cms_GA
Data source: Big Local News · About: big-local-datasette
97 rows where "filedate" is on date 2018-10-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5275 | 5275 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2015-04-30 | 282 | D | 0 | 1 | G64611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to follow the care plan related to falls. This occurred for one (1) resident (#18) from a sample size of thirty six (36) residents. Findings include: Resident #18 was admitted to the facility on (MONTH) 8, 2014. Current [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set assessment dated [DATE] revealed that that the resident was assessed as requiring supervision x 1 person with bed mobility and transfers. Her balance during transition and walking was not steady, but able to stabilize without assistance. Further review revealed that she was coded as having no falls since her prior assessment. Review of the care plan initiated 5/15/2014 and last updated 4/6/15 revealed that the resident was at risk for falls related to deconditioning. The care plan was updated with the falls on 2/17/15, 4/1/15, and 4/6/15. The Interventions included to assess for pain and medicate as ordered, keep call light or personal items available and in easy reach, footwear to prevent slipping, and to keep the environment well lit and free of clutter. The care plan was updated to reflect the falls that occurred on 2/17/15, 4/1/15, and 4/6/15. A new intervention was added on 4/6/15 for a wheelchair alarm. There was no evidence of documentation on the care plan that the resident removes the chair alarm, or that the chair alarm was discontinued. Review of the clinical record for resident #18, the Progress Notes revealed that the resident had falls on 11/30/14, 12/7/14, 2/17/15, 4/1/15, and 4/6/15. Further review revealed that on 4/1/15 the resident sustained [REDACTED]. On 4/6/15 the resident was sent to the hospital with hip swelling and dislocation. Further review revealed that the resident was diagnosed with [REDACTED]. Observation of resident #18 on 4/28/15 at 3:34 p.m. revealed the resident up in her wheelchair rolling herself down the hallway. No chair alarm was observed. Observation… | 2018-10-01 |
| 5276 | 5276 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2015-04-30 | 323 | D | 0 | 1 | G64611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to ensure that one (1) resident (#18) who was at risk for falls received supervision and assistance device to prevent accidents. The sample size was thirty-six (36) residents. Findings include: Resident #18 was admitted to the facility on (MONTH) 8, 2014. Current [DIAGNOSES REDACTED]. Review of the clinical record for resident #18, the Progress Notes revealed that the resident had falls on 11/30/14, 12/7/14, 2/17/15, 4/1/15, and 4/6/15. Further review revealed that on 4/1/15 the resident sustained [REDACTED]. On 4/6/15 the resident was sent to the hospital with hip swelling and dislocation. Further review revealed that the resident was diagnosed with [REDACTED]. Review of the care plan initiated 5/15/2014 and last updated 4/6/15 revealed that the resident was at risk for falls related to deconditioning. The care plan was updated with the falls on 2/17/15, 4/1/15, and 4/6/15. The Interventions included to assess for pain and medicate as ordered, keep call light or personal items available and in easy reach, footwear to prevent slipping, and to keep the environment well lit and free of clutter. The care plan was updated to reflect the falls that occurred on 2/17/15, 4/1/15, and 4/6/15. A new intervention was added on 4/6/15 for a wheelchair alarm. There was no evidence of documentation on the care plan that the resident removes the chair alarm, or that the chair alarm was discontinued. Observation of resident #18 on 4/28/15 at 3:34 p.m. revealed the resident up in her wheelchair rolling herself down the hallway. No chair alarm was observed. Observation of resident #18 on 4/29/15 at 8:43 a.m. and 12:00 p.m. revealed the resident in the dining room in her wheelchair with no chair alarm observed. Observation of resident #18 on 4/29/15 at 1:30 p.m. revealed the resident sitting at end of the hall in her wheelchair reading the paper with no chair alarm observed. Interview… | 2018-10-01 |
| 5277 | 5277 | EARLY MEMORIAL NURSING FACILITY | 115271 | 11740 COLUMBIA STREET | BLAKELY | GA | 39823 | 2015-10-01 | 280 | D | 1 | 0 | X3ER11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that he facility had failed to revise plans of care for actual weight loss for two residents (#2 and #3) of five (5) residents reviewed and observed for weight loss, from a sample of nine (9) residents. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with an admission weight of 127.50 pounds (lbs.). The resident was admitted to the hospital on 8-26-15 through 8-31-15 and 9-6-15 to 9-9-15 for [DIAGNOSES REDACTED]. Review of the weights for this resident revealed that he/she was 126.20 lbs. on 8-4-15, 124.60 lbs. on 8-11-15, 124.20 lbs. on 8-18-15, 120.20 lbs. on 8-25-15, 112.90 lbs. on 9-1-15 and 114 lbs. on 9-15-15. The 8-14-15 plan of care for potential for weight loss related to disease process [DIAGNOSES REDACTED]., with recommendations of House Shake twice a day (Bid) and change to liberalize diet. However, these changes were not documented on the resident ' s plan of care. As of 9-30-15, the plan of care for potential for weight loss had not been updated to reflect the resident ' s actual weight loss or recommendations made by the Registered Dietician (RD) on 9-2-15. Interview with the DON on 10-1-15 at 1:00 p.m. revealed that the plans of care had not been updated for the resident ' s actual weight loss. