until stable, then continue assessing every four (4) hours, to assess and report any signs of decreased circulation or movement. The P&P specified that this assessment was to include, but was not to be limited to, assessing for an increase in pain or pressure, decreased peripheral pulses distal to the site of injury, and changes in the color and skin temperature of the extremity. Record review for Resident #115 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Referenced… | 2018-09-01 |
| 5380 | 5380 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2014-12-11 | 328 | E | 0 | 1 | FNVB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, Respironics Manufacturer's Guidelines review, and facility Oxygen Equipment - Care and Operation Protocols Policy and Procedure review, the facility failed to maintain clean oxygen concentrator inlet filters on eleven (11) oxygen concentrators (in resident rooms 100-2; 107; 113-1; 116-2; 118-1; 123-2; 132-1; 137-1; 138-1; 149-1; and 154-1), and failed to ensure inlet filter placement for two (2) oxygen concentrators (in resident rooms 145-2 and 154-2), of seventeen (17) sampled residents utilizing oxygen concentrators and receiving oxygen therapy, from a survey sample of fifty-six (56) residents. Findings include: Review of the Respironics Manufacturer's Guidelines for the Millenium model oxygen concentrator revealed that weekly user maintenance consisted of inspecting and cleaning the inlet filter. Additionally, review of the Medical Center's Policy and Procedure entitled Oxygen Equipment-Care and Operation Protocols revealed concentrator cleaning and maintenance consisted of cleaning filters if dirty every shift. Specifically, filters were to be removed, cleaned with warm soapy water, rinsed, shaken dry and replaced. 1. Observations conducted on 12/08/2014 from 11:15 A.M. to 11:37 A.M. revealed oxygen concentrator air inlet filters heavily soiled with thick white dust in the following rooms: - Room # 132-1 - Room # 137-1 - Room # 154-1 2. Observation conducted on 12/10/2014 at 10:40 A.M. revealed an oxygen concentrator's air inlet filter heavily soiled with thick white dust in Room# 138-1. 3. Observations conducted on 12/11/2014 from 8:35 A.M. to 9:03 A.M. revealed oxygen concentrator air inlet filters heavily soiled with thick white dust in the following rooms: - Room# 132-1 - Room# 138-1 - Room# 154-1 4. Observations conducted on 12/12/2014 from 9:28 A.M. to 9:44 A.M., with the Director of Nursing (DON) in attendance, revealed oxygen concentrator air inlet filters heavily soiled with thick white dust… | 2018-09-01 |
| 5381 | 5381 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2014-12-11 | 371 | F | 0 | 1 | FNVB11 | Based on observation and staff interview, the facility failed to maintain safe food temperatures on one (1) of one (1) steam table in Building B for one (1) of two (2) buildings (A and B). The facility's Form CMS-672, Resident Census and Conditions of Residents, documented that 118 of the facility's 120 residents received nutrition by way of oral diets. Findings include: Observation conducted on 12/10/2014 at 8:40 A.M. with the Dietary Manager in attendance revealed a large metal bin containing scrambled eggs sitting on the back top of the steam table. Observation at that time revealed inadequate space in the steam table to hold all of the bins containing hot food. The temperature of the scrambled eggs was one-hundred (100) degrees Fahrenheit. Interview conducted on 12/10/2014 at 8:45 A.M. with the Dietary Manager (DM) revealed that food was delivered from the hospital and immediately placed on the steam table, with food temperatures checked at that time. The DM stated that the steam table at the facility did not have a warmer or equipment to reheat food. She stated that if a food item needed to be reheated, it was sent back to the hospital kitchen and then re-sent to the facility. She further stated often there was not enough space in the steam table to hold the alternate food items. | 2018-09-01 |
| 5382 | 5382 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2014-12-18 | 431 | D | 0 | 1 | F0VN11 | Based on observations, review of facility policy and staff interview the facility failed to discard medications timely in one (1) medication storage room (Unit 3) and on one (1) medication cart (Unit 2 ). Observations on 12/17/14 at 10:00am revealed the following : Unit 3 medication storage room had one (1) vial of Tuberculin PPD with an opened date of 9/17/14 and one (1) box of Aginate with an expiration date of 8/11/2014. Unit 2 Medication Cart had one (1) box of Aginate with expiration date of 8/11/2014. A review of the facility's Medication Storage policy revealed outdated medications are to be immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists. A review of the facility's Medication Storage Conditions & Expiration Dates policy revealed the shelf life of Tuberculin PPD is one (1) month after first use. Interview conducted with the DON on 12/17/14 at 10:20am revealed that Tuberculin PPD is only good for 1 month from the date opened. The staff nurses and Resident Care Coordinators are to check medication storage areas at least weekly. We currently do not have sign off sheets for this process. | 2018-09-01 |
| 5383 | 5383 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2015-01-08 | 159 | D | 0 | 1 | WUCD11 | Based on resident interview A, record review and staff interviews, the facility failed to have resident's funds available on weekends and holidays for eighty-nine (89) resident accounts. Findings include: An interview with resident A on 1/05/14 at 1:30 p.m. reveals that she/he does not have access to her/his personal funds account on the weekends or holidays. The resident further states that she/he has to ask ahead of time in order to get money for the weekend or holiday. An interview on 1-07-15 at 11:00 a.m. with Licensed Practical Nurse (LPN) II reveals that residents that want money on the weekend have to ask the Social Worker (SW) and they don't work on the weekends so he/she didn't know how the residents would get money on the weekend. An interview on 1-07-15 at 11:10 a.m. with Unit Secretary JJ reveals that he/she would tell the charge nurse and he/she would handle it. An interview on 1-07-15 at 11:15 a.m. with Licensed Practical Nurse (LPN) KK reveals that residents can get money on the weekends if it is an emergency and there is a SW on call that will come in and get the money for them. An interview on 1-07-15 at 1:15 p.m. with Social Worker (SW) BB reveals that he/she can come in if called and a voucher would be filled out then given to the switch board operator and he/she gets the money for the resident. An interview on 01-07-15 at 1:45 p.m. Resident Trust Fund Manager, revealed that the company has tried to arrange a way that they can leave money on the weekends in the facility but have been unsuccessful. He/she stated that most of the licensed nursing staff working are contract workers. She stated that the Campus Administrator has been working on this issue. He/she stated that if a resident needs money on the weekend they have to request it from the SW by 5 p.m. on Friday. An interview on 1-07-15 at 2:30 p.m. with facility Administrator reveals that they do have a cash box that is left in the medication cart on North 2 on weekends, but we don't want everyone to know that it is there because of the iss… | 2018-09-01 |
| 5384 | 5384 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2015-01-08 | 247 | D | 0 | 1 | WUCD11 | Based on review of the facility policy for room transfer, medical record review, family interview, and staff interview, the facility failed to notify the responsible party for two of three room changes for one (1) resident O from a sample of thirty-four (34) residents. Findings Include: An interview on 1/6/15 at 9:54 a.m. the Responsible Party for residentO revealed that resident O had two (2) room changes without his/her knowledge. An interview on 1/7/15 at 10:45 a.m. Certified Nurse Aide (CNA) LL stated the nurse will informed them that a residents needs to move to another room and the CNA''s will work together to move resident with their belongs. An interview on 1/7/15 at 10:47 a.m., Licensed Practical Nurse (LPN) MM stated that he/she will check and read the communication log daily for any room changes or changes in resident condition. An interview on 1/7/15 at 10:52 a.m. LPN HH stated that the room changes are coordinated with Social Services. And the front office is notified of the room change to update the resident room number and further interview revealed that the family member is notified of the room change. An interview on 1/7/15 at 11:02 a.m. Social Worker BB revealed the family is called to get permission for a room change either by the SW or the nurse. Continued interview revealed that Social Services will write a Progress Note of the room change. An interview on 1/7/15 at 1:00 p.m. with SW AA revealed he/she could find no evidence that the RP was notified of the room changes for resident O on 9/23/14 or on 10/2/14. | 2018-09-01 |
| 5385 | 5385 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2015-01-08 | 309 | D | 0 | 1 | WUCD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that the physican order was followed for one (1) Resident (#222) from a sample size thirty-four (34) residents. Findings Include: Review of the Clinical Record for Resident #222 was admitted to facility on 12/19/15 with [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Further review of clinical record revealed no evidence of CBC, CMP, TSH, Lipid and Pre-[MEDICATION NAME] was done as ordered on [DATE]. An interview with Licensed Practical Nurse (LPN) PP on 1/7/2015 at 2:00 p.m. revealed that he/she was unable to find evidence that the laboratory (lab) test were done as ordered. Further interview with LPN PP on the same day at 3:38 p.m. revealed that the facility protocol is when a new resident is admitted the nurse will complete a Clinical Laboratory Specimen form for the lab to collect the next day. She confirmed, at this time, that a form had not been filled out for this resident and the labs were not done. | 2018-09-01 |
| 5386 | 5386 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2015-09-22 | 312 | D | 1 | 0 | Y67611 | Based on record review, observations and staff interviews, it was determined that the facility had failed to ensure that they had provided the appropriate care to maintain good grooming for two male residents, (#2 and #4) from a total sample of nine (9) residents. Interview with the UM for North Two on 9-23-15 at 1:00 p.m. revealed that a male volunteer barber usually visited the facility one time a month to give free haircuts for male residents who could not afford a barber. She further stated that the facility did not have a list of which male residents had haircuts within the last few month. She stated that if a male resident looked like that they needed a haircut, then they would just send them down to the volunteer for the haircut. She stated that the last visit made by the male volunteer barber had been on 9-9-15. 1. Resident #2 had a 2-26-15 plan of care for total assistance with activities of daily living (ADLs) and an intervention to shave as needed. There were no interventions for to keep nails short and or keep hair trimmed. The UM for North Two stated on 9-23-15 at 1:00 p.m. that the resident did not usually refuse personal hygiene care or grooming care. Observations of the resident on 8-13-15 at 1:20 p.m., 4:00 p.m. and 6:00 p.m. revealed that the resident had a heavy growth of beard on his face, long fingernails and hair that was at mid-neck length. The review of the Personal Hygiene Roster revealed that it was documented that he had not had a shave since 8-2-15 or for eleven days. He was also observed on 9-22-15 at 1:20 p.m., 3:00 p.m. and 4:00 p.m. with food spills and stains on the bottom of his white V-neck Tee shirt and on his pajama bottoms. He was also noted with a heavy growth of beard and long hair, stringy and mid-neck length. 2. Resident #4 had a 6-18-15 plan of care for requiring extensive assistance with ADLs, with an intervention for shaves as needed. He was observed on 8-13-15 at 1:15 p.m. and 5:57 p.m. with a heavy growth of beard and long and dirty fingernails on his right hand. Rev… | 2018-09-01 |
| 5387 | 5387 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2015-09-22 | 325 | D | 1 | 0 | Y67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, it was determined that the facility failed to provide the appropriate care to promote optimal nutrition for two residents (#2 and #3) of six (6) residents at increased risk for nutritional decline, from a sample of nine (9) residents. Findings include: 1. For resident #2, on the Weight Report Roster, the resident was documented as weighing 131 pounds (lbs.) on 6-1-15, 124 lbs. on 7-2-15, 122 lbs. on 7-3-15, 129 lbs. on 7-13-15, 128 lbs. on 7-14-15, 124 lbs. on 7-20-15, 119 lbs. on 7-21-15, 121 lbs. on 7-27-15, 124 lbs. on 8-3-15, 124 lbs. on 9-2-15, hospital from 9-6-15 to 9-9-15 and 122 lbs. on 9-10-15. There was a delay from 7-10-15 until 8-1-15 (21 days) in regards to follow-up for recommended interventions by the Registered Dietician (RD) for this resident. The resident had [DIAGNOSES REDACTED]. The resident was assessed by the Registered Dietician (RD) on the 7-10-15 PAR Nutrition Weight Assessment (NWA) with a current weight of 122 pounds (lbs.) and height of 67 inches. She documented a weight change of 6.9 percent (%) in thirty (30) days, with an unintended weight loss related to inadequate oral intake. On the Registered Dietician Recommendation Sheet (RS) of 7-10-15, she recommended to discontinue double portions, to add EBC (every bite counts) with meals and to add an appetite stimulant. The Nurse Practitioner signed and accepted the recommendation on 7-13-15; however, she did not clarify which appetite stimulant to use. Interview with the unit manager for North Two hall on 9-23-15 at 6:00 p.m. revealed that she confirmed that there had not been clarification by the nursing staff in regards to a specific medication to be used for an appetite stimulant. The Weight Report Roster noted a weight of 128 lbs. on 7-14-15 and a weight of 119 lbs. on 7-21-15. On the 7-24-15 PAR NWA, the RD noted that the resident ' s current weight was 119 lbs., with a BMI of 18.6%. On the intervention note, she d… | 2018-09-01 |
| 5388 | 5388 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 164 | D | 0 | 1 | L1N511 | Based on observation and staff interview, it was determined that the facility failed to ensure personal privacy during the provision of care for one (1) resident (#114) from a sample of thirty four (34) residents. Findings include: Observation of wound care on 10-16-14 at 10:30 a.m. for resident # 114 provided by the wound treatment nurse reveled that the privacy curtain was not wide enough to adequately provide full visual privacy for the resident. When unfurled, the curtain did not prevent the resident from being seen from the doorway at one end, or by her roommate at the other end. If the curtain was pulled to shield the doorway, then the resident was exposed to the roommate. If the curtain was pulled between the resident and her roommate, then the resident had no privacy from the doorway. Continued observation revealed that the corporate nurse consultant, who was present during the procedure, had to hold the privacy curtain from the bottom and stretch it as much as she could toward the head of the bed in an effort to provide privacy for the resident from her roommate during the wound care procedure. When she did pull the curtain between the residents it allowed more exposure from the other end of the curtain where the entrance to the room was. Interview on 10-15-14 at 6:20 p.m. with the Director of Nursing (DON), revealed that she would expect a resident to receive total privacy during care with no openings in the curtain or the door. | 2018-09-01 |
| 5389 | 5389 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 246 | D | 0 | 1 | L1N511 | Based on observation, record review, and staff interview the facility failed to ensure that the environment accommodated the needs of one (1) resident (#64) from a sample of thirty four (34 ) residents. 1. Interview on 10/14/14 at 3:04 p.m. with Licensed Practical Nurse (LPN) EE revealed that the resident had contracutres to both hands. Review of the quarterly Minimum Data Set (MDS) assessment for resident #64 dated 10/7/14 revealed that the resident was assessed as totally dependent on staff for all Activities of Daily Living (ADLs), was incontinent of bladder and bowel and had functional impairment to the upper extremities bilaterally. Observation on 10/15/14 at 8:05 a.m. revealed the resident being fed by staff. The resident had bilateral contractures to the hands. Continued observation revealed that the resident was unable to use the call light provided for him because the call light had a button to depress. Due to contractures, the resident was not able to depress the button. | 2018-09-01 |
| 5390 | 5390 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 253 | E | 0 | 1 | L1N511 | Based on observations, record review and staff interview, it was determined that the facility failed to maintain a sanitary environment on three (3) of six (6) halls (A, D, and F) Findings include: During the initial tour on 10-14-14 beginning at 10:30 a.m. the following was observed: 1. In room A2D a bag of clothing was on the floor and a soiled brief was in the trash can 2. In room A8D there were stains on the bathroom floor. 3. In room F64 dirt was in the corners of the bathroom floor. 4. In room F54 dirt was observed in the corners of the bathroom and there were urine splatters on the toilet and on the floor. The bathroom sink backed up and there were soiled towels in the bath tub. 5. In room F52 dirt was observed in the corners of the bathroom and urine was splattered on the toilet and the floor. 6. In room F53 dirt was in the corners of the bathroom 7. In room D8D a ceiling tile was pushed back to accommodate the TV cable and had not been repositioned. 8. The faucet in the bathroom sink in room D9W sprayed water in all directions when turned on. Interview with the Maintenance Director, on 10-16-14 at 10:30 a.m. revealed that the Maintenance Department makes rounds weekly at the beginning of the week, in each resident 's room to check for problems. A second interview at 4:30 p.m., revealed that there is a maintenance request log at each nurse' s station to be used by staff for reporting equipment that is in need of repair. He acknowledged that he also receives verbal reports from staff for items in need of repair but he encourages staff to use the log for reporting maintenance needs. Review of the weekly maintenance log for October, 2014 revealed no entries that indicate a problem in any of the resident rooms. Interview on 10-17-14 at 11:20 a.m. with certified nursing assistant (CNA) JJ , revealed that if he finds something broken he will write it in the maintenance log or tell the nurse Interview on 10-17-14 at 11:15 a.m. with Licensed Practical Nurse (LPN) BB , revealed that there is a maintenance log to u… | 2018-09-01 |
| 5391 | 5391 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 282 | D | 0 | 1 | L1N511 | **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 the care plan to apply non-skid footwear for two residents (#88 and #104) who had a history of [REDACTED].#88) who received [MEDICAL TREATMENT] services; to obtain glasses for one resident (#53) as prescribed by the ophthalmologist; and to provide a nutritional supplement for one resident (#72) who had weight loss from a sample of thirty four (34) residents. Findings include: 1. Resident #88 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed as having a Brief Interview for Mental Status (BIMS) of 3 indicating that the resident was cognitively impaired, as requiring the extensive assistance of one person for dressing, and as being independent with ambulation but, having an unsteady gait. Review of the 9/12/14 care plan revealed that the resident could ambulate without assistance but, required supervision for ambulating long distances. Further review revealed that the resident was at risk for falls related to his/her occasional unsteady gait, weakness related to his/her [MEDICAL CONDITION] and decreased safety awareness due to his/her dementia with an intervention for staff to ensure that the resident wore non-skid footwear when out of bed. However, observation of the resident on 10/16/14 between 9:26 a.m. and 11:39 a.m., revealed the resident ambulating throughout the secured unit wearing regular socks and without shoes. Staff had failed to apply non-skid footwear on the resident's feet. Refer to F323 Review of the clinical record for resident #88 revealed that the resident received [MEDICAL TREATMENT] services every Monday, Wednesday and Friday. Review of the 8/22/14 care plan revealed that the resident had a [MEDICAL TREATMENT] located on his/her right upper chest with an intervention for registered/l… | 2018-09-01 |