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He/she had a weight of 128 pounds (lbs.) on 8-11-15, 127.20 lbs. on 8-18-15, 125.60 lbs. on 8-25-15, 121.80 lbs. on 9-1-15, 119.90 lbs. on 9-8-15, 119.10 lbs. on 9-15-15. The resident was in the hospital from 9-16-15 to 9-18-15. The weight on 9-18-15 was 124.40 lbs. and on 9-22-15 was 122.30 lbs The 8-25-15 plan of care for potential for weight loss related to complaining about the taste of many foods with decreased intake at meals. As of 9-30-15, the plan of care for potential for weight loss had not been updated to reflect the resident ' s actual weight loss or the reco… | 2018-10-01 |
| 5278 | 5278 | EARLY MEMORIAL NURSING FACILITY | 115271 | 11740 COLUMBIA STREET | BLAKELY | GA | 39823 | 2015-10-01 | 281 | D | 1 | 0 | X3ER11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility had failed to ensure that physicians' orders were clarified in regards to when to to do fingerstick blood sugars (FSBS) and also, when FSBS ordered, when to notify the physician of abnormal blood sugars for one resident (#2) of five (5) residents with abnormal blood sugars, from a total sample of nine (9) residents. Findings include: Resident #2 had a [DIAGNOSES REDACTED]. The resident was admitted to the hospital from 8-26-15 to 8-31-15 for a urinary tract infection. After the 7-31-15 admission and readmission orders [REDACTED]. Interview with the Director of Nursing (DON) on 9-25-15 revealed that there had been no clarification with the physician in regards when to notify the physician if blood sugars were outside of normal ranges. According to the review of the Medication Administration Record [REDACTED]. The resident's blood sugar was 448 on 9-6-15 at 6:00 am. The physician was not notified of this blood sugar of 448 and there were no prior orders for any sliding scale coverage. According to the Departmental Notes (DN) of 9-6-15 at 12:42 p.m., the resident was sent to the hospital emergency room (ER) with symptoms of the resident being weak and not able to stand and change in level of consciousness, unable to register oxygen saturation, FSBS at 580. The resident' was admitted to the hospital on 9-6-15 with a [DIAGNOSES REDACTED]. There was only a 9-9-15 discharge reconciliation sheet from the hospital with a date of 9-9-15 for the medications to be given. There was no order to do FSBS. There was no clarification in regards to if the FSBS should be done or when it was to be done. However, review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Even though the facility was doing the daily FSBS from 9-10-15 to 9-25-15 without an order, they still had no parameters in regards to when to call the physician for out of range blood sugars. Blood sugars ranged from 485… | 2018-10-01 |
| 5279 | 5279 | EARLY MEMORIAL NURSING FACILITY | 115271 | 11740 COLUMBIA STREET | BLAKELY | GA | 39823 | 2015-10-01 | 309 | D | 1 | 0 | X3ER11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility had failed to ensure that physicians' orders were followed for fingerstick blood sugar checks for resident (#2) from a total sample ten (10) residents. Findings include: Resident #2 had a [DIAGNOSES REDACTED]. The resident was admitted to the hospital from 8-26-15 to 8-31-15 for a urinary tract infection. She had readmission orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. According to the Departmental Notes (DN) of 9-6-15 at 12:42 p.m., the resident was sent to the hospital emergency room (ER) with symptoms of the resident being weak and not able to stand and change in level of consciousness, unable to register oxygen saturation, FSBS at 580. The resident was readmitted from the hospital on 9-9-15. Review of the medical record for this resident on 9-25-15 and interviews with the Director of Nursing (DON) and Administrator (ADMIN) at 5:45 p.m. revealed that there was no evidence of readmission physician's orders [REDACTED]. The DON stated that the readmission orders [REDACTED]. The DON and ADMIN went to the physician's office to search for the readmit orders; however, they both verified that they could not be located at the physician's office. There was only a discharge reconciliation sheet from the hospital with a date of 9-9-15 for the medications to be given. There were no specific orders in regards to the status of the FSBS for this resident. There was no order to do FSBS. However, review of the (MONTH) (YEAR), the facility was doing the FSBS daily without an order to do so. | 2018-10-01 |