| 5392 | 5392 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 309 | D | 0 | 1 | L1N511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that licensed nursing staff monitored the [MEDICAL TREATMENT] and administered a medication as ordered by the physician for one resident (#88) from a sample of thirty four (34) residents. Findings include: 1. Resident #88 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident received [MEDICAL TREATMENT] services every Monday, Wednesday and Friday. Review of the 8/22/14 care plan revealed that the resident had a [MEDICAL TREATMENT] located on his/her right upper chest with an intervention for registered/licensed nursing staff to assess the site for signs and symptoms of infection and to document on the Medication Administration Record [REDACTED] Interview with Licensed Practical Nurse (LPN) AA on 10/16/14 at 11:50 a.m., revealed that nursing staff should monitor the resident's right upper chest [MEDICAL TREATMENT] every shift every day for bleeding, swelling and infection. Further interview with AA revealed that nursing staff should document the assessment on the Treatment Record or the nurses' notes. Review of the 9/2014 and 10/2014 Medication Administration Records (MARS) and Treatment Records with LPN AA at that time revealed that there was no evidence that the resident's [MEDICAL TREATMENT] had been monitored every shift every day for those months. Review of the nurses' notes revealed that there was no evidence that licensed nursing staff assessed the resident's [MEDICAL TREATMENT] every shift for 9/2014 and 10/2014. Interview with the Director of Nursing (DON) on 10/17/14 at 6:45 p.m., revealed that the resident's [MEDICAL TREATMENT] should be assessed at least daily and the assessment documented on the Treatment Record. Review of the physician's orders [REDACTED]. The [MEDICATION NAME] was to be discontinued on 10/2/14. However, review of the 10/2014 Medication Administration Record [REDACTED]. I… | 2018-09-01 |
| 5393 | 5393 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 313 | D | 0 | 1 | L1N511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to ensure that two (2) residents (#53 and A) of three (3) residents reviewed for vision impairment received prescribed eye glasses timely from a sample of thirty four (34) residents. Findings include: 1. Review of the clinical record for resident A revealed that the resident was admitted in 2010 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed that the resident was assessed as having impaired vision (able to see large print but not regular print in newspapers/books) with no corrective lenses. Review of the care plan dated 1/04/12 and reviewed quarterly, revealed that the resident had decreased vision with an intervention for staff to obtain eye exam at least annually, use large print material. Review of the Optometrist notes dated 3/11/2014 revealed that the resident needed corrective lenses and Bifocals were recommended. Review of a Trident USA clinical report revealed Glasses on order if approved. Interview on 10/17/14 at 12:45 p.m. with the Social Worker revealed that she overlooked the order for the resident to have corrective lenses. Continued interview revealed that she did not send a letter out or call the residents family and was not sure why she did not see the order form date (MONTH) 20, 2014 of this year with recommendations for the resident to have corrective lenses. Interview on 10/17/14 at 1:00 p.m. with the Administrator revealed that it is her expectation that once the facility receives an order for [REDACTED]. Interview on 10/17/14 at 1:45 p.m. with resident A revealed, that the resident was seen back in (MONTH) of 2014 by the Optometrist. Continued interview revealed that he has requested corrective lenses on several occasions and would love to have them. 2. Resident #53 was admitted in 2008 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated … | 2018-09-01 |
| 5394 | 5394 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 323 | D | 0 | 1 | L1N511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to ensure that fall prevention measures were in place for two (2) residents (#88 and #104),) with a history of falls from a sample of 34 residents and failed to ensure that toilet seats were secured in seven (7) resident bathrooms (B6, B8, D6, D10, F64, F41 and F72) on three (3) of six (6) halls. Findings include: 1. Resident #88 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was coded on the 9/9/14 Admission Minimum Data Set (MDS) as having a Brief Interview for Mental Status (BIMS) of 3 indicating that the resident was cognitively impaired, as requiring the extensive assistance of one person for dressing, and as being independent with ambulation but, having an unsteady gait. Review of the 9/12/14 care plan revealed that the resident could ambulate without assistance but, required supervision for ambulating long distances. Further review revealed that the resident was at risk for falls related to his/her occasional unsteady gait, weakness related to his/her COPD and decreased safety awareness due to his/her dementia with an intervention for staff to ensure that the resident wore non-skid footwear when out of bed. Review of the Fall Risk Evaluation dated 9/2/14 revealed that staff had assessed the resident as being at high risk for falls. Review of the 10/9/14 at 3:22 p.m. nurses' note revealed that the resident was found on the floor at the doorway of his/her room. The resident did not sustain an injury from the fall. On 10/16/14 at 9:26 a.m., the resident was observed in his/her wheelchair in the dining room of the secured unit. The resident was wearing regular socks without shoes at that time. Staff had failed to apply non-skid footwear on the resident's feet. The resident was observed at that time to get up from his/her wheelchair in the dining room and ambulate down E hall and back again to the din… | 2018-09-01 |
| 5395 | 5395 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 325 | D | 0 | 1 | L1N511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a closed record and staff interview, it was determined that the facility failed to provide a nutritional supplement as ordered by the physician for one (1) resident (#72) of four (4) residents reviewed for weight loss from a sample of thirty four (34) residents. Findings include: Review of the closed clinical record for resident #72 revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Weight Log revealed that the resident weighed 95 pounds on admission on 7/8/14 and 90 pounds on 7/17/14 which represented a 5.3 percent (%) significant weight loss in nine days. Licensed nursing staff notified the physician of the resident's significant weight loss on 7/17/14 and the physician ordered licensed nursing staff to administer 4 ounces (ozs) of Med Pass (a nutritional supplement) three times a day. Review of the 7/17/14 care plan revealed that the resident was a picky eater, did not like meat and was below his/her ideal body weight and had an intervention for staff to administer Med Pass (a nutritional supplement) as ordered by the physician. Review of the 7/2014 Medication Administration Record [REDACTED]. However, review of the 8/2014 and 9/2014 MARS revealed that staff failed to administer the Med Pass to the resident in those months. There was no indication that the physician had discontinued the Med Pass or that the resident had refused the supplement. Review of the Weight Log revealed that the resident had no additional weight loss but, weighed 93 pounds on 8/14/14, a gain of four pounds since 7/17/14. Interview with the Director of Nursing (DON) on 10/17/14 at 6:50 p.m., revealed that licensed nursing staff were responsible for administering the Med Pass to the resident and documenting the percent consumed on the MAR. She confirmed at that time that licensed nursing staff failed to administer the Med Pass to the resident as ordered by the physician for 8/2014 and 9/2014. | 2018-09-01 |
| 5396 | 5396 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 371 | E | 0 | 1 | L1N511 | Based on observation and staff interview the facility failed to date and label food items stored in the walk in cooler and the dry storage area. The census was 91 residents. Findings include: Observation on 10-14-14 at 10:55 a.m. revealed several items in the walk in cooler that were opened and but not dated with the date opened. These were Pimento cheese, beef base, chicken base, fruit cocktail. Other items that had been opened were labeled inaccurately with only the month and date and no year. These were: tomato sauce, hard boiled eggs which were in water in a metal container covered with plastic wrap, Italian dressing, Ranch dressing, and pickles. Continued observation revealed a large plastic container of frosting which had been opened but not dated and a crate containing four 1/2 gallons of syrup that had not been opened sitting on the floor under a wire rack behind the door in the dry storage area. This is the area where rodent droppings are also observed. Interview with the dietary manager on 10-14-14 at 10:55 a.m. revealed that she would expect the items to be labeled correctly. | 2018-09-01 |
| 5397 | 5397 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 428 | D | 0 | 1 | L1N511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that the consultant pharmacist identified and reported to the attending physician and the Director of Nursing that a medication was not discontinued after thirty days as ordered by the physician for one (1) resident (#88) of five (5) residents reviewed for unnecessary medication use from a sample of thirty four (34) residents. Findings include: Review of the clinical record for resident #88 revealed that the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The Depakote should have been discontinued on 10/2/14. However, review of the 10/2014 Medication Administration Record [REDACTED]. Interview on 10/17/14 at 11:55 a.m with Licensed Practical Nurse (LPN) AA revealed that after reviewing the 10/2014 MAR, she confirmed that licensed nursing staff had failed to discontinue the Depakote after 10/2/14 as ordered by the physician. Review of the 10/1/14 to 10/31/14 physician's orders [REDACTED]. However, review of the Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations form dated 10/14/14 revealed that the resident was on the list. The consultant pharmacist failed to identify and report to the attending physician and Director of Nursing that the Depakote was not discontinued after 30 days as ordered by the physician but, continued to be administered from 10/3/14 to 10/8/14. | 2018-09-01 |
| 5398 | 5398 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 431 | E | 0 | 1 | L1N511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to dispose of expired medication in two (2) of three (3) medication storage rooms. Findings include: 1. Observation of the medication storage room for Station three (3) on [DATE] at 1:30 p.m., revealed, two (2) prefilled Insulin syringes were placed in a storage bag labeled expired [DATE], one( 1) Lorazepam milligram per milliliter vial was expired on [DATE], and two Aspirin suppositories expired on ,[DATE], and were in the medication refrigerator. Interview with Licensed Practical NurseMM at this time, verified that the medications were expired. 2. Observation of the medication storage room for Station two (2) on [DATE] at 2:00 p.m., revealed two (2) Hepatitis Vaccine vials expired on [DATE], and two (2) Aspirin suppositories expired on ,[DATE] in the medication refrigerator. Interview with Licensed Practical Nurse PP at this time verified that the medications were expired. Interview with the Director of Nurses on [DATE] at 3:40 p.m. revealed that the night shift nurse and unit managers were responsible for removing expired medication from storage areas. | 2018-09-01 |
| 5399 | 5399 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 441 | E | 0 | 1 | L1N511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to ensure that staff washed or sanitized their hands during the meal service for two (2) of two (2) meals on five (5) of six (6) halls (A, B, D, E and F) . Findings include: Observation during the meal service in the dining room for the secured unit (E and F halls) on 10/14/14 at 5:23 p.m., certified nursing assistant (CNA) OO obtained a tray from the meal cart and served a resident sitting at one of the tables. OO touched the resident's shoulder when she/he spoke to the resident. Without washing/sanitizing her/his hands, OO obtained a tray from the cart for another resident, placed the tray on the table, removed the straw from its wrapper and placed the straw in the resident's cup. Without washing/sanitizing her/his hands, OO obtained a tray from the cart for another resident, pulled a chair closer to the resident, assisted the resident into the chair and set up the resident's tray. Without washing/sanitizing her/his hands, OO obtained a tray from the cart for another resident and set the tray on the table. OO then obtained a rolling chair from the nurses' station to sit in and without washing/sanitizing her/his hands, picked up the utensils and began feeding the resident. Interview with the Licensed Practical Nurse (LPN) responsible for Infection Control surveillance on 10/17/14 at 5:15 p.m., revealed that staff should wash/sanitize hands between each resident contact during meal service. 2. Observation of meal service on the A hall at 5:20 p.m. on 10/14/15 revealed a CNA take a residents tray into his room, touch the overbed table and cut the sandwich in half touching it with her fingers. Without washing/sanitizing hands , the CNA picked up another residents tray, took it into the resident's room, touched the resident's over bed table several times and then cut the residents sandwich in half touching it with her fingers. 3. Observation of lunch trays bein… | 2018-09-01 |
| 5400 | 5400 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 456 | F | 0 | 1 | L1N511 | Based on observation and staff interview, the facility failed to maintain equipment in the laundry. Census=91 residents Findings include: Observation of the laundry area on 10/15/14 at 12:15 p.m., 3:30 p.m. and on 10/16/14 at 9:00 a.m. revealed that the washing machine room had two washers, one had not been working for over a month, and the other was leaking. There was a blue blanket in front of the washer to catch the water. The sink on the wall next to the washer was dirty with soiled towels on top of it; there was a large hole in the wall behind the sink with a piece of wood in front of it and some of the ceiling tiles were stained and bulging from the ceiling. Interview on 10/15/14 at 12:15 p.m. with Laundry aide NN revealed that the facility has two washers but only one working machine at this time, however, this machine leaks. Continued interview revealed that the second washer had been broken for over a month and that the facility is waiting on a part before the washer can be fixed. | 2018-09-01 |
| 5401 | 5401 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 463 | E | 0 | 1 | L1N511 | Based on observations, record review and staff interview, it was determined that the facility failed to ensure that call lights were functioning at the bedside or in the bathrooms for five (5) resident rooms (A6/W, A2/D, A8/D, A2/W and B6/D) on two (2) of six (6) halls (D and W). Findings include: During the initial tour on 10-14-14 beginning at 10:30 a.m. the following was observed: 1. In room A6W and A8D the bathroom call light was not visible above the hallway door when the bathroom call light was activated. 2. In room A2W and A2D, the light on the box in the room did not light up when the call light was activated. 3. In room B6D, the call light box was loose from the wall. Interview with the Maintenance Director, on 10-16-14 at 10:30 a.m. revealed that the Maintenance Department makes rounds weekly at the beginning of the week, in each resident's room to check for problems. A second interview at 4:30 p.m. revealed that there is a maintenance request log at each nurse's station to be used by staff for reporting equipment that is in need of repair. He stated that he checks these logs at the beginning of each day. Review of the weekly maintenance log for October, 2014 revealed that rounds had been made for each week in (MONTH) by the maintenance department. There were no entries that indicated a problem with the call system in any of the resident rooms. Interview on 10-17-14 at 11:20 a.m. with certified nursing certified nursing assistant (CNA) JJ , revealed that if he found something broken he would write it in the maintenance log or tell the nurse Interview on 10-17-14 at 11:15 am with Licensed Practical Nurse (LPN) BB, revealed that there is a maintenance log to use to report things that need repair to maintenance. | 2018-09-01 |
| 5402 | 5402 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 469 | D | 0 | 1 | L1N511 | Based on observation, interview, and record review the facility failed to maintain an effective pest control program. Findings include: Observation on 10-14-14 at 10:45 a.m. and on 10/15/14 at 9:30 a.m. revealed rodent droppings in the dry storage area in a corner under a wire storage rack behind the door into the dry storage room. Observation and interview on 10-16-14 at 4:30 p.m. with the, Maintenance Supervisor revealed that the droppings were in the same location. The maintenance supervisor stated that it looks like rodent droppings. Continued interview revealed that the exterminator comes every month. Review of the pest control log revealed that Borden Pest Control services the facility monthly. Tamper proof rodent traps are placed around the foundation of the building during the visit. | 2018-09-01 |
| 5403 | 5403 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2014-10-17 | 514 | D | 0 | 1 | L1N511 | Based on observation, record review and staff interview the facility failed to maintain a complete and accurate medical record for one (1) resident (#48) from a sample of thirty four (34) residents. Findings include: Observation on 10/16/14 at 10:00 a.m. revealed resident #48 in bed. The resident had a contracture to the left hand. Review of Physician Order's revealed a current order for passive range of motion to the left upper extremity, left elbow,and left wrist and finger digits for Resident #48. Review of treatment record for October, 2014 revealed no evidence that this order had been transcribed to the treatment record for the month of October. Interview with Restorative Nurse on 10/16/14 at 2:00 p.m. revealed that the resident was not being seen by the Restorative Program and that Nursing was responsible for passive range of motion for the resident. Interview with the Unit Manager, Licensed Practical Nurse BB on 10/17/14 at 11:00 a.m. revealed that there was no transcription to the Treatment administration record for (MONTH) 2014, as in previous months, (8/2014, and 9/2014), for passive range of motion to the left upper extremity, left elbow and left wrist and finger digits. Continued interview revealed that this was an oversight. | 2018-09-01 |