| 5280 | 5280 | EARLY MEMORIAL NURSING FACILITY | 115271 | 11740 COLUMBIA STREET | BLAKELY | GA | 39823 | 2015-10-01 | 325 | D | 1 | 0 | X3ER11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, it was determined that the facility had failed to ensure that they had provided the appropriate care to maintain or to promote optimal nutrition for two residents (#3 and #4) of five (5) residents at risk for nutritional decline from a total sample of none (9) residents. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He/she had a weight of 128 pounds (lbs.) on 8-11-15, 127.20 lbs. on 8-18-15, 125.60 lbs. on 8-25-15, 121.80 lbs. on 9-1-15, 119.90 lbs. on 9-8-15, 119.10 lbs. on 9-15-15. The resident was in the hospital from 9-16-15 to 9-18-15. The weight on 9-18-15 was 124.40 lbs. and on 9-22-15 was 122.30 lbs Record review of 9-25-15 revealed that there was a 9-2-15 Nutritional Consult Form (NCF) by the Registered Dietician (RD) that documented a recommendation for Supplemental Shakes three times a day (TID). Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. In addition, the RD noted on the 9-2-15 NCF the resident's inaccurately documented the resident's current weight as 128 lbs. (admission weight) and did not reflect documentation of the actual weight of 121.80 lbs. of 9-1-15. The RD also failed to assess the resident ' s needs to maintain adequate protein and hydration levels, failed to document percentages of meal intakes since admission to the facility and failed to note any abnormal laboratory results. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a Hematology report of 8-5-15 which noted red blood cell count (RBC) of 2.78 (low) with a normal range of 3.0 to 4.9, a hemoglobin (HGB) of 9.2 (low) with a normal range of 11.5 to 14.7 and a hematocrit (HCT) of 26.6 (low) with a normal range of 38 to 49 percent. There was a handwritten physician ' s assistant order of 8-6-15 on the bottom of the Hematology report, to add B-12 and Folate levels and a dietary consult. There was a w… | 2018-10-01 |
| 5281 | 5281 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2015-06-12 | 159 | C | 0 | 1 | PPN711 | Based on observations, resident/family interviews, record review and staff interviews, the facility failed to have residents' personal funds available on weekends and holidays for five (5) residents of a sample of thirty-five (35) residents. Findings Include: An observation on 06/11/15 at 10:50 a.m. revealed a posted sign near the business office entrance that reads Resident Trust Fund Monies are Available during Business Office Hours. An interview on 06/08/15 at 12:14 p.m. with the responsible party for resident X revealed that the business office is open Monday to Friday and this was the only time he/she can get money from the resident personal trust account and that the family member is unable to get monies on the weekend. An interview on 06/08/15 at 12:31 p.m. with resident W revealed he/she had not tried to get money on the weekends, however, revealed that you can only get money when the front office is open. An interview on 06/08/15 at 12:46 p.m. with resident Z revealed that the business office closed on Friday afternoon and could not get any money on the weekends. An interview on 06/08/15 at 2:57 p.m. with resident A revealed he/she has to get money on Friday before the business office closed and that no one in the facility can get money on the weekends. An interview on 06/09/15 at 9:23 a.m. with resident M revealed that he/she could not get money on the weekends because the business office is closed. An interview on 06/11/15 at 10:50 a.m. with the Business Office Manager (BOM) revealed that the facility managed seventy-two (72) personal trust fund accounts and that there was no facility policy for resident trust funds. The business office hours were Monday to Friday from 7:30 a.m. to 4:30 p.m., and any resident wanting money from their personal trust account could come to the office and ask. The BOM continued to state any resident with a trust fund would need to get their money before 4:30 p.m. on Friday but the residents do not have access to their money after hours or on weekends. | 2018-10-01 |
| 5282 | 5282 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2015-06-12 | 314 | D | 0 | 1 | PPN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to accurately track and trend the progression of a left hip pressure wound for one (1) resident, #79 of thirty five (35) sampled residents. Findings Include: A review of Hospital Discharge Summary dated 03/23/15 revealed the resident was admitted to the facility with a diagnose of a decubitus skin ulcer to the coccyx and left hip, [MEDICAL CONDITION] due to old cerebral infarction, history of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Observation during the wound treatment on 06/11/15 at 9:15 a.m., with Registered Nurse (RN) II and RN DD revealed the resident had a left hip wound with 100% yellow slough in the wound bed and pinkish outer edges. A review of skin condition report with images dated 03/23/15 revealed that the initial admission skin assessment for the resident was noted as a stage II decubitus (pressure ulcer) to the coccyx and left upper buttock. There were no baseline measurements obtained for the left upper buttock or the coccyx. On 04/01/15 the coccyx wound was noted as healed. There were no recorded measurement for this pressure ulcer to reflect the healing progression. On 04/07/15, after sixteen days in the facility the resident's left hip pressure ulcer measurements were obtained. An interview on 06/11/15 at 8:15 a.m. with Physical Therapist (PT) HH revealed that he/she evaluated the resident's left hip pressure ulcer on 06/04/15. PT HH revealed this was the first time seeing the pressure ulcer and felt it needed to be debrided additionally, PT HH revealed tunneling at the 10:00 position, moderate purulent drainage with a foul odor and yellow/brown wound bed. PT HH further revealed that on 06/09/15 he/she performed a sharp debridement of necrotic tissue from the wound bed of the left hip. Record review of the Physical Therapy Module-Evaluation dated 6/9/15 confirmed the resident had a sharp debridement. Review of the electronic Skin Condition Re… | 2018-10-01 |
| 5283 | 5283 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2015-06-12 | 323 | D | 0 | 1 | PPN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to monitor and assess post-fall status for two (2) residents (#9 and 91) from a sample of thirty-five (35) residents. Findings Include: An observation on 06/11/15 at 1:50 p.m., revealed resident #9 lying in his/her bed with quarter side rails in the up position, a bed alarm that was not connected and call light within reach. Review of the Patient History sheet dated 05/07/15, revealed the resident had multiple diagnoses, including: Dementia, Hypertension, Schizophrenia, Non Insulin Dependent Diabetes Mellitus and Degenerative Joint Disease, History of GI Bleed, Arthritis, and Gout. Review of Optimus (Electronic Medical Record) EMR Fall Risk assessment dated [DATE], noted the resident was at high risk for falls. The resident had interventions on the Care Plan for call light to be within reach, bed in lowest locked position, wear appropriate foot wear and keep floors from spill and clutter. Review of an Incident Detail Report dated 05/22/15 revealed the resident had an unwitnessed fall in her room. Record review revealed no other documentation regarding this fall. Review of Optimus EMR Incident Details dated 05/12/15 revealed resident #91 had an unwitnessed fall and was found on the floor in his/her room. The Medical Doctor was notified and ordered a left leg and hip x-ray. Further investigation noted 05/12/15 that an initial neurological check was initiated but was not completed for resident #91. An interview on 06/11/15 at 4:33 p.m., Licensed Practical Nurse (LPN) EE revealed that for unwitnessed fall, he/she would take vital signs, notify MD/family and complete the Incident Report. An interview on 06/11/215 at 4:35 p.m., LPN CC stated for unwitnessed fall that he/she would check for pain, record the vital signs, and document every 8 hours in the Optimus EMR. LPN CC continued to state that he/she and would complete and record neurological checks. Review of the Fall … | 2018-10-01 |
| 5284 | 5284 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2015-06-12 | 329 | D | 0 | 1 | PPN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to monitor residents receiving antipsychotic medications for potential adverse side effects on three (3) residents ( #9, 40, and 55) of twenty (20) residents receiving antipsychotic medications. The census was seventy one (71) residents and the census sample was thirty five (35). Findings include: 1. Record review for Resident #40 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Date of 3/23/15 which documented in Section I - Active Diagnosis, that the resident had [DIAGNOSES REDACTED]. Section N - Medications documented that the resident received antipsychotic medications. The current (MONTH) (YEAR) Physician order [REDACTED]. The Physician order [REDACTED]. However, there was no documentation to indicate side effects were being monitored, except for one (1) time in the six months. An interview conducted on 6/10/2015 at 12:15 p.m. with the Director of Nurses (DON) confirmed the order for side effects monitoring and there was only one documentation of side effects monitoring for Resident # 40. The DON further revealed the side effects monitoring is not consistent. 2. Review of Patient History Sheet dated 05/07/15 revealed resident #9 had [DIAGNOSES REDACTED]. Review of Optimus EMR (Electronic Medical Record) Current Care Plan dated 05/21/15 revealed that the resident had potential for drug related complications associated with use of [MEDICAL CONDITION] medications and interventions to administer medication as ordered, report and monitor side effects and behaviors. Review of Admission Sheet revealed that resident #9 was admitted on [DATE] and had a physician order [REDACTED]. 3. Review of Patient History Sheet dated 12/01/11 Resident #55 had [DIAGNOSES REDACTED]. Review of Optimus EMR Current Care Plan dated 03/19/15 for the resident revealed a potential for drug related complications associated with use of [MEDICAL CONDITION] drugs with interventions… | 2018-10-01 |
| 5285 | 5285 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2015-06-12 | 441 | F | 0 | 1 | PPN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy, record reviews, and staff interviews, the facility failed to ensure that staff wash or sanitized hands after direct resident contact during meal service and failed to follow facility policy in administering resident mandatory [DIAGNOSES REDACTED] Testing for three (3) residents (#9, 79 and 20). The census was seventy one (71) residents with four (4) tube feed residents. The census sample was thirty five (35). Findings include: 1. Observation of the noon meal service on 06/09/15 at 1:17 p.m. in the main dining room revealed Certified Nursing Assistant (CNA) BB adjusted a resident's geri chair up to the table, touching the arms and back of the chair. The CNA then set up the resident's tray and silverware. CNA BB then obtained another tray from the food cart and carried the tray down the hall to a room at the end of the hallway. He/she entered the room and adjusted the resident's bed touching the remote control, positioned the resident up in bed and moved the bedside table over the resident. The CNA then set up the resident's food tray. The CNA did not wash or sanitize her hands before or after assisting the two (2) residents. An interview with CNA BB conducted on 06/05/15 at 1:42 p.m. confirmed she did not wash or sanitize her hands between residents. An interview with the DON conducted on 06/11/15 at 2:44 p.m. revealed that she expects the staff to wash or sanitize their hands between residents when setting up meal trays. 