| 5404 | 5404 | CHULIO HILLS HEALTH AND REHAB | 115287 | 1170 CHULIO ROAD | ROME | GA | 30161 | 2015-02-05 | 309 | D | 0 | 1 | BI2I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer [MEDICATION NAME] in accordance with the Physician's order for one (1) resident (#99) from a sample of thirty four (34) residents. Findings include: Resident #99 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Resident #99 was receiving [MEDICATION NAME] therapy since his admission. On 12/29/14, the Physician wrote an order to increase the [MEDICATION NAME] dose to 7.5 mgs for 12/29/14 only, and then resume 5mg daily. Review of the Medication Administration Record [REDACTED]. An interview conducted on 2/5/15 at 3:48pm with the Director of Nursing (DON) confirmed that [MEDICATION NAME] 7.5 mgs was administered on 12/30/14 and 12/31/14 in error. | 2018-09-01 |
| 5405 | 5405 | CHULIO HILLS HEALTH AND REHAB | 115287 | 1170 CHULIO ROAD | ROME | GA | 30161 | 2015-02-05 | 328 | D | 0 | 1 | BI2I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of ventilator flow sheets and staff interview, the facility failed to perform functional checks daily on oxygen concentrators in use with ventilators for on one (1) resident (#126) from a sample of thirty-four (34) residents. Findings include: Record review for resident #126 revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. An observation conducted on 2/5/15 at 7:45am revealed resident #126 was bed, connected to the ventilator with oxygen bled into the ventilator at 2lpm via an oxygen concentrator. Review of the ventilator flow sheets with reference dates from (MONTH) 16, (YEAR) through (MONTH) 5, (YEAR) revealed no evidence of daily functional checks to analyze adequate oxygen concentration of the concentrator in use with the ventilator. An interview conducted on 2/5/15 at 8:36am with the Respiratory Director revealed she was not aware oxygen concentrators being used to provide oxygen in conjunction with a ventilator, required a functional test daily by analyzing the oxygen concentration of the concentrator. A further interview conducted at 2:05 PM revealed there were five (5) residents on ventilators of which four (4) use oxygen concentrators in line with the ventilators. She confirmed no functional checks for analyzing oxygen concentration have ever been performed on any of the high flow concentrators that were in use with the ventilators. | 2018-09-01 |
| 5406 | 5406 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2015-02-26 | 371 | E | 0 | 1 | CMHB11 | Based on observations and staff interview the facility failed to maintain the rinse cycle of the dish machine above one hundred and eighty degrees Fahrenheit (180 F) to properly sanitize dishware; failed to properly demonstrate the usage of the three (3) compartment sink to prevent the potential for food borne illness. The facility census was ninety-three (93) residents with three (3) residents receiving enteral feedings. Findings include: 1. Observation on 02/23/15 at 9:50 a.m. revealed the high temperature dish machine in the kitchen was not able to reach the required 180 F during the rinse cycle. Continued observation revealed 3 attempts were made and the temperature readings were as follows: 178 F, 178 F, and 175 F. Interview on 02/23/15 at 9:50 a.m. with the Registered Dietitian (RD) revealed that the rinse cycle on the dish machine needs to be 180 F for sanitation purposes. She acknowledged that after the three observed attempts the dish machine did not reach the appropriate temperature to properly sanitize the dishware. Continued interview with the RD revealed that she was not informed that the dish machine had any problems and that the temperature this morning was above 180 F. Interview on 02/25/15 at 12:45 p.m. with the Dietary Manager (DM) revealed that he expects staff to record the wash and rinse temperatures of the dish machine on the log sheet located near the dish room. Continued interview revealed that he expects staff to notify him immediately if the temperatures are not as indicated on the log sheet, wash cycle of 150 F and rinse cycle of 180 F. Review of the dish machine temperature log for (MONTH) (YEAR) revealed two (2) days where staff logged the rinse temperature below the minimums recorded of 150 F Wash and 180 F Rinse. On 2/12/15 the rinse was 178 F and on 2/22/15 the rinse was 179 F. 2. Observation on 02/25/15 at 9:05 a.m. of the 3 compartment sink revealed AA cook was unable to properly demonstrate the proper technique for sanitizing dish ware. The cook was observed washing pots and pan… | 2018-09-01 |
| 5407 | 5407 | CALHOUN HEALTH CARE CENTER | 115340 | 1387 HIGHWAY 41 NORTH | CALHOUN | GA | 30701 | 2015-02-12 | 441 | D | 0 | 1 | 5S1511 | Based on observations, staff interview and review of facility policy, the facility failed to label and/or properly store personal care equipment in a sanitary manner on one (1) (400) of four (4) halls (200, 300, 400,and 500). Findings include: An observation conducted on 2/9/15 from 10:50am to 11:25am and on 2/10/15 from 8:05am to 8:15am revealed personal care equipment not labeled and/or not stored in a sanitary manner on the 400 Hall in the following rooms: The bathroom in rooms 401-403, for which 4 residents share, there were 3 unlabeled, uncovered tooth brushes lying together behind the sink faucet and one unlabeled urinal sitting on the back top of the toilet. The bathroom in rooms 405-407, for which 4 residents share, there was an unlabeled, uncovered wash basin sitting on top of the paper towel dispenser, 2 hair unlabeled hair brushes sitting on the back top of the toilet and one unlabeled, uncovered toothbrush and tooth paste lying behind the faucet of the sink. The bathroom of rooms 406-408, for which 4 residents share, there was one unlabeled, uncovered toothbrush and toothpaste lying behind the faucet of the sink and one unlabeled denture cup, containing, dentures on the sink. The bathroom of rooms 410-412, for which 4 residents share, there was one unlabeled, uncovered tooth brush and tooth paste lying behind the faucet of the sink, one unlabeled, uncovered wash basin sitting on top of the paper towel dispenser and on unlabeled denture cup on the sink. During observations of the above resident bathrooms and Interview with Director of Nursing (DON) conducted on 2/11/15 at 2:10pm revealed that she acknowledged that resident personal care items were not labeled and/or improperly stored. The DON indicated that resident personal care items such as tooth brushes, tooth paste and hair brushes are expected to be kept in a labeled zip lock bag and kept in the resident's night stand drawer. Denture cups are to be labeled and all urinals, wash basins and bed pans are expected to be labeled and individually bagge… | 2018-09-01 |
| 5408 | 5408 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2015-01-29 | 246 | D | 0 | 1 | NNRH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to accommodate the needs of two (2) residents, resident (X) related to [MEDICATION NAME] care, and resident (Z) related to her physical environment. The sample size was thirty-one (31). Findings include: 1.) Review of the clinical record for resident Z revealed that the resident had [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Brief Interview Mental Status (BIMS) was thirteen (13), indicating that the resident was cognitively intact. Observation on 1/26/15 at 12:42 p.m., from the doorway revealed resident Z in bed her lunch tray was served by Certified Nursing Assistant (CNA) AA. The resident informed CNA AA that her bag needed to be changed. Continued observation revealed that CNA AA told the resident that she needed to eat first. CNA AA set up the resident's tray and left the room. Observation on 1/26/15 at 1:00 p.m. revealed that resident Z had a [MEDICATION NAME] bag, which was located on her right side. The bag was observed to be completely full of yellow-brownish liquid. Resident Z revealed that she wished that staff would have just changed the bag when she asked them to. Continued interview revealed that she was unable to remember if that was the first time that staff had made her wait to empty the [MEDICATION NAME] bag. Observation on 1/26/15 at 1:27 p.m., revealed that staff entered the room of resident Z and removed the lunch tray, but the [MEDICATION NAME] bag was not emptied. The [MEDICATION NAME] bag was observed to still be full. Observation on 1/26/15 at 1:51 p.m., revealed that resident Z was still sitting up in bed and the [MEDICATION NAME] bag was still full of yellow-brownish liquid. Resident Z revealed that she wished they would change it, as it needs it. Continued observation revealed the resident pushed the call light and the nurse came to the room at 1:53 p.m., t… | 2018-09-01 |
| 5409 | 5409 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2015-01-29 | 247 | D | 0 | 1 | NNRH11 | Based on record review, resident and staff interviews the facility failed to follow the policy for documenting when a resident receives a new roommate. The sample size was thirty one (31) residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment for resident Q dated 11/13/14 revealed that the resident had a Brief Interview for Mental Status (BIMS) of fifteen (15), which indicated that the resident was cognitively intact. Interview on 01/26/14 at 1:25 p.m. with resident Q revealed that she received a new roommate a few months ago and did not receive any notification prior to the new resident being placed in the room with her. Interview on 01/28/15 at 9:45 a.m. with the Social Services Director (SSD) confirmed that resident Q did receive a new roommate about three (3) months ago. The SSD further revealed that she informed resident Q verbally that she was receiving a new roommate, but she did not document that conversation in the resident's medical record. Continued interview revealed she knew that she should be documenting when she discusses room changes or new roommates with the residents, or their responsible party (RP). Review of the medical record for resident Q revealed there was no evidence of documentation of the resident receiving notification of a new roommate. Review of the Social Services Documentation Policy last updated (MONTH) 2014 revealed that it was often necessary for Social services to write progress notes and initiate care plan updates in between quarterly reviews and for reasons other than a significant change in the patient. These notes included room or room-mate changes. | 2018-09-01 |
| 5410 | 5410 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2015-01-29 | 253 | E | 0 | 1 | NNRH11 | Based on observations, record review and staff interviews, the facility failed to maintain a clean, and comfortable environment as evidenced by stained or damaged floors, broken or missing tiles, doorframes, towel racks and cracking, peeling ceiling paint on four (4) of five (5) halls. Findings include: A.) During initial tour of the facility on 1/26/15 at 10:15 a.m., the following concerns were identified: 200-Hall: 1.) In the bathroom between room 201 and 203: the left side of the towel rack was missing with the end sitting up and only two (2) screws in the wall on the right side, the toilet paper holder was loose on the left side and coming away from the wall, the doors and door frames were marred, another towel rack on the right side under the window was loose, and there were three (3) green border tiles missing to the right of the toilet. 2.) In room 205: the door and door frame was marred. 3.) In the bathroom between room 205 and 207: the door and door frames were marred, the towel rack on the left side under the window was missing, two (2) beige tiles to the right of the toilet were loose and coming away from the wall, and there was a black unknown substance around the base of the toilet. 4.) In room 206: the bathroom door frame was marred. 500-Hall: 1.) In the bathroom between rooms 508 and 510: there were two (2) tiles, approximately 5 x 3, coming loose from the wall. B.) During environmental tour on 1/28/15 between 10:56 a.m. to 1:00 p.m., the following concerns were identified: 100-Hall: 1.) In the bathroom between rooms 102 and 104: the ceiling light cover was off and the door frames were marred. 2.) In room 102: the bathroom door had a small oblong hole and the bathroom door frames were marred. 3.) In the bathroom between 101 and 103: the door frames were marred, and the towel rack on the left side over the toilet was loose. 4.) In room 101: the wall to the left side after entering the room was marred. 5.) In the bathroom between rooms 105 and 107: the door frames were marred, the towel rack on the l… | 2018-09-01 |
| 5411 | 5411 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2015-01-29 | 282 | D | 0 | 1 | NNRH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to ensure that staff provided care according to the fall interventions in the plan of care for one (1) resident (#62); and failed to monitor the [MEDICAL TREATMENT] for one (1) resident (#132), from a sample of thirty-one (31) residents. Findings include: Review of the clinical record for resident #132 revealed he/she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of monthly Physician order [REDACTED]. Interview with RN Supervisor EE on 1/28/15 at 5:15 p.m. revealed that nursing staff were not documenting that the [MEDICAL TREATMENT] was being monitored for resident #132. RN EE further revealed that it was her fault, because she did not include monitoring the access site daily on the Treatment Administration Record (TAR), when the care plan was developed. Continued interview revealed that sometimes there was documentation in the Nurses Notes, but this was inconsistent. Interview with RN FF on 1/28/15 at 5:30 p.m., revealed that when resident #132 returns from [MEDICAL TREATMENT], staff assists the resident to bed, completes a physical assessment, check vital signs and documents the vital signs on the TAR. RN FF further revealed that staff then checks the left forearm fistula dressing for any bleeding. Continued interview revealed that the nurses are supposed to document daily monitoring of the access site on the TAR, but have not been doing this. Interview with the DON on 1/29/15 at 8:17 a.m., revealed that it was her expectation for nursing staff to be checking [MEDICAL TREATMENT] daily, and they should be documenting this on the TAR. Review of the (MONTH) (YEAR) TAR revealed that although the staff was documenting blood pressures before and after [MEDICAL TREATMENT], there was no indication that staff was documenting monitoring of the resident's left forearm fistula. Review of the clinical record for resident #62 revealed that she had a history of [REDAC… | 2018-09-01 |
| 5412 | 5412 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 241 | D | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure all residents were treated in a manner that maintained the residents' dignity and enhanced the residents' self-worth. This deficient practice had the potential to affect five residents (R73, R185, R234, R167, and R109) in a Stage II sample of 36 and two unsampled residents. Findings include: 1. During lunch service on 3/30/15 on Unit One, Licensed Practical Nurse (LPN39) was at the open door an unsampled resident and she stated the unsampled resident was a feeder. Both residents were in the room and looking at the nurse as she used this term to describe a resident who required staff assistance with meals. 2. At 4:01 p.m. on 3/30/15 in the secured unit, an unsampled resident was seated in a geri-chair with her dress bunched up around her waist and her incontinent brief was clearly visible from the common hallway. At 4:06 p.m., LPN28 stopped at the doorway of the unsampled resident's room and spoke for several minutes to another person. At 4:36 p.m. the unsampled resident remained in her geri-chair, and was clearly visible from the common hallway. The resident was dress was still bunched up around her waist and her incontinent brief was still visible to anyone who passed by her room. 3. Observation of wound care for R73 on 4/1/15 at 11:10 a.m. revealed the resident's door was closed, the curtains pulled because the sacral (buttocks) wound was exposed. When a Certified Nursing Assistant (CNA) knocked on the door, the treatment nurse called out,wound care. However, the CNA entered the room without permission and inquired about a subject unrelated to R73, thereby denying R73 the right to privacy, dignity and respect, while receiving wound care. During an interview with the Director of Nursing (DON) and the Staff Development Coordinator (SDC) on 4/2/15 at 6:10 p.m. confirmed that the staff interactions in regard to resident dignity, were inappropriate. 2. Observation of on 3/30/15 at… | 2018-09-01 |
| 5413 | 5413 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 244 | E | 0 | 1 | NBZI11 | Based on interview and documentation review, the facility failed to respond to multiple concerns voiced by residents during the Resident Council aka (also known as) Speak-Out meeting. There was no evidence of response to seven of 21 concerns voiced by the Resident Council for (MONTH) 2014 - (MONTH) (YEAR). Findings include: Interview on 4/1/15 at 1:19 p.m. with R1 revealed she believed the facility did not respond adequately to the concerns voiced during the Resident Council meeting. She said the appropriate staff was not always present to provide an explanation of the resolution related to the concerns voiced during the previous meeting(s). Interview on 4/1/15 at 1:32 p.m. with Social Service employee (SS146) revealed if there was a complaint or concern voiced during the Resident Council meeting, a Grievance/Complaint Form was to be filled out. The form was to be provided to the applicable department manager who was then to address the concern. The Administrator was to review the completed form for appropriate resolution. The Resident Council concerns were to be entered into the Grievance/Complaint log and were to be reported monthly during the facility quality assurance (QA) meeting. Review of the concerns reported during Resident Council meetings against the Grievance/Complaint Log for the corresponding dates revealed a Grievance/Complaint Form was not completed for particular departments as follows: Dietary - (MONTH) 2014: juice watered down, food not thoroughly cooked, food served late, menu not consistent with what was served, preferred choice meal not served - (MONTH) 2014: undesirable spices used on food, ice tea served hot - (MONTH) 2014: food worse, run out of food and condiments, juice sour/watered down, food not warm, burnt food, too much repetition, not notified when change in menu, do not receive requested alternate, poor presentation Laundry - (MONTH) 2014: turnover time too long, missing items Housekeeping - (MONTH) 2014: not cleaning floors properly - (MONTH) (YEAR): not cleaning floors properly,… | 2018-09-01 |
| 5414 | 5414 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 253 | E | 0 | 1 | NBZI11 | Based on observation and interview the facility failed to ensure that housekeeping and maintenance services were provided to ensure a clean environment and furnishings in good repair. This had the potential to affect 28 out of approximately 80 resident rooms in the facility. Findings include: On 3/30/15 and 3/31/15 during observation of the rooms for 40 Stage 1 sample residents, 28 resident rooms were found to have walls, floors, dressers, doors or other areas in need of repair. On 4/2/15 from 3:45 p.m. to 4:55 p.m., a tour was conducted with the Maintenance Director, Housekeeping Supervisor and Environmental Manager to observe to the physical environment in the following rooms (Rooms 212B, 216B, 221A, 221B, 222A, 223A, 225A, 227A, 302A, 302B, 305A, 305B, 403B, and 418A). The tour revealed: Room 212: bottom drawer of dresser was difficult to open and missing a piece of wood. Paint was peeling around the ceiling light in the bathroom. Room 216: dresser drawer had scratched wood. The wall was dented. The side of the resident's bed had scratched and chipped wood. Room 222: bathroom wall was scratched. There were black marks on the bottom of the wall. The door to the entrance of the room was scratched. Room 223: walls had black scratch marks. Orange marks were located on the ceiling. Bathroom door had scratch marks. Wood was loose on the side of the over-the-bed table/tray. Room 225: bathroom walls had black scratch marks. Dresser drawers were smaller than the spaces for the drawers. Room 227: dresser drawer had scratched, chipped wood and missing wood pieces. Door to the room and bathroom had scratched and chipped wood. Room 302: dresser drawer had chipped wood. The plywood located on the edge of the counter to the sink in the bathroom was chipped. Air conditioning vent in the bathroom had dust. Room 305: wall between the dresser and bathroom had black scratch marks. The baseboard was scratched and had chipped wood. Room 403: floor was not flush to the baseboard on the wall, leaving an open space under the baseboard… | 2018-09-01 |
| 5415 | 5415 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 278 | D | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to develop accurate comprehensive assessments for three (R46, R125 and R167), residents in the Stage 2 sample of 36. Findings include: 1. Observation of R46 on 3/30/15 at 2:08 p.m. revealed that she did not have any teeth on her top jaw and she was missing most of her teeth on her bottom jaw. The resident's tongue was lying on her gums between the missing teeth on her bottom jaw. An interview with the Speech Therapist on 4/2/15 at approximately 9:30 a.m. confirmed that R46 had been placed on a pureed diet many months prior due to missing teeth, difficulties chewing, and some swallowing problems. Review of the Diet Type Report dated 3/31/15 confirmed that R46 had a physician's orders [REDACTED]. Review of the initial nursing assessment dated [DATE] revealed that R46 had some missing teeth and she had both chewing and swallowing issues. Observation of R46 on 4/2/15 from 8 a.m. until 9:30 a.m. revealed that she was seated outside of the dining room in a Geri chair and she coughed continuously. Review of the Minimum Data Sets (MDS) assessments revealed that the facility failed to accurately code R46's difficulties with chewing and or swallowing. Review of the quarterly MDS dated [DATE] and Section L - Oral and Dental Status revealed that the facility had not coded R46 as having difficulties chewing. Review of the quarterly MDS assessment dated [DATE], the discharge MDS assessment dated [DATE] and the entry tracking record dated 3/19/15, revealed that the facility did not code R46 as having difficulties chewing. An interview with the MDS coordinator on 4/2/25 at approximately 9:45 a.m. confirmed that she had completed R46's MDS assessments and she had miss-coded Section L. The MDS coordinator stated that the MDS assessments were inaccurate. 2. On 3/30/15 at 4:16 p.m., observation revealed R125 seated in a geri-chair in the resident's room. R125 wore an upper denture, but did no… | 2018-09-01 |
| 5416 | 5416 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 282 | D | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assure services were provided in accordance with the plan of care for one of five residents (R16) reviewed for accidents in the Stage 2 sample of 36. Findings include: Review of the clinical record of R16 revealed [DIAGNOSES REDACTED]. Review of incident reports revealed the resident had a history of [REDACTED]. Review of the care plans for R16 revealed that on 3/9/15, the facility revised the care plan for a problem of is/has potential to demonstrate physical behaviors and verbal abuse towards other r/t (relative to) Dementia, [MEDICAL CONDITION]. Review of this care plan revealed that its approaches included: When resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress. On 4/2/15 at 1:53 p.m., R16 was observed in the secured unit in a wheelchair using the handrail to pull himself along the hallway. An unsampled female resident was behind R16 and propelled her wheelchair into the back of R16's wheelchair. Observation revealed the two wheelchairs were wedged together, and could not be separated by the residents. R16 began screaming profanities and flailing his/her arms around in an attempt to strike the female resident. Although R16's care plan called for staff to intervene before an escalation of agitation, and to guide the resident away from the source of distress, observation revealed this did not occur until surveyor intervention. Three staff were present in the area and witnessed R16 screaming profanities, attempting to strike the other resident, and unable to remove himself from the situation. However, none of these staff came from behind the nurses' station where they were standing for 96 seconds, until assistance/intervention was requested by the survey team. An interview was conducted immediately after Licensed Practical Nurse (LPN) 39 disentangled the two resident's wheelchairs and removed the residents from the situ… | 2018-09-01 |
| 5417 | 5417 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 312 | D | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADL), including nail care for one of three Stage 2 sampled residents (R167) reviewed for ADLs. Findings include: 1. Observation on 3/31/15 at 11:23 a.m. of R167 revealed many of her fingernails had a dark yellow discoloration and were thick with rough edges. Interview with R167 at that time revealed her fingernails have a fungus on them. She reported, The nurse is supposed to put cream on them, but she was told to do it myself. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed R167 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that her cognitive abilities were intact. The Bathing ADL was coded for R167 as Total Dependence on one staff person for that activity. Review of the care plan for R167, printed from the electronic clinical record on 4/2/15, revealed a Focus of ADL Self-Care Performance Deficit with an intervention for Bathing that was Initiated: 09/09/2014. According to the care plan, the Certified Nursing Assistants (CNA) was responsible to Check nail length and clean on bath day as necessary. Report any changes or necessity for trimming to the nurse. Review of the Visual Bedside Kardex that was accessible on the Point of Care (P[NAME]) computer kiosks for the CNAs revealed the same instructions. Review of the (MONTH) (YEAR) P[NAME] Response History for Skin Assessment with Shower revealed the CNAs provided assistance with R167's shower three days a week on Monday, Wednesday, and Friday. Despite the assistance provided on those days, interview on 4/1/15 at 5:04 p.m. with CNA93, who identified herself as consistently assigned to R167 four days a week on the evening shift, revealed that CNA93 had not identified or reported R167's discolored and thickened fingernails. Review of the Progress Notes regarding R167 revealed the condition of the resident's nails was do… | 2018-09-01 |
| 5418 | 5418 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 361 | F | 0 | 1 | NBZI11 | Based on observation, interview and record review, the facility failed to ensure that the Registered Dietitian (RD) worked collaboratively with the kitchen staff and was utilized in planning, managing and implementing dietary service activities in order to assure that the kitchen staff utilized safe and sanitary techniques. This had the potential to affect all 125 of the residents who ate their meals in this facility. Findings include: 1. Observation of the kitchen during two days of the survey, on 3/30/15 during the initial tour and again on 4/1/15 from 9:45a.m. until 2:30 p.m. revealed that the kitchen staff had failed to utilize safe and sanitary techniques when they failed to: 1) Discard potentially contaminated health shakes, 2) maintain potentially hazardous foods at the appropriate temperature (below 41 degrees Fahrenheit (F) or above 135 degrees F), 3) separate soiled equipment from clean dishware, 4) cover food securely in the dry storage area, and 5) air dry the Robot Coupe (blender) before each use. (Refer to F371.) 2. Observation of the food production and meal service revealed the facility failed to ensure that the kitchen staff utilized standardized recipes and followed the preplanned written menus when they prepared the residents' lunch meal. (Refer to F363.) 3. Observation of the meal service, interviews with residents and taste tests revealed the facility failed to prepare and serve food that was attractive, palatable, and pleasing to the residents. (Refer to F364.) 4. Observation of the kitchen revealed that the facility failed to maintain the kitchen environment in a safe and functional fashion. (Refer to F465.) 5. Observation, interview and record review revealed the facility failed to employ sufficient staff to ensure that their food production was managed effectively and that the staff was trained and competent to perform their duties and responsibilities. (Refer to F361.) 6. Observation of the meal service on 4/1/15 at 11:30 a.m. revealed that the cook and the Food Service Director (FSD) we… | 2018-09-01 |
| 5419 | 5419 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 363 | F | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that the kitchen staff utilized standardized recipes and followed the preplanned written menus when they prepared the residents' lunch meal. This deficient practice had the potential to affect all of the 125 residents who ate their meals in this nursing facility. Findings include: Observation of the kitchen on 4/1/15 from 9:45 a.m. through 2:30 p.m. revealed that the cook, D3 did not follow the facility's policies and procedures relative to following the preplanned written menus and the standardized recipes. Review of the Diet Type Report dated 3/31/15 revealed that the facility had 125 residents who ate their meals at this facility. Of those 125 residents there were 55 residents who had a physician's orders [REDACTED]. The 55 residents included 31 residents who had a physician's orders [REDACTED]. Review of the Week-At-A-Glance . Week 1 revealed that the facility was to prepare the following foods for lunch on Wednesday, 4/1/15: Fried Chicken Smothered Steak Cornbread Braised Cabbage Whole Kernel Corn Macaroni & Cheese Noodles Mandarin Oranges Observation of the steam table at 12:15 just before the lunch tray line began, revealed that the cook, D3, did not prepare the mechanically altered foods per the menu. D3 did not prepare mechanical soft or pureed fried chicken, mechanical soft or pureed smothered steak, pureed noodles, pureed cream style corn, or pureed mandarin oranges. After interviews with the staff, most of the foods listed above, were prepared. Observation of the meal preparation revealed that D3 had floured the raw chicken for those residents who were on a regular diet, but for those residents on a mechanically altered diet, D3 boiled chicken cubes and then ground and pureed that for the residents who were ordered a mechanical soft or pureed diet. Review of the recipe titled; Corporate Recipe .Entrees - chicken revealed that staff was to grind the fr… | 2018-09-01 |
| 5420 | 5420 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 364 | F | 0 | 1 | NBZI11 | Based on interview, observation, record review and taste tests, the facility failed to prepare and serve food that was attractive, palatable, and at a temperature that was pleasing to the residents. This deficient practice had the potential to affect all of the 125 residents who ate their meals at this nursing facility. Findings include: During the Stage 1 interviews, many of the residents complained about the taste and the quality of the food served at this facility. An interview with R222 on 3/30/15 at 12:14 p.m. revealed that she was unhappy with the food. The resident stated, I hate to complain but I do not eat the food here. I very seldom eat because the food is not good. I have told the facility that I would just prefer soup and crackers but they still send me the same food that I do not like. An interview with R26 on 3/30/15 at 1:34 p.m. revealed that she did not like the food at this facility. The resident stated, The food is terrible. The black eyed peas are as hard as a rock. They are not following the menu. Many times I just get a chicken patty and pudding. An interview with R48 at 3/30/15 at 1:40 p.m. revealed that she did not like the food at this facility. The resident stated, I always have to ask for something else to eat because the food does not look good or taste good. An interview with R62 on 3/30/15 at 2:17 p.m. revealed that he did not like the food at this facility. The resident stated, I think that all of us think the food could be better. An interview with R198 on 3/30/15 at 3:36 pm revealed that she thought the food was, Usually too cold to eat. Observation of the main dining room on 3/31/15 at approximately 7:30 a.m. revealed that the food being served did not appear appetizing. The fried eggs were prepared ahead of time and they were discolored and appeared rubbery, the oatmeal was runny and discolored, and the bacon was lying in grease. Observation of the food preparation on 4/1/15 from 9:45 a.m. until 2:30 p.m. revealed that the facility failed to maintain and serve food at appropriat… | 2018-09-01 |
| 5421 | 5421 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 365 | F | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to prepare and serve food that was designed to meet each resident's individual needs. This deficient practice had the potential to affect 55 residents who had a physician's orders [REDACTED]. Findings include: Review of the Diet Type Report dated 3/31/15 revealed that the facility had 125 residents who ate their meals at this facility. Of those 125 residents there were 55 residents who had a physician's orders [REDACTED]. The 55 residents included 31 residents who had a physician's orders [REDACTED]. Per the Academy of Nutrition and Dietetics pureed foods for dysphagia (swallowing problems) should be homogenous and cohesive and Pudding - Like. Mechanical soft and pureed foods are prepared to ensure that each resident who experienced chewing and/or swallowing problems could consume their food safely and prevent coughing, choking, and aspiration pneumonia. Observation of the breakfast meal on 3/31/15 at 7:30 a.m. revealed that the pureed oatmeal was lumpy, thin in texture and not holding its shape. Observation of the steam table on 4/1/15 at 12:15 p.m. just before the lunch tray line began, revealed that the cook, D3, did not prepare the mechanically altered foods per the menu. D3 did not prepare mechanical soft or pureed fried chicken, mechanical soft or pureed smothered steak, pureed noodles, pureed cream style corn, or pureed mandarin oranges. The facility did not prepare the pureed noodles, pureed mandarin oranges, and the mechanical soft smothered steak until surveyor intervention. On 4/1/15 at 2:30 p.m. a test tray was obtained from the kitchen. The test tray was prepared at the end of the meal service by the kitchen staff and it contained mechanically altered foods, which were tasted for texture. The test tray contained: Pureed chicken, pureed cabbage, pureed bread, cream corn, and ground breaded chicken patties. The food was tasted for texture by three surveyors. Per… | 2018-09-01 |
| 5422 | 5422 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 371 | F | 0 | 1 | NBZI11 | Based on observation, record review and interview, the facility failed to ensure food safety when they did not; 1) Discard potentially contaminated health shakes, 2) maintain potentially hazardous foods at the appropriate temperature (below 41 degrees Fahrenheit (F) or above 135 degrees F), 3) separate soiled equipment from clean dishware, 4) cover food securely in the dry storage area, and 5) air dry the Robot Coupe (blender) before each use. This deficient practice had the potential to affect all of the 125 residents who ate their meals in this nursing facility. Findings include: 1. Observation of the kitchen and the refrigerated unit (walk-in) on 3/30/15 at 9:00 a.m. revealed approximately two cases of undated defrosted health shakes that were placed on the metal ready to use shelving. Observation of the 4 ounce (oz) health shakes revealed a statement from the manufacturer, which was placed under the spout, that read: discard after 14 days of defrost. Observation of the panty on Unit One on 3/30/15 at 9:30 a.m. revealed approximately 25 defrosted health shakes that did not contain a label or a use by date. Review of the Dietary - Supplements list dated 3/31/15 revealed that the facility had 10 residents who received a daily health shake, including Residents #48, #51, #99, #147, and six un-sampled residents. An interview with the Food Service Director (FSD) on 3/30/15 at 10:00 a.m. confirmed that the facility utilized health shakes for those residents who were nutritionally compromised. The FSD added that the health shakes were physician ordered and it was necessary to discard the defrosted shakes after the 14 day defrost period. When interviewed about why the defrosted health shakes in the walk-in and in the pantry on Unit One did not contain a date or a label, the FSD stated she was uncertain. 2. Observation of the kitchen on 4/1/15 from 9:45 a.m. until 2:30 p.m. revealed that the facility did not demonstrate safe and sanitary techniques while preparing the residents' lunch meal. The following observations we… | 2018-09-01 |
| 5423 | 5423 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 412 | D | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify dental and oral health concerns and obtain dental services for one of three Stage 2 sampled residents (R167) reviewed for dental and oral health concerns. Findings include: During interview on 3/31/15 at 11:33 a.m. with R167, the resident replied Yes each time when asked three separate questions to determine if the resident had any mouth or facial pain with no relief, chewing or eating problems, or tooth problems. The resident reported she had her natural teeth but had problems with some of them. She opened her mouth and pointed out the fourth tooth from the back on the upper right that was loose and another one in the back on the upper left that was decayed. She said the tooth on the upper left needed a crown. During the interview, R167 rubbed the right side of her jaw by her ear. She said she had an earache and was getting antibiotic drops for it. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed R167 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that her cognitive abilities were intact. Follow-up interview with R167 on 4/2/15 at 11:50 a.m. confirmed that she had trouble with (the loose) tooth all year, but she put (getting dental care) off because of the cost. She explained she needed to get it done because she felt a lump on the side of my face. She also reported she had a lump on the left side of her face as well because of her tooth that needed a crown. R167 cupped her hand on her left jawline close to her ear. Review of a Dentist's Progress Notes dated 11/7/14 revealed a Missing/Broken diagram that indicated R167 had upper and bottom teeth. The following teeth on the upper jawline were marked as problematic: tooth 1 at the back on the left, tooth 5 forward from the back on the left, and the last four teeth 13 - 16 at the back on the right. The diagram also displayed the last three teeth on the left and r… | 2018-09-01 |
| 5424 | 5424 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 441 | E | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility documentation, the facility failed to ensure standard infection control practices. Direct care staff wore long fingernails, and/or long unrestrained hair that posed infection control concerns. Failure to develop, institute, and maintain an effective infection control program has the potential to affect all one hundred twenty-six residents residing in the facility. Findings include: 1. On 3/30/15 between 12:24 p.m. and 12:55 p.m., meal service on Unit One revealed the following: a. At 12:24 p.m., Licensed Practical Nurse (LPN39) delivered a tray to room [ROOM NUMBER]A and provided meal set up for the resident. LPN39 had long hair that was pulled back in a low ponytail, with the exception of an approximately 2 inch wide swatch of hair that hung down the left side of her face. The hair reached the middle of her chest and each time she leaned forward to remove the covers from the food on the tray, her hair swung forward and brushed against the resident's face and over the food tray. b. At 12:26 p.m., LPN39 was observed delivering trays throughout Unit One while unconsciously twirling her lock of hair with her fingers after using hand sanitizer and before delivering trays to multiple rooms. c. At 12:38 p.m., LPN15 was observed serving and setting up trays on Unit One during lunch on 3/30/15 and was seen to have acrylic fingernails greater than 1/4 inch past her fingertips. d. At 12:45 p.m., Certified Nursing Assistant (CNA101) was observed as she fed the resident in room [ROOM NUMBER]. CNA101 had long unrestrained hair that was chest length and wore long acrylic fingernails. e. At 12.54 p.m., CNA102 was observed in room [ROOM NUMBER] as she assisted a resident in B bed with lunch. CNA102 had long acrylic fingernails greater than 1/2 inch past the end of her fingertips. Observations throughout the facility during the survey (3/30/15-4/3/15) also revealed additional direct care staff with long, … | 2018-09-01 |