2. Record review for resident # 9 revealed a physician order dated 05/07/15 for a 2 step PPD (testing for [DIAGNOSES REDACTED] exposure) on admission. Review of the Nursing Home Immunization Record revealed 1st step administered on 05/07/15. There was no evidence of the 2nd step being administered. 3. Record review for resident #79 revealed a physician order dated 03/23/15 for a 2 step PPD on admission. Review of the Nursing Home Immunization Record revealed the 1st step administered on… | 2018-10-01 |
| 5286 | 5286 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2015-07-31 | 159 | B | 0 | 1 | OBW211 | Based on review of resident fund accounts, review of the Resident Trust Fund Account Agreement and resident, family and staff interviews, the facility failed to ensure quarterly statement for three (3) cognitive residents ( C, D and E ) and the responsible parties for two (2) cognitively impaired residents (F and G) of five (5) residents reviewed from thirty four (34) personal funds accounts managed by the facility. Findings include: A review of the Resident Trust Fund Account Agreement form documents: It is understood that the personal funds to be placed in an interest bearing Resident Trust Fund Account (Handled as a petty cash and/or checking account), and that a quarterly accounting of such funds will be given to the resident and/or responsible party/legal representative. An interview conducted on 07/27/15 at 1:31 p.m. with resident C revealed she does not receive a quarterly statement of her personal funds account. An interview conducted on 07/28/15 at 9:30 a.m. with resident E revealed she does not receive a quarterly statement of her personal funds account. An interview conducted on 07/28/15 at 10:16 a.m. with the responsible party of resident F revealed she does not receive a quarterly statement of her personal funds account. An interview conducted on 07/28/15 at 10:19 a.m. with resident D revealed she does not receive a quarterly statement of her personal funds account. An interview conducted on 07/28/15 at 11:01 a.m. with the responsible party of resident G revealed she does not receive a quarterly statement of her personal funds account. An interview conducted on 07/29/15 at 3:20 p.m. with the Business Office Manager revealed she does not provide quarterly statements for residents with a personal funds account, regardless of cognition, unless they request one. She does send a statement to the responsible parties. She has never provided a quarterly statement to either the residents C and G or their responsible party because the facility is not the representative payee for these accounts. She was not awa… | 2018-10-01 |
| 5287 | 5287 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2015-07-31 | 161 | F | 0 | 1 | OBW211 | Based on record review and staff interview, the facility failed to ensure that the surety bond covered the ending balance in the resident trust fund account for six (6) of seven (7) months reviewed (December 2014, January, February, March, April, (MONTH) and (MONTH) of (YEAR)). The facility managed thirty four (34) trust fund accounts. Findings include: Review of a resident trust fund account Bond Continuation Certificate for the period of 09/25/14 through 09/25/15 indicated the bond was in the amount of $100,000. Review of Resident Trust Account bank statements from (MONTH) 2014 through (MONTH) (YEAR) revealed the ending balances exceeded the surety bond limit in the following amounts: December 2014: $106,945.77 January (YEAR): $126.55.18 February (YEAR): $106,714.42 March (YEAR): $137,433.66 April (YEAR) $177, 005.91 May (YEAR): $169,059.63 This was verified by the Business Office Manager during interview conducted on 07/29/15 at 3:20 p.m. | 2018-10-01 |
| 5288 | 5288 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2015-07-31 | 221 | D | 0 | 1 | OBW211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to ensure one (1) resident (#77) was free from a physical restraint, from a sample of thirty one (31) residents Findings include: On 07/27/15 at 2:59 p.m. resident #77 was observed with a clip belt in place around their waist. Staff revealed it was a self releasing belt. The resident was unable to release the clip belt, attempted but was too weak. The belt was unfastened by staff, and the resident was not able to refasten the belt. Staff refastened the belt for the resident. Further observation of the resident on 07/28/15 at 11:15 a.m. revealed the clip belt had been removed. On 07/29/15 the resident was observed in a morning activity without the clip belt in place. Review of physician's orders [REDACTED]. Further review of nursing notes dated 07/27/15 at 5:00 p.m. indicated the Responsible Party (RP) had been notified the seatbelt had been discontinued because the resident could no longer remove the belt due to lack of strength in their hands. Review of the resident's Care Plan indicated no goal or interventions in place for a self release belt, or potential restraint. On 07/29/15 at 11:25 a.m. the Minimum Data Set (MDS) Nurse OO stated the resident's care plan needed to be updated for the use of the self release belt. After reviewing the care plan and not finding any mention of a self releasing belt, nurse OO stated the resident apparently had not had a seat belt in place. Upon request a list was obtained that indicated self releasing seat belts had been discontinued for fourteen (14) residents on 07/27/15. Interview with the Assistant Director of Nursing (ADON) on 07/29/15 at 12:34 p.m. revealed that the resident's seat belt was removed because the facility was re- evaluating the need for use because the resident had not had a fall in the past three (3) months. The self release clip belts were removed from all fourteen (14) residents that were wearing them on Mo… | 2018-10-01 |
| 5289 | 5289 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2015-07-31 | 241 | D | 0 | 1 | OBW211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to promote care in a manner that maintained the dignity of one (1) resident (#79) related to incontinent care for eighteen (18) sampled residents. Findings include: Review of the clinical record for resident #79 revealed multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], assessed the resident as occasionally incontinent of both bowel and bladder, and required extensive assistance for toilet use by one (1) person. The resident's cognition was assessed as having no adverse behaviors and a BIMS score of 5 (not generally interviewable.) Observation and interview of resident #79 on 07/28/15 at 7:00 a.m. revealed the resident sitting in his wheel chair in front of the bathroom door of his room, with his head down. Resident further revealed he had been waiting for hours for assistance to the toilet. He then began touching the front lower portion of his shirt, and the waist to the knee area of his jogging pants, and stated it is soaking wet. He further revealed that he had been waiting for staff to assist him to the bathroom, and no one came all night. He then stated that this makes him feel bad. The Assistant Director of Nursing (ADON) was interviewed on 07/31/15 at 12:37 p.m. and revealed resident #79 requires assistance for toileting. The ADON further revealed the resident should not have been left wet all night until the morning, and should have received incontinent care every 2 hours as per the resident care status sheet, and facility policy. | 2018-10-01 |
| 5290 | 5290 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2015-07-31 | 278 | E | 0 | 1 | OBW211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interview, the facility failed to accurately assess the Oral/Dental Status for two (2) residents (#45 and #86), failed to accurately assess the use of antidepressant medication for one (1) resident (#23) and failed to accurately assess a fall for one resident (#60) on the Minimum Data Set (MDS) assessment affecting a total of four (4) residents on a sample of thirty one (31) residents. Findings include: 1. A record review conducted of resident #23 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. An interview conducted on 07/30/15 at 3:51 p.m. with the Registered Nurse (RN)/MDS Coordinator OO revealed she obtains the information for medication use from the nursing MAR. She confirmed resident #23 was assessed for anti-anxiety medication use but missed the antidepressant. She stated she would modify the assessment. 2. Resident #45 was admitted to the facility on [DATE]. An observation on 07/30/15 at 9:00 a.m. of the resident's mouth revealed she had no natural teeth (edentulous). A review of the Dentist's Progress Note dated 06/03/15 documented that the resident had missing teeth/edentulous. A review of the Significant Change assessment dated [DATE] MDS Section L- Oral/Dental Status did not check question C-No natural teeth or tooth fragments. The assessment indicated question Z- None of the above conditions were present. An interview conducted with the RN/MDS Coordinator OO on 07/30/15 at 3:51 p.m. revealed she assessed a resident's oral/dental status by asking them to open their mouth. She answers the questions for Section L of the MDS based on what she observed. She said she did not check question C because the resident had dentures and she did not think she had to check this condition if a resident had dentures. 3. Resident #86 was admitted to the facility on [DATE]. An observation on 07/29/15 at 9:50 a.m. revealed one obvious, long f… | 2018-10-01 |
| 5291 | 5291 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2015-07-31 | 309 | D | 0 | 1 | OBW211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to ensure physicians orders related to diet, Ted hose, and medication consistency were followed for three (3) residents (#H, #80, and #103) from a sample of thirty one (31) residents. Findings include: 2. Review of Physician orders [REDACTED].) Observation of resident #80 on 07/27/15 at 3:05 p.m. revealed the resident was wearing regular socks and shoes. Further observations on 07/28/15 at 9:30 a.m., 07/28/15 at 2:30 p.m., 07/29/15 at 11:00 a.m., 07/29/15 at 3:05 p.m., 07/30/15 at 1:40 p.m. revealed that the resident was always wearing regular socks and shoes. Review of the Medication Administration Record [REDACTED]. From 07/27/15 to 07/29/15 documentation indicated Ted hose were in place AM, and removed at HS. Further review of the care plan indicated feet could be elevated for [MEDICAL CONDITION]. No mention of Ted hose. Interview with the Licensed Practical Nurse (LPN) MM on 07/30/15 at 3:09 p.m. confirmed the resident was not wearing Ted hose. MM was not aware they had not been put on the resident's legs for the past four (4) days. Interview with the Certified Nursing Assistant (CNA) on 07/30/15 at 3:12 p.m. revealed she was not aware the resident was supposed to have Ted Hose. Review of the Activity of Daily Living (ADL) work sheets indicated a general statement of how the resident dressed, putting on, taking off clothing, including Ted Hose if applicable. 