| 5425 | 5425 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 465 | F | 0 | 1 | NBZI11 | Based on observation, interview and record review, the facility failed to maintain the kitchen environment in a safe and functional fashion. This deficient practice had the potential to affect all of the residents who resided in this facility. Findings include: Observation of the kitchen on 3/30/15 at 9:00 a.m. revealed that the tile floor in the dish room and throughout the food preparation area was cracked, discolored and missing tiles. The floor in the dish room was missing many tiles and the concrete underlayment was exposed. The area missing tiles measured approximately 3 feet by 4 feet. There were large holes and crevices in the underlying concrete that were filled with discolored water. There was approximately 1/2 to 3/4 inches of water covering the entire dish room floor. Observation of the cook's preparation area revealed that the tiles were cracked, there was a black build up in the corners and around the drains and there were two uncovered floor drains that were covered with food debris and a black tar like material. Observation of the kitchen floor on 3/30/15 at 9:00 a.m. and again on 4/1/15 at 9:45 a.m. until 2:30 p.m., revealed that there were two large grease traps under the kitchen sinks. The grease traps were leaking water and debris all over the floor in the food production area. The floor was covered with water that had pooled in the center in the food production area. The pooled water was approximately one inch deep and staff was observed walking through the greasy pooled water during the entire time they prepared and served the resident's lunch meal. An interview with the Food Service Director (FSD) and the Regional Director of Food Service confirmed that the kitchen floor was maintained in poor condition. They added that they were unaware of the two uncovered floor drains, what they were used for, or why they were covered with debris. Observation of the back door that separated the kitchen from the outside garbage area revealed that it was missing paint, missing metal pieces, and it did not … | 2018-09-01 |
| 5426 | 5426 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2015-03-26 | 323 | E | 0 | 1 | 7YW311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure that chemicals were inaccessible to residents in two (2) of two (2) common shower rooms, and failed to ensure that equipment that posed a potential burn hazard was inaccessible in one (1) of (1) Beauty Shops. There was a total of twenty-five (25) independently mobile, cognitively impaired residents in the facility. The facility census was fifty-nine (59) residents. Findings include: During observation on 03/23/15 at 3:02 p.m., resident #69 was noted to wander constantly throughout the facility. Upon further observation, she was noted to remove the bedspread off her bed and place it over the commode in her bathroom, then went down the B-hall to another resident's room and obtained a foam wedge and box of tissues from this room and went walking down the hall with them. On 03/24/15 at 10:00 a.m., resident #69 was observed to be walking about the facility without apparent purpose; nursing staff were in attendance but the resident resisted their efforts to redirect her to a common area with other residents and staff. During interview with the Administrator on 03/23/15 at 5:22 p.m., she stated the resident had just been admitted to the facility on [DATE], and verified that the resident wandered constantly and they were trying different interventions to address this. During observations throughout the facility on 03/23/15 at 5:00 p.m., the unlocked General Bath on the A-hall on the side with odd-numbered rooms was noted to contain two 1-quart spray bottles of Comet Disinfecting-Sanitizing Bathroom Cleaner on top of a rolling cart. Upon further observation, one of the bottles was noted to be almost empty, and the other half-full. Review of the labeling on the bottles included causes eye irritation, may be harmful if swallowed. Observation of this rolling cart revealed that it had a compartment with a lock, but the compartment was not locked and contained numerous … | 2018-09-01 |
| 5427 | 5427 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2015-03-26 | 371 | E | 0 | 1 | 7YW311 | The facility failed to maintain steam table temperatures of one hundred and thirty-five degrees Fahrenheit (135 F) to ensure that food items on the steam table were at the proper temperature to prevent potential foodborne illness for (59) fifty-nine residents who received oral alimentation. Findings include: During observation on 3/24/15 at 12:40 p.m. of food items held on the steam table being served to residents at lunch revealed that the following food items were found to be below the minimum safe temperature level of one hundred and thirty-five degrees (135 F). Baked Ham one hundred degrees (100 F). Baked Chicken one hundred and twenty degrees (120 F). Pureed Rice one hundred and twenty degrees (120 F) Pureed Green Beans (125) one hundred and twenty-five degrees (125 F) The above observations were made using (1) one out of (3) three attempted digital thermometers that belonged to the dietary department. Interview on 3/24/15 at 12:40 p.m. with Cook AA revealed that the above food items temperatures were not appropriate and that she had checked the food temperatures prior to serving several residents who were already seated and eating lunch. Interview on 3/24/15 at 1:05 p.m. with the Dietary Manager and the Administrator revealed that they expect Cook AA to maintain food temperatures on the steam table at the appropriate temperatures. Continued interview they acknowledged that after attempting to use (3) three of the facilities digital thermometers the food items were still below the required temperature of one hundred and thirty-five degrees 135 F. | 2018-09-01 |
| 5428 | 5428 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2015-03-26 | 456 | E | 0 | 1 | 7YW311 | Based on observations and staff interviews, the facility failed to ensure that the milk cooler in the kitchen was in safe operating condition. Findings include Observation of the milk cooler on 3/23/15 at 9:15 a.m. revealed that there was a (1) one inch thick build up of ice in the milk cooler and the temperature was thirty degrees Fahrenheit (30 F). Observation on 3/24/15 at 8:05 a.m. revealed that there was still a (1) one inch thick build up of ice in the milk cooler. The temperature was still thirty degrees (30 F). Interview on 3/23/15 at 9:15 a.m. with the Dietary Manager (DM) revealed that the milk cooler had not been functioning properly and keeping the milk cold. The DM further revealed that she had called to have the milk cooler serviced on (MONTH) 9, 2014. Continued interview revealed that after being serviced the milk cooler started having ice build up. The DM revealed that staff are responsible for taking the milk cooler outside every (2) two weeks and defrosting it by hosing it down. The DM further revealed that the milk cooler has not been serviced by Mayfield Foods since (MONTH) 9, 2014 and that she does not keep a log of how often staff defrosts the milk cooler. Interview on 3/24/15 at 10:00 a.m. with the Maintenance Supervisor, revealed that maintenance was not responsible for servicing any equipment in the kitchen. The Maintenance Supervisor revealed that maintenance was only responsible for plumbing issues. | 2018-09-01 |
| 5429 | 5429 | PROVIDENCE OF SPARTA HEALTH AND REHAB | 115397 | 60 PROVIDENCE STREET, PO BOX 86 | SPARTA | GA | 31087 | 2014-11-06 | 282 | D | 0 | 1 | 5OVP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility in-service record review, and staff interview, the facility failed to provide incontinence care in accordance with the Plan of Care for one (1) resident (Z), regarding the provision of incontinence care to keep the resident clean, from a total survey sample of twenty-five (25) residents. Findings include: Resident Z's Quarterly Minimum Data Set assessment of (MONTH) 2014 documented [DIAGNOSES REDACTED]. Section H - Bladder and Bowel documented incontinence of bowel and bladder, and Section G - Functional Status documented the resident required extensive assistance with toileting. Review of the Plan of Care for Resident Z revealed an entry entitled Problems/Strengths which identified the resident to be incontinent of bowel and bladder, as identified in the Minimum Data Set assessment referenced above. A Plan of Care Intervention related Resident Z's incontinence specified that staff keep the resident both dry and clean. Review of facility staff in-service training related to female resident pericare revealed that, per protocol, staff were to spread the labia, wipe one side of the labia and then the other using a clean area of the cloth with each stroke, and were to wipe the urinary meatus. However, during observation on 11/05/2014 at 10:30 a.m., Certified Nursing Assistant (CNA) AA wiped Resident Z's perineal area in an up-and-down motion, rather than spreading the labia and wiping down each side using a clean area of the cloth with each stroke. In addition, CNA AA did not clean Resident Z's urinary meatus. This CNA's failure to provide incontinence care to Resident Z per facility protocol resulted in a failure to ensure incontinence care which kept the resident clean, as specified by the Plan of Care referenced above. During interview on 11/06/2014 at 4:55 p.m., the Director of Nursing stated facility staff were to provide pericare in accordance with in-service training. Cross refer to F315 for mo… | 2018-09-01 |
| 5430 | 5430 | PROVIDENCE OF SPARTA HEALTH AND REHAB | 115397 | 60 PROVIDENCE STREET, PO BOX 86 | SPARTA | GA | 31087 | 2014-11-06 | 315 | D | 0 | 1 | 5OVP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's in-service record, resident interview, and staff interview, the facility failed to provide incontinence care per facility protocol to prevent potential urinary tract infections for one (1) resident (Z) from a total survey sample of twenty-five (25) residents. Findings include: Record review for Resident Z revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of (MONTH) 2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns documented that Resident Z had a Brief Interview for Mental Status Summary Score of 15, indicating the resident was cognitively intact. Section H - Bladder and Bowel documented that the resident had been always incontinent of bowel and bladder during the look-back period, and Section G - Functional Status documented the resident required the extensive assistance of staff with toileting. During an interview conducted on 11/03/2014 at 11:56 a.m. with female Resident Z, the resident stated that certified nursing assistant (CNA) staff provided her with incontinence care when she needed cleaning due to incontinence. On 11/05/2014 at 10:30 a.m., during an observation of bowel and urinary incontinence care for Resident Z, CNA AA was observed to use a soapy washcloth to wipe the resident's perineal area in an up-and-down motion. CNA AA did not spread the resident's labia in order to wipe down one side and then the other side, and did not consistently use a clean area of the cloth with each stroke. CNA AA also did not clean the resident's urinary meatus during this incontinence care procedure. During an interview conducted on 11/06/2014 at 4:55 p.m., the facility's procedure for the provision of incontinence care to female residents was discussed with the Director of Nursing (DON). The DON provided a PowerPoint in-service with documented steps for appropriate pericare for female residents. Revi… | 2018-09-01 |
| 5431 | 5431 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 242 | D | 0 | 1 | ZZBE11 | Based on observations, resident and staff interviews, the facility failed to honor meal perference/choice for one () residents (K) from a sample of thirty-two (32) residents. Findings Include: 1. Interview conducted 3/3/15 at 9:20am with resident K revealed that he used to get vegetable soup and a grilled cheese for his alternate meal but now he only gets cereal. K further indicated that for the past month the kitchen has served him the main menu and do not honor his request for vegetable soup and grilled cheese sandwich. The resident revealed he was told by the dietary staff that it is too much of a hassle to make him a grilled cheese sandwich and that he may eat cereal and milk instead. Interview on 03/03/15 at 12:10pm with the Dietary Manager revealed the meal alternative is decided each morning and is her choice. She further revealed that the alternate is posted with the main menu in the hall near the dining room each morning When the Dietary Manager was asked about a policy regarding if a resident did not like the meal or the alternate, she responded with you are talking about the vegetable soup and grilled cheese sandwich. She indicated that the facility stopped providing any other alternatives for meal choice other than the daily chef choice for a meal alternative because it got out of control, it was like a domino effect, everyone was asking for a grilled cheese sandwich. Interview conducted 03/05/15 at 10:45am with the Director of Nursing (DON) revealed that residents have the right to choose their meal and an alternate is provided. DON further revealed the if residents do not like the meal or alternate, they may ask for something else, provided they ask in advance. Choices can be voiced at any time; however, residents cannot choose an alternative during meal time. They must wait until after the meal time is completed, then they may ask for a different meal. Observation conducted 03/02/15 at 1:00pm revealed the menu was posted in hallway to dining room but no alternate choice was posted. Observation cond… | 2018-09-01 |
| 5432 | 5432 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 282 | D | 0 | 1 | ZZBE11 | Based record review, and staff interview, the facility failed to follow plan of care for one (1) resident (A) from thirty-two (32) sampled residents. Findings include: Review of the care plan for resident A revealed a care plan related to poor dentition for teeth described as broken and discolored. An intervention for this was to provide medications as ordered and that the resident was receiving Magic mouth wash. This plan of care was developed on 5/29/2014 and was reviewed on 8/25/2014, 10/16/2014, and 1/14/2015 which continue to include the Magic Mouthwash as an intervention. Interview with Case Mix Coordinator CC conducted on 3/3/2015 at 2:00 p.m. revealed that the Magic Wash was ordered upon admission and was placed as one of the intervention, however, the Magic Wash was never ordered from the pharmacy and resident had never received it. Refer to F412, Example #1. | 2018-09-01 |
| 5433 | 5433 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 412 | D | 0 | 1 | ZZBE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to provide dental services for two (2) residents ( A and B) from thirty-two (32) sampled residents. Findings includes: 1. Observation conducted on 3/2/15 at 12:39 PM for resident A revealed multiple stain, missing, decayed /and or broken teeth. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] assessed the resident as having natural broken teeth. Review of the Care Area (CAA) Assessment Summary for this assessment revealed that dental care triggered and would be care planned. Review of an oral assessment conducted admission on 5/20/2014 revealed the resident had six (6) missing teeth and poor oral health. Review of admission physician's orders [REDACTED]. Interview with resident A conducted 3/3/2015 at 1:20 p.m. revealed she have never use any mouth wash since her admission nor seen a dentist. Interviews conducted 3/3/2015 at 1:30 p.m. with two (2) Certified Nursing Assistant (CNA) AA and BB, who cared for resident A revealed that they have never given the resident any mouth wash during oral care. Interview with Case Mix Coordinator CC conducted 3/3/2015 at 2:00 p.m. revealed that the Magic Wash was ordered upon admission, however, it was never ordered from the pharmacy and resident has never received it. 2. Observation conducted 3/2/2015 at 2:19 PM of resident B revealed missing lower teeth, with dark stain on her natural teeth. Interview with resident B on 3/3/2015 at 1:36 p.m. revealed when she was admitted to the facility she had a lower partial denture plate. Following her admission to the facility her dentures became missing and staff were unable to locate them. She revealed that she has asked on several occasions for facility staff to assist her in scheduling an appointment to have her partial replaced, without success. She further revealed that she has to eat soft food because her missing teeth make it hard for her to chew. She… | 2018-09-01 |
| 5434 | 5434 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 465 | D | 0 | 1 | ZZBE11 | Based on observations, resident and staff interviews the facility failed to provide a comfortable water temperature for bathing for two (2) residents (C and D) from a sample of thirty-two (32) residents. Findings Include: Interview with resident C on 03/03/15 at 9:43am revealed that water temperature in shower room was too cold. He indicated he had reported this Certified Nursing Assistant (CNA) and the nursing staff. Interview conducted with resident D on 03/04/15 at 3:10pm revealed he felt the water temperature in the men's shower room was cold. He indicated that it had been this way for quite some time and is worse in the winter months. Staff are aware and no one seems to know how to fix it. Interview conducted on 03/05/15 at 9:05am with CNA GG revealed that female residents complain about once or twice a week about the water in the shower rooms being too cold. When this happens we shut the water off in both the men's and women's shower rooms temporarily to give the water time to heat up again. We usually wait fifteen (15) to thirty (30) minutes. If this does not work we call maintenance. GG indicated that maintenance is usually called once or twice each week about the water in the shower rooms being too cold. Interview conducted with Maintenance Director on 03/05/15 at 09:20am revealed. he receives calls or verbal requests about the water being too cold in the shower rooms about once a week. He will adjust water valve and recheck the water temperatures to make sure the water temperatures are maintain at the proper temperature level for residents comfort. Water temperature for the Men's and Women's showers taken on 3/5/15 at 1:42pm by the Maintenance Director revealed the following: Men's Shower 96 and 98 degrees Fahrenheit (F.) Women's Shower 96 degrees F. | 2018-09-01 |
| 5435 | 5435 | PRUITTHEALTH - BLUE RIDGE | 115468 | 99 OUIDA STREET | BLUE RIDGE | GA | 30513 | 2014-12-11 | 279 | D | 0 | 1 | WU5011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive care plan based on Minimum Data Set (MDS) assessment for two residents (#132 for vision and #150 for Nutrition) from a sample of thirty-four (34) residents. Findings include: 1. Record review for resident #132 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which assessed the resident as having vision impairment. Review of the Care Area Assessment (CAA) dated 7/25/14 revealed that the resident triggered for vision and vision would be care planned. Further review revealed there was no evidence that a care plan had been developed after the Admission MDS assessment had been completed. Interview conducted 12/10/2014 at 1:15 p.m .with the Case Mix Director AA revealed that no comprehensive care plan was developed to address resident #132 impaired vision. 2. Record review for Resident #150 revealed an Admission MDS assessment dated [DATE] which assessed the resident as being on a therapeutic diet. Review of the Care Area Assessment (CAA) for Nutrition Status revealed nutrition triggered and would be care planned. Further review revealed no evidence that a care plan for Nutrition was developed. Interview on 12/10/2014 at 3:45 p.m. with Case Mix Director ( AA ) revealed that the care plan had not be developed for nutrition and she could not find a care plan in the computer system. | 2018-09-01 |
| 5436 | 5436 | PRUITTHEALTH - BLUE RIDGE | 115468 | 99 OUIDA STREET | BLUE RIDGE | GA | 30513 | 2014-12-11 | 282 | D | 0 | 1 | WU5011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based record, care plan, and Medication Administration Record [REDACTED]. Findings include: Record review for resident #66 revealed a [DIAGNOSES REDACTED]. Review of the resident's care plan for her [MEDICAL CONDITION] and [MEDICAL TREATMENT] revealed an intervention for monitoring blood pressure (B/P) and pulse before and after [MEDICAL TREATMENT]. Interview conducted 12/11/2014 at 9:30 a.m. with the Director of Nursing (DON) revealed blood pressure, and pulse are documented by nurses on resident #66 Medication Administration Record [REDACTED] Review of the (MONTH) and (MONTH) 2014 MARs revealed no evidence that the care plan was followed related to B/P and Pulse before and after [MEDICAL TREATMENT] for eight (8) days in (MONTH) and two (2) days in December. Cross-Refer to F309 | 2018-09-01 |
| 5437 | 5437 | PRUITTHEALTH - BLUE RIDGE | 115468 | 99 OUIDA STREET | BLUE RIDGE | GA | 30513 | 2014-12-11 | 309 | D | 0 | 1 | WU5011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the Medication Administration Records (MARs) the facility failed to follow physician's order for one (1) resident (# 66) from a sample of thirty-four (34) residents. Finding includes: Record review for resident #66 revealed a physician's order dated 11/5/2014 to monitor blood pressure (B/P) and pulse before and after [MEDICAL TREATMENT]. Review of the (MONTH) 2014 MAR indicated [REDACTED]. Review of the (MONTH) 2014 MAR indicated [REDACTED]. Interview with Director of Nursing (DON) conducted on 12/11/2014 at 9:30 a.m. revealed blood pressure, and pulse are to be done according to physician's order and documented by nurses on resident #66 MAR. | 2018-09-01 |
| 5438 | 5438 | HEART OF GEORGIA NURSING HOME | 115471 | 815 LEGION DRIVE | EASTMAN | GA | 31023 | 2012-10-12 | 279 | D | 0 | 1 | 9NKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview and record review, the facility failed to develop a care plan for range of motion for one (1) resident (A) from a sample of thirty eight (38) residents. Findings include: Observation on 10/10/12 at 8:19 a.m., on 10/11/12 at 9:30 a.m. and 11:30 a.m. and on 10/12/12 at 8:40 a.m. revealed the resident sitting up in a geri-chair, leaning to the left. The resident's left arm had dropped down between his/her body and the arm of the geri-chair. The resident's left hand was curled. Continued observation revealed there was no positioning device in place to prevent the resident from leaning to the left or to prevent the left arm from dropping down. Review of the clinical record for resident A revealed that the resident was admitted with a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed with [REDACTED]. Review of the resident care plan revealed no evidence that a care plan had been developed for limited range of motion to the left upper and lower extremities. Interview with resident A on 10/11/12 at 9:30 a.m., revealed that he/she could not move the left arm without using the right arm to lift it, but because the arm was heavy, he/she was unable to move it very far. Continued interview revealed that the resident was unable to open his/her left hand completely and that he/she had never had a splint to wear on the left hand. | 2018-09-01 |
| 5439 | 5439 | HEART OF GEORGIA NURSING HOME | 115471 | 815 LEGION DRIVE | EASTMAN | GA | 31023 | 2012-10-12 | 281 | D | 0 | 1 | 9NKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Georgia Practical Nurses Act and staff interview, the facility failed to follow the standards of practice related to sliding scale Insulin administration for two (2) residents (#25 and #83) from a sample of thirty eight (38) residents. Findings include: 1. Review of the clinical record for resident #25 revealed that the resident was admitted to the facility in September, 2012 with [DIAGNOSES REDACTED]. Review of the physician progress notes [REDACTED]. Review of the physician's orders [REDACTED]. (BS-100/30= #u [MEDICATION NAME] Insulin.) Review of Medication Administration Records for resident #25 from (MONTH) 10, 2012 through (MONTH) 30, 2012 and (MONTH) 1, 2012 through (MONTH) 10, 2012 revealed twenty-six (26) times that the [MEDICATION NAME] Insulin was not administered as ordered. Interview with the Director of Nursing (DON) and Administrator on 10/10/2012 at 3:33 p.m. revealed that the physician's orders [REDACTED]. Continued interview revealed that the physician orders [REDACTED]. 2. Review of the clinical record for resident #86 revealed that the resident was was admitted to the facility in (MONTH) 2012 with a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].# of units. Review of the Medication Administration Records from (MONTH) 5, 2012 through (MONTH) 7, 2012 revealed forty five (45) times that the [MEDICATION NAME] R Insulin was not administered as ordered. Interview with the Administrator and Director of Nursing (DON) on 10/11/12 at 10:55 a.m., confirmed the above concerns. continued interview revealed that in front of each Medication Administration Record [REDACTED]. Review of the Georgia Practical Nurses Practice Act revealed that the practice of licensed practical nursing means the provision of care for compensation related to the maintenance of health and prevention of illness which shall include: -2.3.2-Section J #3-Administers medications accurately Section E-Seeks clari… | 2018-09-01 |
| 5440 | 5440 | HEART OF GEORGIA NURSING HOME | 115471 | 815 LEGION DRIVE | EASTMAN | GA | 31023 | 2012-10-12 | 309 | D | 0 | 1 | 9NKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to follow physician orders [REDACTED].#25 and #68) from a sample of thirty-eight (38) residents. Findings include: 1. Resident #86 was admitted to the facility in (MONTH) 2012 with a [DIAGNOSES REDACTED]. Review of Physician order [REDACTED].=# of units. Review of the (MONTH) 2012 Medication Administration Record [REDACTED] 1. 7/4: Accucheck at 6:30 a.m. was 270, Insulin given was five (5), should have received six (6) units. 2. 7/13: Accucheck at 4:30 p.m. was 216, Insulin given was three (3) units, should have received four (4) units. 3. 7/18: Accucheck at 4:30 p.m. was 295, Insulin given was six (6) units, should have received seven (7) units. 4. 7/23: Accucheck at 4:30 p.m. was 344, Insulin given was eleven (11) units, should have received eight (8) units. 5. 7/25: Accucheck at 4:30 p.m. was 208, Insulin given was three (3) units, should have received four (4) units. 6. 7/30: Accucheck at 4:30 p.m. was 328, Insulin given was seven (7) units, should have received eight (8) units. Review of the (MONTH) 2012 Medication Record revealed the following concerns: 1.) 8/2: Accucheck at 4:30 p.m. was 261; however, no coverage was given. 2.) 8/3: Accucheck at 11:30 a.m. was 309, Insulin given was nine (9) units, should have received seven (7) units. 3.) 8/4: Accucheck at 4:30 p.m. was 338, Insulin given was seven (7) units, should have received eight (8) units. 4.) 8/8: Accucheck at 4:30 p.m. was 291, Insulin given was seven (7) units, should have received six (6) units. 5.) 8/9: Accucheck at 4:30 p.m. was 261, Insulin given was seven (7) units, should have received five (5) units. 6.) 8/16: Accucheck at 4:30 p.m. was 360, Insulin given was eight (8) units, should have received nine (9) units, 6:30 a.m. was 297 with no documentation of Insulin given. 7.) 8/18: Accucheck at 4:30 p.m. was 300, Insulin given was six (6) units, should have received seven (7) units. 8.) 8/20: Accucheck at 4… | 2018-09-01 |
| 5441 | 5441 | HEART OF GEORGIA NURSING HOME | 115471 | 815 LEGION DRIVE | EASTMAN | GA | 31023 | 2012-10-12 | 318 | D | 0 | 1 | 9NKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and resident and staff interviews, it was determined that the facility failed to provide care to prevent further decline in range of motion for one (1) resident (A) from a sample of thirty eight (38) residents. Findings include: Observations of resident A on 10/10/12 at 8:19 a.m. and on 10/11/12 at 9:30 a.m. and 11:30 a.m. revealed the resident sitting up in a geri-chair. The resident was leaning to the left with the left arm down between his/her body and the arm of the wheelchair and the left hand was curled. Continued observation revealed no positioning device between the resident's body and the arm of the geri-chair to prevent the resident from leaning and/or the arm from dropping down and there was no splint on the left hand. Observation 10/12/12 at 8:40 a.m. revealed the resident in a geri-chair in the hallway attempting to feed him/herself breakfast. Continued observation revealed the resident was slumped to the left side of the geri-chair with the left arm between the chair and his/her body. Interview with the resident 10/12/12 at 8:40 a.m revealed that he/she could not pull him/herself up to a more upright position. Review of the clinical record for resident A revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data assessment dated [DATE] revealed that the resident was assessed with [REDACTED]. Interview with the resident at 11:30 a.m. on 10/11/12,revealed that he/she was unable to stretch the left hand completely open and was unable to exercise the left arm and shoulder without assistance because it was too heavy. Continued interview revealed that he/she was no longer receiving any type of therapy or exercises by the staff. Interview with the Director of Nurses (DON) on 10/11/12 at 10:50 a.m. revealed that she would expect the Certified Nursing Assistants (CNA) to provide range of motion (ROM) for the residents during routin… | 2018-09-01 |
| 5442 | 5442 | HEART OF GEORGIA NURSING HOME | 115471 | 815 LEGION DRIVE | EASTMAN | GA | 31023 | 2012-10-12 | 323 | D | 0 | 1 | 9NKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (1) resident (#68) from a sample of thirty-eight (38) residents Findings include: Review of the medical record for resident #68 revealed that the resident had [DIAGNOSES REDACTED]. Review of the resident care plan revealed that the resident was care planned for falls with an intervention for a lap buddy, that was discontinued per family request on 8/25/12. Continued review revealed that the resident had been care planned for a tab alarm that had been removed 5/10/12. Review of the nurses notes dated 9/25/12 revealed that the resident fell from the wheelchair sustaining a swollen, bruised area to the left eye. Continued review revealed that the resident was evaluated in the emergency room and then transferred back to the facility with no evidence of fracture. Review of the facility investigation revealed that the resident leaned forward too far in the wheelchair and fell to the floor. Review of the physician's orders [REDACTED]. Interview on 10/11/12 at 2:15 p.m. with the Administrator revealed that there were no interventions in place to prevent the 9/25/12 fall. The lap buddy and the tab alarmed had been removed. Continued interview revealed that there was no order to discontinue the lap buddy. | 2018-09-01 |
| 5443 | 5443 | HEART OF GEORGIA NURSING HOME | 115471 | 815 LEGION DRIVE | EASTMAN | GA | 31023 | 2012-10-12 | 431 | D | 0 | 1 | 9NKE11 | Based on observations and staff interviews the facility failed to document an opened date on one (1) vial of Purified Protein Derivative (PPD) and that one (1) of three (3) Medication Carts used on four (4) halls was locked when unattended. Findings include: Observation of the locked drug storage room on 10/11/12 at 9:00 a.m. revealed one (1) vial of Tuberculin Purified Protein Derivative (PPD), the only vial available, was open with no puncture date. There was less than one half (1/2) of the medication left in the bottle. Interview on 10/11/12 at 9:30 a.m. with the Administrator revealed the vials of PPD must be discarded past twenty eight (28) days from the open date. There were at least eight (8) new admissions that potentially received the Tuberculin test from that vial (Lot # 2). Further observation on 10/11/12 at 9:00 a.m. revealed a medication cart (1-2) was unlocked while the nurse was inside a resident room, behind a closed curtain, administering medications to a resident. Interview on 10/11/12 at 9:45 a.m. with the Licensed Practical Nurse (LPN) AA using the unlocked cart revealed that she knew her cart was unlocked, she just forgot. | 2018-09-01 |
| 5444 | 5444 | HEART OF GEORGIA NURSING HOME | 115471 | 815 LEGION DRIVE | EASTMAN | GA | 31023 | 2012-10-12 | 441 | D | 0 | 1 | 9NKE11 | Based on observation, staff interview and facility policy review, the facility failed to ensure a Blood Glucose Monitor was properly cleaned for one (1) resident (#86) from a sample of thirty-eight (38). Findings include: Observation of an accucheck during medication pass for resident #86 on 10/10/12 at 12:35 p.m. revealed that the Glucometer was not cleaned or disinfected prior to the test, and was returned to the cart after the test without being cleaned or disinfected. During an interview on 10/11/12 at 9:45 a.m., Licensed Practical Nurse (LPN) AA revealed that she was not sure what kind of wipes were used to clean and disinfect Glucometers before or after accuchecks were performed. She further revealed that there were no wipes kept on the cart. Interview with the LPN BB on 10/11/12 at 10:00 a.m. revealed that there were no wipes on her cart to clean and disinfect Glucometers, and could not identify what type of wipes were used. Interview with the LPN CC on 10/11/12 at 10:10 a.m. revealed that her cart did not have any disinfectant wipes, and was not able to identify the disinfectant used. Review of the facility policy and procedure for Disinfecting Blood Glucose Meters revealed that the facility would disinfect blood glucose meters to prevent the spread of infection. The blood glucose meter would be cleaned before and after each use with an EPA registered Tuberculocidal disinfectant with bleach. The meter would be disinfected prior to entering a resident's room and after performing a blood glucose procedure. | 2018-09-01 |
| 5445 | 5445 | HEART OF GEORGIA NURSING HOME | 115471 | 815 LEGION DRIVE | EASTMAN | GA | 31023 | 2012-10-12 | 499 | C | 0 | 1 | 9NKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility file review, Georgia Secretary of State Website review, and staff interview, the facility failed to ensure a current license was maintained for (1) Registered Professional Nurse from a sample of five(5) professional staff files reviewed. Findings include: Review of the Assistant Director of Nursing's (ADON) employee file revealed that her Registered Professional Nurse License had expired on [DATE]. Review of the information printed from the Georgia Secretary of State Website on [DATE] revealed that the Registered Professional Nurse License for the ADON had expired on [DATE] and the License Status was Lapsed. Interview with the Director of Nursing (DON) on [DATE] at 10:30 a.m. revealed that the Nursing License for the ADON had expired on [DATE]. | 2018-09-01 |
| 5446 | 5446 | GREENE POINT HEALTH AND REHABILITATION | 115488 | 1321 WASHINGTON HIGHWAY | UNION POINT | GA | 30669 | 2014-12-18 | 312 | D | 0 | 1 | FHU911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, it was determined that the facility failed to provide timely bowel incontinence care for one resident (Z) from a sample of twenty-five (25) residents. Findings include: Resident Z was admitted on [DATE] with the following diagnoses; [MEDICAL CONDITION] [MEDICAL CONDITION], Depression, [MEDICAL CONDITION] (CAD) and status [REDACTED]. Review of the fourteen (14) day Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed as having a Brief Interview for Mental Status (BIMS) score of eight (8) indicating that she was alert and oriented most of the time,she was non-ambulatory, having limitations in range of motion of her extremities on one side, frequently incontinent of bowel and bladder and as being totally dependent on staff for toileting. Review of the resident's care plan dated 12/4/14 revealed that staff was suppose to assist the resident with activities of daily living (ADLS) as needed. Interview with resident Z on 12/15/2014 at 2:18 p.m., revealed that she had waited up to one (1) hour for staff to provide incontinence care. On 12/16/14 at 8:35 a.m., the resident was observed lying in her bed. Interview with resident Z at that time revealed that she had just used the call light to request assistance from staff to provide bowel incontinence care. Observation of the light above the resident's door at that time revealed that it was not blinking to indicate to staff in the hall that the resident needed assistance. Continued observation at 8:45 a.m., revealed a Certified Nursing Assistant (CNA)who removed breakfast trays from residents' rooms, placed the trays on the cart in the hall and then returned the cart to the kitchen. At 8:55 a.m., the same CNA was observed to return to the hall carrying clean linens into another resident's room and close the door. Continued observation at 9:14 a.m., the light above resident Zs door was turned on and answ… | 2018-09-01 |
| 5447 | 5447 | GREENE POINT HEALTH AND REHABILITATION | 115488 | 1321 WASHINGTON HIGHWAY | UNION POINT | GA | 30669 | 2014-12-18 | 323 | D | 0 | 1 | FHU911 | Based on observation, review of the Weekly Water Temps/Equipment Log, and staff interviews the facility failed to ensure that hot water for resident use was at a safe temperature for one (1) shared bathroom on one (1) of three (3) halls. Findings include: Observation on 12/15/14 at 10:45 a.m., of random resident bathrooms during initial tour revealed that the hot water in the bathroom sink for the adjoining rooms 214 and 216, shared by four (4) residents was uncomfortably hot to the touch. The hot water temperature was taken with a thermometer and was noted to be one hundred and twenty (120) degrees Fahrenheit (F). Interview with the Director of Nursing (DON) and the Maintenance Director on 12/15/14 at 11:00 a.m. to notify them of the unsafe water temperature, the DON revealed that none of the residents had sustained burns from hot water temperatures. On 12/15/2014 at 11:15 a.m. the hot water temperature was verified at one hundred and twenty degrees (120F) with the Maintenance Director using the facility's thermometer. The hot water was adjusted by the Maintenance Director and the temperature was rechecked and verified to be one hundred degrees (100F) . Interview with the Maintenance Director on 12/15/2014 at 12:00 p.m., revealed that the four rooms at the end of the (200) hallway are on a different hot water heater. He further revealed that he was able to lower the hot water by adjusting the valve. Continued interview revealed that if a resident or staff identifies hot water being very hot, staff notify him right away and staff completes a work order, and places it in the Maintance book which he checks every day. The Maintenance Director revealed that he checks the hot water temperatures randomly in the resident bathrooms. Review of the Weekly Water Temps and Equipment Log revealed that there was no evidence that the hot water temperatures were checked in the adjoining bathrooms for rooms 214 and 216 in the months of August, September, October, (MONTH) or (MONTH) 2014. Interview with the Administrator on 12/18/… | 2018-09-01 |