3. Review of the medical record for resident #103 indicated a Pharmacy recommendation on 05/15/15 to clarify route of [MEDICATION NAME]. All other medications were per feeding tube, but the [MEDICATION NAME] was listed by mouth (PO). The pharmacist had recommended a [MEDICATION NAME] solution. On 05/20/15 the physician agreed with the pharmacist and ordered [MEDICATION NAME] by solution. As of 07/31/15 the resident was still receiving [MEDICATION NAME] sprinkles through her feeding tube. Interview with the … | 2018-10-01 |
| 5292 | 5292 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2015-07-31 | 312 | D | 0 | 1 | OBW211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews, the facility failed to provide incontinence care as per facility Activity of Daily living care sheet, and policy for incontinent care for one (1) resident (# 79) from a sample of eighteen (18) residents. Findings include: Record review for resident #79 revealed a Minimum Data Set 3.0 (MDS) quarterly assessment dated [DATE] documenting a Brief Interview for Mental Status (BIMS) score of 5. Further documented was that the resident requires extensive assistance of one person assistance for toileting/personal hygiene. Review of the comprehensive care plan for activity of daily living (ADL) dated 05/12/2015 documented resident requires that staff assist for dressing, grooming, transfers, bathing, incontinent care of bladder/bowel, perineal care when incontinent, staff keep clean and dry. Review of the resident status sheet dated 7/01/2015 documented resident is incontinent of bladder/bowel and requires incontinent/toileting assist every 2 hours. Observation and interview of resident #79 on 07/28/15 at 7:00 a.m. revealed the resident sitting in his wheel chair in front of the bathroom door of his room, with his head down. He then began touching the front lower portion of shirt, and the waist to the knee area of his jogging pants, and stated it is soaking wet. He further revealed that he has been waiting for a staff to assist him to the bathroom, and no one had come all night. Two Certified Nursing Assistants (CNA) RR and SS validated on 07/28/15 at 7:15 a.m., that the resident's clothing was saturated with urine. Interview with the night shift Certified Nursing Assistant (CNA) ZZ on 07/28/15 at 7:05 a.m. revealed that she was assigned to resident #79's hall (C hall), but only provided incontinent care to the lower end of the C hall. She then revealed that the resident should have received incontinent care every 2 hours. The Assistant Director of Nursing (ADON) was interviewed on … | 2018-10-01 |
| 5293 | 5293 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2015-07-31 | 332 | E | 0 | 1 | OBW211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medication pass observations, the facility failed to ensure that it was free of a medication error rate of five (5) percent or greater. Observations of four (4) nurses on two (2) different shifts, on three (3) of three (3) halls, from thirty six (36) opportunities resulted in seven (7) medication errors. The medication error rate was nineteen and forty four (19.44) percent. Findings include: Observations of medication pass conducted on 07/27/15 at 5:00 p.m., and 07/30/15 at 9:00 a.m. revealed the following medication errors were made: Resident #27 had a physicians order for Aspirin (ASA) eighty one (81) milligrams (mg) by mouth (po), [MEDICATION NAME] coated (EC) ASA 81 mg po was administered. There was also a physician's orders [REDACTED]. Resident #39 had a physician's orders [REDACTED]. Resident #79 had a physician's orders [REDACTED]. [MEDICATION NAME] 100 mg one (1) capsule was administered. Resident #113 had a physician's orders [REDACTED]. For a 07/11/15 return from hospital Order for Sennosides 17.2 mg po every day as needed (PRN), [MEDICATION NAME] (2) tablets was administered. An order dated 07/11/15 for ASA 81 mg po daily was administered as chewable ASA 81 mg. Interview with the Licensed Practical Nurse (LPN) KK on 7/30/15 at 11:25 a.m. revealed she overlooked the MOM 30 cc po. She further stated that she thought it had been discontinued. She also stated that she did not realize Aspirin needed to be clarified as [MEDICATION NAME] coated, chewable, or just plain. Interview with the Assistant Director of Nursing (ADON) on 7/30/15 12:35 p.m. revealed that a nurse cannot change the time of administration of a medication on the Medication Administration Record [REDACTED]. [MEDICATION NAME] 40 mg po was administered at the 5:00 p.m. med pass, the MAR indicated [REDACTED]. Interview with LPN MM on 07/30/15 at 11:25 a.m. revealed she just over looked two (2) [MEDICATION NAME], and gave only one (1). Interview with the LPN JJ on 7… | 2018-10-01 |