| 5448 | 5448 | GREENE POINT HEALTH AND REHABILITATION | 115488 | 1321 WASHINGTON HIGHWAY | UNION POINT | GA | 30669 | 2014-12-18 | 371 | E | 0 | 1 | FHU911 | Based on observations and staff interview the facility failed to properly distribute the resident's meals in a sanitary manner on three (3) of ( 3) halls for two (2) of (2) dining observations. Findings include: Observation on 12/17/14 at 7:55 a.m. of the B Hall revealed that nursing staff received the food cart from the dietary staff with a clear plastic bag covering all the resident trays. Continued observation revealed that once nursing staff received the food cart they removed the clear plastic bag exposing the resident trays while pushing the cart from room to room for distribution. Observation of the residents' breakfast trays revealed that each tray contained an uncovered beverage and uncovered dishes of fruit. Observation of the A Hall on 12/18/14 at 12:35 p.m. revealed a Certified Nursing Assistant (CNA) receiving the food cart from the dietary staff. The food cart was covered with a clear plastic bag which was removed by the CNA. Continued observation revealed that the resident's lunch trays had several food items which were not individually wrapped such as the beverages, the banana pudding, and the dinner rolls. The CNA pushed the food cart down the hall for distribution without covering the cart while it was in motion. Continued observation revealed a Licensed Practical Nurse (LPN) who removed a resident's lunch tray from the uncovered cart and carried it to a resident on the C Hall. Interview on 12/18/14 at 12:35 p.m. with the Dietary Manger (DM) revealed that she expects all food items on the resident's meal tray to be covered when staff delivers it to their rooms. The DM confirmed that nursing staff were removing the clear plastic bag completely from the food cart. She further confirmed that nursing staff were pushing the food cart down the hall while food items were uncovered on the trays. The DM confirmed the observation of the LPN delivering the resident's uncovered lunch tray to the C Hall. She acknowledged that all food items should be covered on the meal tray if walked down the hallway. | 2018-09-01 |
| 5449 | 5449 | GREENE POINT HEALTH AND REHABILITATION | 115488 | 1321 WASHINGTON HIGHWAY | UNION POINT | GA | 30669 | 2014-12-18 | 372 | B | 0 | 1 | FHU911 | Based on observation and staff interview the facility failed to properly contain waste in one (1) of two (2) dumpsters to prevent the harborage of pests. Findings include: Observation on 12/16/14 at 3:30 p.m. of the dumpster area revealed that there were two (2) large dumpsters sitting on a concrete pad. The dumpster on the left was observed with the top lid open. Continued observations revealed that there were nine (9) empty cardboard boxes on the ground between the two ( 2) dumpsters. One of the cardboard boxes contained twelve (12) pieces of cut tomato tops, and on the ground there were eight (8) pieces of cut tomato tops on the ground between the 2 dumpsters. Interview on 12/16/14 at 3:30 p.m. with the Dietary Manager (DM) revealed that she expected all trash to be contained in the dumpster. The DM verified that there were several empty cardboard boxes on the ground between the two (2) dumpsters and that one (1) of the boxes contained cut tomato tops. She verified that there was tomato debris on the ground by the empty boxes. The DM confirmed that all lids need to be closed on the dumpsters at all times. She verified that the lid on the dumpster was open. Continued interview revealed that the dietary staff had placed the empty cardboard boxes on the ground because the dumpster was full. She further revealed that she did not realize that her staff had put food product in the empty boxes and put those boxes on the ground. The DM revealed that she would expect her staff to place food debris that needs to be discarded into a plastic bag. Interview on 12/18/14 at 12:15 p.m. with the Maintenance Director revealed that the dumpsters are emptied twice a week on Tuesdays and Fridays. He revealed that as soon as he saw how full the dumpsters were he called the waste disposal company for an earlier pick up. Continued interview revealed that the maintenance staff was responsible for the dumpsters and the dumpster area. The Maintenance Director further revealed that the maintenance staff discard trash a minimum of three (… | 2018-09-01 |
| 5450 | 5450 | GREENE POINT HEALTH AND REHABILITATION | 115488 | 1321 WASHINGTON HIGHWAY | UNION POINT | GA | 30669 | 2014-12-18 | 441 | D | 0 | 1 | FHU911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the facility's Procedural Guideline for Hand Hygiene and staff interview, it was determined that the facility failed to ensure that staff washed or sanitized their hands during the meal service for one (1) of two (2) meals on one (1) of three (3) halls (A Hall). Findings include: Review of the facility's Procedural Guideline for Hand Hygiene revealed that handwashing/hand hygiene was the most important single procedure for preventing healthcare-associated infections. Further review revealed that handwashing with a non-antimicrobial soap and water or an antimicrobial soap and water was to be done when the hands were visibly dirty, contaminated with proteinaceous material, visibly soiled with blood and other body fluids and in the case of a resident with a spore-forming organism. In all other clinical situations and when hands were not visibly soiled, an alcohol-based hand rub could be used for routinely decontaminating hands. During observation of the breakfast meal service on 12/17/14 between 7:35 a.m. and 7:50 a.m., Certified Nursing Assistant (CNA) BB obtained a meal tray from the meal cart and served the resident in room [ROOM NUMBER] A. BB set the meal tray on the resident's overbed table and pulled the privacy curtain back closer to the wall. Without sanitizing or washing her hands, BB returned to the cart, obtained a coffee cup touching the mouth of the cup she poured coffee into the cup. BB placed the coffee cup on a meal tray and served the resident in room [ROOM NUMBER] B. Continued observation BB placed the tray on the resident's overbed table, moved the overbed table closer to the resident and opened the carton of milk, touching the spout. Without sanitizing or washing her hands, BB returned to the cart, obtained a coffee cup for another resident, poured coffee into the cup and placed the cup on a tray that was served to a resident by another CNA. BB then obtained a coffee cup touching the mouth of … | 2018-09-01 |
| 5451 | 5451 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2015-09-04 | 225 | D | 1 | 0 | DKBB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to report an alleged abuse to the state agency for one (1) resident Q from a sample size of thirty-three (33) residents. Findings include: Medical record review revealed resident Q was an [AGE] year old female with a [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] included a Brief interview Mental Status (BIMS) score of 15 which indicates the resident is cognitively intact. The resident required limited assistance with supervision of her Activities of Daily living (ADL). Resident Q reported a claim of alleged abuse to the Director of Nursing (DON) on 8/30/15. Family member for resident Q revealed that she had informed the DON that on the evening of 8/27/15 her mother was receiving her daily Insulin injection by nurse AA. She requested that the nurse use another site and was told by the nurse to remove her arm. She moved her arm and allowed the nurse to give the injection. She reported this to the DON who said she would re-educate the nurse. That same nurse came in on 08/29/15 and again resident Q placed her arm over her upper stomach the nurse informed her that if she did not move her arm she will stick the needle somewhere else. Her daughter revealed that she called the DON on 08/30/15 and told her that Q was threatened by the Licensed Practical Nurse AA and she was concerned about her safety. The family member continued to reveal that she was concerned that the nurse was still working with her mother and had not been removed on 08/28/15 when the DON was first informed that there was a concern with AA . Interview on 09/01/15 at 3:40 p.m. with the DON revealed that she was notified about the abuse allegation on Sunday 08/30/15 and felt the nurse only needed re-education. She continued to reveal that she was not aware of the protocols for reporting abuse in Georgia and did not send any report into the state office. She did not seek the advice of the Regional Nurse or … | 2018-09-01 |
| 5452 | 5452 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2015-09-04 | 279 | D | 1 | 0 | DKBB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan related to nutrition for one (1) resident (#253) from a sample size of thirty-three (33) residents. Findings include: Review of medical record for resident #253 revealed the resident was admitted to the facility on [DATE] and discharged to an Assisted Living Facility on 04/21/15. Her [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] of the Care Area Assessment revealed that the resident's nutritional status was triggered and was to be addressed with a plan of care. Review of resident #253 medical records revealed there was no evidence that a care plan for nutrition had been developed. Interview conducted on 09/03/15 at 2:25 p.m. with the Registered Dietitian (RD) confirmed that she expected the MDS department to develop a care plan addressing the resident's nutrition status. Interview conducted on 09/03/15 at 3:00 p.m. with the MDS Coordinator confirmed that there was no care plan addressing nutrition for this resident. | 2018-09-01 |
| 5453 | 5453 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2015-09-04 | 323 | D | 1 | 0 | DKBB11 | Based on observation, facility policy review and staff and resident interviews, the facility failed to ensure that the resident environment was free of chemical hazards for one resident (#88) from a sample of thirty-three (33) residents. Findings include: Observation on 09/01/15 at 10:12 a.m. revealed a thirty (30) ounce bottle of bleach noted in the resident's #88 bathroom shared with his roommate. Observation on 9/01/2015 at 11:20 a.m. revealed further observation of two (2) containers of Clorox brand wipes on resident #88 bedside table. Observations on 09/01/15 at 4:55 p.m. and 09/02/15 at 8:32 a.m. revealed the bleach remained on resident #88 bathroom counter and the Clorox wipes on his bedside table. Interview on 09/02/15 at 9:40 a.m. with Director of Nursing confirmed chemical hazards, that included bleach and wipes should not be in the resident's room. Review of the facility ' s policy revealed hazardous chemicals should be kept in a locked area. | 2018-09-01 |
| 5454 | 5454 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2015-09-04 | 354 | D | 1 | 0 | DKBB11 | Based on record review and staff interview the facility failed to ensure that the active Director of Nursing (DON) had a current and valid Georgia nursing license while in position for ten (10) days. This deficiency had the potential to effect all one hundred forty five (145) residents in the facility. Findings include: Review of the Interim Director of Nursing employee file revealed she accepted the position and was to start the position at the facility on 08/24/15. Continued review of the employee file revealed that the Registered Nurse (RN) did not have a current Georgia Nursing License. Interview on 09/03/15 at 10:35 a.m. with the Administrator and the Regional Clinical Director, RN revealed that they both confirmed that the Interim DON did not have a valid Georgia Nursing License. They both revealed that the Interim DON had let her Georgia Nursing License lapse and did not get it renewed before she accepted the position with the facility. The regional Clinical Director revealed that the Interim DON had been employed by the facility in the past and she assumed that her nursing license was valid when she was offered the position of Interim DON. The Regional Clinical revealed that the Interim DON was the acting DON from 08/24/15 until 09/02/15. The Regional Clinical Director revealed that she will assume the role as DON until appropriate documents are obtained from the previous Interim DON. Interview with the administrator revealed that she also assumed that the Interim DON had a valid Georgia Nurses License before starting work at the facility. | 2018-09-01 |
| 5455 | 5455 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2015-09-04 | 371 | E | 1 | 0 | DKBB11 | Based on observation and staff interview the facility failed to ensure that the floors in the walk-in refrigerator and walk-in freezer were clean and free from food debris. The facility failed to ensure the food containers were free from food spillage and that bulk items were in an air tight container in the dry storage area. This deficient practice had the potential to effect one hundred thirty three (133) resident receiving an oral diet. Findings include: Observation on 08/31/15 at 8:30 a.m. of the walk-in refrigerator revealed a smashed red onion on the floor towards the left side near the door. Continued observation revealed that there was a mayonnaise condiment packet and a pat of butter in a plastic container under the wire shelf units on the left side. Further observation revealed that there was a milk spill on the floor near the back right corner and the back right corner also had a brown dirt-like substance that covered an area about one foot by one foot. Observation of the walk-in freezer revealed that there was a four (4) ounce health shake nutritional supplement under the wire rack on the left hand side. Observation of the dry storage area revealed that there was a five (5) gallon container of Cattleman's Barbeque (BBQ) Sauce that had dried sauce around the pouring spout. The dried BBQ sauce covered half of the rim of the container lid. Continued observation of the dry storage area revealed that there were three (3) squeeze bottles that contained vanilla sauce, caramel sauce, and chocolate sauce that were opened, not securely wrapped and were not labeled properly. Interview on 08/31/15 at 9:45 a.m. with the Dietary Manager (DM) confirmed that there was a smashed red onion on the floor in the walk-in refrigerator as well as a condiment packet and a butter packet under the wire rack. The DM confirmed that there was split milk on the floor in the back right corner, dirt in the back right corner of the walk-in refrigerator, a health shake under the wire rack in the walk-in freezer and dried BBQ sauce on t… | 2018-09-01 |
| 5456 | 5456 | PRUITTHEALTH - SWAINSBORO | 115533 | 856 HIGHWAY 1 SOUTH | SWAINSBORO | GA | 30401 | 2014-12-10 | 441 | E | 0 | 1 | X0US11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure that staff sanitized hands between serving resident's meal trays on five (5) of five (5) halls during three (3) dining observations. Findings include: 1. During dining observation on 12/7/14 at 5:45 p.m. a Certified Nursing Assistant (CNA) delivered a meal tray to a resident in room [ROOM NUMBER]. She applied a clothing protector to resident in B bed and touched the resident's neck and back of the head. She then exited that room and carried a meal tray to resident in room [ROOM NUMBER] without washing or sanitizing her hands. 2. During dining observation on 12/10/14 at 7:50 a.m. a CNA coughed into her hand, then picked up a tray and delivered it to 402 B without sanitizing her hands. She then repositioned the resident in bed, then held the resident's bread in her bare hand while applying jelly to the bread. She then put a pair of gloves on and washed the resident's face, then removed the gloves . She did not wash or sanitize her hands. She then delivered a meal tray to room [ROOM NUMBER]. 3. During dining observation on 12/7/14 at 5:20 p.m. a CNA delivered a meal tray to resident in room [ROOM NUMBER] A and placed it on the bedside table. The CNA the moved the bedside commode, repositioned the resident in bed and then took a meal tray to room [ROOM NUMBER] B without washing or sanitizing her hands in between resident contact. The CNA then delivered a tray to room [ROOM NUMBER] and placed it on the bedside table. The CNA then left the room without sanitization or washing her hands and delivered a tray to 210. The CNA then returned to room [ROOM NUMBER]. The CNA did not sanitize or wash her hands in between resident contact. 4. During observation on 12/10/14 at 7:30 a.m. a CNA delivered a meal tray to resident in room [ROOM NUMBER] and then 207. The CNA moved a bedside commode in room [ROOM NUMBER], then she provided set up and placed a clothing protector on the resident. Sh… | 2018-09-01 |
| 5457 | 5457 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2015-02-26 | 174 | E | 0 | 1 | TEWL11 | Based upon observation, staff and resident interview the facility failed to provide access to a telephone to make a telephone call without being overheard by others. Findings include: An interview with resident A on 2/23/15 at 2:03 p.m. revealed that he/she cannot make private telephone calls except on certain days of the week. Observation on 2/25/15 at 8:15 a.m. of resident F talking on the telephone at the Station 1 Nurses desk surrounding by other residents in the area and nursing staff. Observation on 2/26/15 at 10:20 a.m. of a random resident using the telephone at the Station 1 Nurses desk. An interview with the Administrator on 2/25/15 at 9:40 a.m. revealed that on Tuesday and Thursday, as an activity, the resident's can use the phone in the locked Social Worker's office to make private calls. Continued interview reveals that at other times, the only telephone available is at the Nurses stations. An interview with the Administrator on 2/26/15 at 10:45 a.m. reveals the facility has plans to make a private area for the resident's to make telephone calls but could not provide any supporting documentation. | 2018-09-01 |
| 5458 | 5458 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2015-02-26 | 250 | D | 0 | 1 | TEWL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, family and staff interviews the facility failed to ensure that a resident's family who wished to have a resident transferred to a facility closer to the family was handled in a timely manner. Findings include: Resident F was admitted to the facility on [DATE] from a Metro Atlanta hospital after a hospital stay. The resident had multiple [DIAGNOSES REDACTED]. A telephone interview with the family member of resident F on 2/23/15 at 1:38 p.m. revealed the resident had been transferred to the facility without the family's permission from the local hospital. The family member revealed that it was over a three (3) hour drive to this facility and would like to have the resident closer to his/her family. Further interview revealed that the family member had made multiple request to the facility for assistance in transferring the resident to a closer facility but that no one had responded to these request. The family member had visited the facility on several occasions. An interview with the Administrator on 2/24/15 at 3:45 p.m. revealed the facility had been without a Social Worker from 12/20/14 until 2/23/15 due to a motor vehicle accident. The Administrator, which is an interim position, had also left on 12/20/14 and had returned on 2/1/15. He/She was not aware of the families request to move the resident to another facility until now. During a telephone interview on 2/25/15 at 9:50 a.m. with the family member, the Administrator and the nurse surveyor revealed that the family had spoken to the Director of Nursing (DON) regarding transferring the resident to a closer location but that no one from the facility had followed up with family member regarding this request. An interview with the DON, Administrator and the Nurse Consultant on 2/25/15 at 10:40 a.m. revealed that the DON had been made aware of the families request to transfer the resident to a facility closer to the family but was uncertain of the date he/she was mad… | 2018-09-01 |
| 5459 | 5459 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2015-02-26 | 253 | D | 0 | 1 | TEWL11 | Based on observations and staff interview, the facility failed to maintain a clean and comfortable environment in one (1) room (#28) of forty (40) rooms. Findings include: Observation of room #28 on 2/24/15 at 3.30 p.m. revealed the window blind over the bed next to the outer wall to be broken and in disrepair. Also the cold water faucet on the sink in the bathroom to be inoperable. Tour of room #28 with the Maintenance Director on 2/25/15 at 2.47 p.m. revealed a new window blind over the bed, however, the cold water faucet was inoperable. The Maintenance Director acknowledge he had replaced the window blind but was not aware of the inoperable cold water faucet. Interview with the Maintenance Director on 2/25/15 at 2.47 p.m. revealed that the cold water faucet was inoperable. The Maintenance Director stated that the facility had a system in place for work orders to be communicated to him and that the cold water faucet had not been previously communicated to him. | 2018-09-01 |
| 5460 | 5460 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2015-02-26 | 371 | F | 0 | 1 | TEWL11 | Based on observations, review of facility policy, and staff interviews, the facility failed to ensure that foods were served at the appropriate temperatures to prevent foodborne illnesses. The facility resident census was one hundred and eight (108) with zero (0) feeding tubes. Findings include: Food temperatures taken with the Dietary Manager on 2/24/15 at 12.05 p.m. using the facilities calibrated thermometer, during noon meal revealed the holding temperature of the fried chicken to be 110 degrees Fahrenheit (F). The Dietary Manager acknowledged the temperature to be 110 degrees (F) and confirmed all hot foods should be at least 140 degrees (F). An interview with the Dietary Manager on 2/24/15 at 12.10 p.m. revealed there was no problem with the steam table. He/she stated that food temperatures are taken by the dietary staff every meal and recorded on Food Temperature Records. Review of Food Temperature Records from 1/13/15 until present revealed food temperatures within appropriate range. However, during an interview with dietary cook EE on 2/24/15 at 12.15 p.m. revealed he/she obtains the food temperatures on the stove prior to transferring the foods to the steam table. Review of the facility policy with the Dietary Manager reveals that All potentially hazardous food shall be kept at 140 degrees (F) or above for hot foods. Check temperatures on and to residents in dining room and on floors. revealed he/she could not confirm that food temperatures were checked according to the policy. Food temperatures taken with the Dietary Manager on 2/25/15 at 12.35 p.m. of noon meal test tray revealed the following: Baked Fish - 97 degrees (F), Green Beans - 106 degrees (F), and French Fries - 85 degrees (F). Dietary Manager acknowledged the food temperatures were below appropriate range. During an interview with Resident A on 2/23/15 at 2:10 p.m. revealed that the resident eats in the dining room and that the food is always cold during every meal. | 2018-09-01 |
| 5461 | 5461 | DADE HEALTH AND REHAB | 115558 | 1234 HIGHWAY 301 SOUTH | TRENTON | GA | 30752 | 2014-09-11 | 322 | D | 0 | 1 | KVX611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of facility policy, the facility failed to check tube placement prior to administration of medication for one (1) resident (#89) from a sample of twenty-nine (29) residents. Findings include: Review of the clinical record for resident #89 revealed the resident was admitted to the facility on (MONTH) 1, 2014 with an enteral feeding tube. Observation of medication administration for resident #89 conducted on 9/3/2014 at 10:15 a.m. revealed the Medication Nurse AA pause the feeding pump, using a syringe flushed the tube using undetermined amount of water pour from resident drinking cup, and proceeded to administer each medications diluted with water. Following administering the medications AA flushed the tube again with undetermined amount of water. AA failed to check placement of tube prior to administering medication. Interview with AA following the procedure, revealed that she check for tube placement at 8:00 a.m. ` Interview with Director of Nurses (DON) conducted on 9/4/2014 at 2:10 p.m. revealed that all nurses are to check for enteral tube placement right before administering the medication and should be documented on MAR by placing their initial at the appropriate time. A physician's orders [REDACTED]. Further medical record review revealed a physician's orders [REDACTED]. Review of facility policy indicated to verify tube placement by use either of the following procedures: (a). Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope or gurgling sound or (b) Aspirate stomach contents with syringe. Check placement of tube prior to hanging new formula container, prior to any type of bolus including medications and routinely every four hours. | 2018-09-01 |
| 5462 | 5462 | DADE HEALTH AND REHAB | 115558 | 1234 HIGHWAY 301 SOUTH | TRENTON | GA | 30752 | 2014-09-11 | 323 | D | 0 | 1 | KVX611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and policy review, the facility failed to complete Neurological Assessments on one (1) resident (#14) involved in an un-witnessed fall out of a sample of thirty-two (32) residents. Findings include: Resident #14 was admitted to the facility [DIAGNOSES REDACTED]. Review of nurses' note dated 8/1/14 revealed nursing staff was called to the room by the Certified Nurse Assistant (CNA). The resident was found sitting on the floor with her legs outstretched. The resident stated she had not hit her head. Neurological checks began. The physician notified. Review of the Neurological Assessment Flow Sheet revealed neurological assessments were conducted on 8/1/14 at 6:55 AM through 8/2/14 at 8:40 AM for a total of twenty five (25) hours. Review of the Policy and Procedure for Accidents and Incidents Investigating and Reporting revealed that neurological assessment to include vital signs will be initiated on all residents with an un-witnessed fall or other incident with a blow to the head (with or without apparent injury), and/or suspected head injury. Neurological Assessments will be performed by the licensed nurse every fifteen (15) minutes times four (4), every hour times four, every two (2) hours times four, every four hours times four, then every eight (8) hours times four, totaling seventy two (72) hours. This frequency may not be reduced. | 2018-09-01 |
| 5463 | 5463 | DADE HEALTH AND REHAB | 115558 | 1234 HIGHWAY 301 SOUTH | TRENTON | GA | 30752 | 2014-09-11 | 333 | E | 0 | 1 | KVX611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, staff and physician interviews, the facility failed to ensure that two (2) residents (#52, #24)were free of significant medication errors related to the administration of [MEDICATION NAME]/[MEDICATION NAME] according to physician's orders [REDACTED]. Findings Include: 1. Record review revealed that resident #52 was admitted to the facility on [DATE] and has numerous [DIAGNOSES REDACTED]. Further record review revealed that on 5/14/14 the physician ordered a change in the resident [MEDICATION NAME]/[MEDICATION NAME] dose to six(6) milligrams (mg) daily at eight (8) PM. On 6/3/14 the physician was notified of the results of the [MEDICATION NAME] Time (PT) of 35.9 and International Normalized Ratio (INR) of 3.75 drawn on 6/3/14. The physician ordered to hold the [MEDICATION NAME]/[MEDICATION NAME] for two (2) doses and repeat the PT/INR on Thursday. Review of the (MONTH) 2014 Medication Administration Record [REDACTED]. There was no evidence in the medical record of a physician's orders [REDACTED]. The PT/INR was repeated on 6/5/14 and [MEDICATION NAME]/[MEDICATION NAME] 6mg was restarted. On 6/17/14 resident #52 was receiving [MEDICATION NAME]/[MEDICATION NAME] 6mg daily at 8:00 PM. The Physician was notified of PT/INR drawn on 6/17/14 with the results of PT of 31.6 and the INR of 3.17. The physician ordered to hold [MEDICATION NAME]/[MEDICATION NAME] 6mg for two doses then repeat PT/INR on 6/19/14. Review of the (MONTH) 2014 MAR indicated [REDACTED]. The 6/19/14 PT/INR results revealed an increase PT to 40.2 and an INR of 4.34. The physician ordered Vitamin K to be given Now and repeat the PT/INR on 6/20/14. The 6/20/14 PT/INR results revealed an increase in the PT of 47.8 and an INR of 5.43. The physician again ordered Vitamin K to be administered Now and repeat PT/INR on Monday. Review of the (MONTH) 2014 MAR indicated [REDACTED]. An PT/INR drawn on 6/25/14 revealed a PT of 14.1 and INR of 1… | 2018-09-01 |
| 5464 | 5464 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2015-04-02 | 287 | C | 0 | 1 | 5VSB11 | Based on review of the State Agency (SA) Minimum Data Set (MDS) Missing OBRA Assessment Report and staff interview, the facility failed to ensure that nine (9) MDS assessments were transmitted to the SA in a timely manner. Findings include: Review of the SA MDS Missing OBRA Assessment Report having a Run Date of 3/19/2015 revealed that as of that date, the facility had nine (9) missing MDS assessments. During an interview conducted on 3/31/15 at 10:45 a.m. with the MDS Coordinator, he/she acknowledged that some resident MDS assessments were late or missing. He/she stated that when he/she took the MDS position in (MONTH) 2014 numerous MDS assessments were late at that time. | 2018-09-01 |
| 5465 | 5465 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2015-04-02 | 323 | D | 0 | 1 | 5VSB11 | Based on observation and staff interview the facility failed to ensure that five (5) of thirty five (35) resident bathrooms' grab bars were securely attached to the wall. Findings include: During the initial tour of the facility on 3/30/2015 at 11:30 a.m., the bathrooms in rooms 27, 28, 34 and 39 were observed to have loose grab bars that were not securely attached to the wall. During initial tour of the front hall on 3/30/15 at 11:28 a.m. revealed the grab bar in the bathroom in room 6 was not securely attached to the wall. On 3/30/2015 at 12:52 p.m. the Administrator was notified of the loose grab bars in resident bathrooms 6, 27, 28 ,34 and 39. The Administrator produced a record indicating handrails were inspected for securely attached on (MONTH) 3 - 19, (YEAR). Interview with the Maintenance Director on 4/2/2015 at 2.45 p.m. revealed he/she does not routinely check the grab bars in the bathrooms. He/she stated that the nurses or Certified Nursing Assistants (CNA) inform him/her if a bar is loose and he will then secure the bar. | 2018-09-01 |
| 5466 | 5466 | WARM SPRINGS MEDICAL CENTER NURSING HOME | 115603 | 5995 SPRING STREET | WARM SPRINGS | GA | 31830 | 2015-03-19 | 160 | B | 0 | 1 | GIJU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident fund accounts and staff interview, the facility failed to ensure that resident personal funds were dispersed within thirty (30) days of death for three (3) of six (6) accounts reviewed. Findings include: Review of resident personal funds accounts for deceased residents revealed the following: 1. Resident AA died on [DATE] with a balance of $20.00 that was not dispersed until [DATE] 2. Resident BB died on [DATE] with a balance of $501.60 that was not dispersed until [DATE] 3. Resident CC died on [DATE] with a balance of $22.54 that was not dispersed until [DATE] An interview conducted [DATE] at 12:24pm with the Business Office Manager revealed she is aware that funds are to be dispersed within 30 days after death but she was just simply behind in her work. | 2018-09-01 |
| 5467 | 5467 | WARM SPRINGS MEDICAL CENTER NURSING HOME | 115603 | 5995 SPRING STREET | WARM SPRINGS | GA | 31830 | 2015-03-19 | 279 | D | 0 | 1 | GIJU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plans for two (2) residents (#9 and # 74) from a sample of twenty nine (29) residents. Findings include: 1. A review of the Significant Change Minimum Data Sets (MDS) for resident #9 dated 12/22/14 and 2/13/15 revealed the resident was admitted to Hospice Services on 12/19/14. These MDS assessed the resident as having a change in her bladder incontinence, from occasional to frequently incontinent of bladder. Further review revealed the Care Area Assessment (CAA) Summary's indicated that urinary incontinence triggered and would be care planned. Review of the resident's care plan revealed the facility had not developed a comprehensive care plan to reflect care that facility staff would be responsible for providing. The only provision of care was provided by Hospice Services. Continue review of the care plan revealed a care plan for urinary incontinence had not been developed. An interview conducted 3/18/15 at 10:20 AM with the MDS Coordinator revealed she failed to develop a comprehensive care plan to include Hospice services and for the resident's decline in urinary incontinence. 2. Review of the Admission Assessment MDS dated [DATE] for resident # 74 revealed the resident was assessed as always incontinent. Care Area Assessment (CAA) Summary indicated Urinary Incontinence triggered and would be care planned. Review of the care plan for resident #74 revealed no evidence of a comprehensive care plan for Urinary Incontinence. An interview conducted 3/19/15 at 10:05am with the MDS Coordinator revealed she failed to develop a comprehensive care plan for Urinary Incontinence for resident #74. | 2018-09-01 |
| 5468 | 5468 | WARM SPRINGS MEDICAL CENTER NURSING HOME | 115603 | 5995 SPRING STREET | WARM SPRINGS | GA | 31830 | 2015-03-19 | 309 | D | 0 | 1 | GIJU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records review, and staff interview, the facility failed to follow physician's orders for two (2 ) residents (X and #25) from a sample of twenty-nine (29) residents. Finding includes: 1. Record review for resident X revealed a physician's order date 11/25/2014 for fluid restriction of one (1) quart a day. Observation conducted 3/17/2015 at 9:18 am revealed Certified Nursing Assistant (CNA) AA filled the resident's water pitcher with ice and water, which resident began to drink. Followed up observation at 2:14 p.m. revealed the resident's water pitcher was empty. Observation conducted 3/18/2015 at 11:00 a.m. revealed resident's water pitcher was full of water and he was observed drinking from the pitcher. A second observation at 3:00 PM revealed the water pitcher was empty. Interview with resident X conducted, during the observation on 3/17/2015 at 2:14 p.m. revealed that he had consumed all the water in the pitcher. A second interview conducted with resident X on 3/19/2015 at 11:00 am revealed that he was unaware of his fluid restriction and that staff fill his pitcher with ice and water at least two (2) or three (3) times a day. He further indicated that he always consumes all the water. Interview with License Practical Nurse BB conducted 3/17/2015 at 2:20 p.m. revealed resident X is on fluid restriction of 940 cc a day and that only dietary and nurses are to administer fluids to resident. Interview with Registered Dietitian conducted 3/17/2015 at 2:25 p.m. revealed the resident is on 940 cc fluid restriction a day for which dietary and nursing are accounting for the amount of fluid resident receives. Interview with Dietary Manager conducted on 3/17/2015 at 2:30 p.m. revealed the resident is on fluid restriction of 940 cc a day. At breakfast he receives four (4) ounces of coffee and juice for 240 cc. Lunch and dinner has four (4) ounces of tea for 240 cc for a total of 480 cc per day by dietary. Interviews and observat… | 2018-09-01 |
| 5469 | 5469 | WARM SPRINGS MEDICAL CENTER NURSING HOME | 115603 | 5995 SPRING STREET | WARM SPRINGS | GA | 31830 | 2015-03-19 | 372 | B | 0 | 1 | GIJU11 | Based on observations and staff interviews, the facility failed to ensure that garbage and refuse was properly disposed and contained to prevent leaks for one (1) of one (1) garbage dumpster. Findings include: Observation and interview conducted on 3/16/15 at 10:30 AM with the Dietary Manager of the dumpster revealed the side door for the disposal of trash was left opened, there was trash and gloves on the ground around the dumpster and a large amount of foul smelling liquid draining from the dumpster. The Dietary Manager acknowledged the presence of the leak and foul smelling fluid, trash and gloves on the ground. The Dietary Manager indicated that the door of the dumpster was open and should be closed. Observation and interview conducted 3/16/15 at 2:30 PM with the Maintenance Director confirmed the leak and foul odor coming from the dumpster. He indicated that he had been trying to get a new dumpster for years due to constant leaking and odors. He further revealed that the company had refused to bring a new dumpster and had repaired the leaks on several occasions, but the leaks just come back. | 2018-09-01 |
| 5470 | 5470 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2015-03-26 | 156 | D | 0 | 1 | ZJXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interviews the facility failed to ensure that the facility policy was followed and that staff had a clear understanding of the Advanced Directive status for one (1) resident #52 of twenty four (24) sampled residents. Findings include: Record review the Face Sheet for resident #24 revealed the the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the Advance Directive Checklist dated [DATE] and signed by the resident's representative revealed the resident had executed an advance directive which would be supplied to the facility in addition to a No Cardiopulmonary Resuscitation (DNR) signed on the same day by the resident's representative. Review of the Physician order dated [DATE] revealed an order for [REDACTED].>Record review of the Nurses Notes dated [DATE] at 3:15 a.m. revealed the resident was found not breathing, unresponsive and without a pulse during rounds by Licensed Practical Nurse (LPN) CC. Cardiopulmonary Resuscitation (CPR) was started on the resident and 911 was called. After the Emergency Personal was onsite, it was discovered the resident had a DNR status and CPR was stopped and the resident was pronounced at this time by the on call Registered Nurse (RN). An interview on [DATE] at 3:27 p.m. with LPN CC revealed that she would have to check the chart to determine DNR status but she would error on the side of caution and being CPR. An interview on [DATE] at 3:29 p.m. with LPN BB revealed that she would check the chart under the Advanced Directive tab to determine the Code Status of a resident and that there is a list of DNR status resident on each Medication Administration Record [REDACTED]. An interview and review of the MAR indicated [REDACTED]. LPN CC revealed at this time that he/she did not know who was responsible for updating the list. An interview and review of the facility policy for Do Not Resuscitate Policy: Georgia updated on ,[DA… | 2018-09-01 |
| 5471 | 5471 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2015-03-26 | 279 | D | 0 | 1 | ZJXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility failed to develop a care plan for a Pressure Sore for one (1) resident #74 of twenty four (24) sampled residents. Findings include: Record review revealed the resident was admitted to the facility from the hospital on [DATE] with the following Diagnoses: [REDACTED]. Review of the Admission/Nursing Observation Form dated 11/7/14 revealed under the Hospital Report that the resident had a Pressure Ulcer to the Right heel. The Body Audit Form dated 11/7/14 revealed the resident had no open areas. Review of the Body Audit Form dated 11/10/14 and signed by Licensed Practical Nurse (LPN) DD the Treatment Nurse revealed an open area to the right heel measuring 4.2 centimeters (cm) by 1 by less than 1 in depth. It is noted the resident had a BKA of the left leg. Record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed no pressure areas were assessed although the resident was at risk for developing pressure ulcers. The resident had a Braden Score of 16 dated 11/7/14 for mild risk. Record review of the initial care plan revealed the resident had a care plan for at risk for Impaired skin. The Comprehensive Care Plan dated 11/10/2014 assessed the resident at risk for impaired skin integrity although was not assessed as having a pressure ulcer. Record Review of the Tissue Tolerance Test form dated 11/10/14 and signed by LPN DD noted the resident to have an open area to the right heel and that the resident stated a blister was there previously. An interview on 3/25/15 at 11:06 a.m. with the Director of Nursing (DON) revealed the treatment nurse stated last night that this was a healed blister and not an open area. She could not explain why the record repeatedly stated there was an open area. She felt the resident was not care planned for a pressure area since the treatment nurse did not feel it was an open area. Cross to F314 | 2018-09-01 |
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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 );