| 5294 | 5294 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2015-07-31 | 356 | C | 0 | 1 | OBW211 | Based on observation and staff interview the facility failed to ensure the daily posted staffing sheet indicated the name of the facility and the total hours worked, and failed to maintain the sheets for a period no less than eighteen (18) months. Findings include: Observation of the posted staffing sheet for 07/27/15 indicated there was not a facility name or actual hours worked on the sheet. The facility was unable to produce staffing sheets for 07/28/15, 07/29/15, and 07/30/15. Interview with the Assistant Director of Nursing (ADON) on 07/31/2015 at 11:35 a.m. revealed that they were unaware of the guidelines for the posting sheet, Facility name, Date, Number of Registered Nurses (RN), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) working, and the total number of hours worked for each shift. The ADON stated that the daily staffing sheets had not been kept, and were thrown away each day past the date used. The ADON was unaware the posted staffing sheets had to be kept a minimum of eighteen (18) months. | 2018-10-01 |
| 5295 | 5295 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2015-07-31 | 502 | D | 0 | 1 | OBW211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a pharmacist recommendation, the physician response, and staff interview, the facility failed to obtain a laboratory test as ordered for one (1) resident (#80) from a sample of thirty one (31) residents. Findings include: Review of a Pharmacist recommendation dated 01/15/15 indicating that resident #80 received [MEDICATION NAME] Sodium and had not had a lipid profile since admission, six (6) months prior and to please obtain a lipid panel on the next convenient laboratory (lab) day. The physician responded to implement as ordered. An order was written dated 02/16/15 for a fasting Lipid Panel next lab draw day and annually in (MONTH) thereafter. Interview with the Licensed Practical Nurse (LPN) HH on 07/30/15 at 4:15 p.m. revealed the laboratory test was not completed as ordered. LPN HH further double checked with the laboratory and they confirmed the test was not done. | 2018-10-01 |
| 5296 | 5296 | DUBLINAIR HEALTH & REHAB | 115356 | 300 INDUSTRIAL BLVD | DUBLIN | GA | 31021 | 2015-04-23 | 246 | D | 0 | 1 | 9QX911 | Based on observations and resident and staff interviews, the facility failed to ensure call lights were within reach and functional for four (4) residents (#2, #37, #162, and #171) capable of using the call lights from a sample of twenty-seven (27) residents. Findings include: Observation on 04/21/15 at 4:08 p.m. of resident #171 revealed that the call light hanging on the back hand rail of his Geri chair was out of his reach. Interview on 04/23/15 at 12:05 p.m. with housekeeper LL, that was in the resident's room, revealed that he utilized his call light and it worked appropriately. Observation on 04/21/15 at 2:43 p.m. of resident #A revealed that the call light lying on the bed was out of reach when she was sitting in her chair. Observation on 04/22/15 at 1:35 p.m. of resident #A revealed the resident sitting in her chair receiving breathing treatment and the call light that was lying on the bed was out of her reach. Interview on 04/23/15 at 11:14 a.m. with resident #A revealed that she can use the call light if they put it where she can reach it. Observation on 04/21/15 at 12:39 p.m. of resident #C revealed the resident sitting up in the chair on the right side of bed with call light lying on the floor on the left side of the bed. Interview on 04/23/15 at 10:19 a.m. with resident #C revealed that she could use the call light if she could reach it. Observation on 04/21/15 at 12:03 p.m. of resident #B revealed the resident to be sitting up in their chair with the call light wrapped around the side rail of the bed and was out of her reach. Observation on 04/22/15 at 12:55 p.m. of resident #B revealed the resident sitting up in their chair with the call light lying on the bed behind the resident and out of her reach. Interview on 04/23/15 at 11:19 a.m. with the resident revealed that she is able to use the call light to get assistance. Interview on 04/23/15 at 11:05 a.m. with Certified Nursing Assistant (CNA) GG revealed that she had received inservice training on call light placement and that the call light shoul… | 2018-10-01 |
| 5297 | 5297 | DUBLINAIR HEALTH & REHAB | 115356 | 300 INDUSTRIAL BLVD | DUBLIN | GA | 31021 | 2015-04-23 | 431 | D | 0 | 1 | 9QX911 | Based on observation and staff interviews, the facility failed to ensure expired medications were properly disposed of in a timely manner in (2) of (5) medication carts. Findings Include: Observation of Medication Cart for A Hall on 04/22/15 at 10:55 a.m. revealed the following expired medications: [REDACTED] Novolog Insulin 10 milliliters (ml) Multidose vial for Resident #6 with an opened date label of 03/21/15 which would expire in twenty eight (28) day on 04/18/15. Lantus Insulin 10 milliliters (ml) Multidose vial for Resident #6 Opened 03/07/15. The twenty eight (28) date should be 04/04/15. During an interview on 04/22/15 at 10:58 a.m. with Licensed Practical Nurse(LPN) BB he/she confirmed that both Insulins were expired. In addition, he/she stated that all the Insulins expire 28 days from the date they are opened. During an interview on 04/22/15 at 10:59 a.m. with the Unit Manager for Unit One, he/she also confirmed that all of their Insulins expire twenty eigh (28) days from the date the insulin is opened. He/she stated they do not have an insulin expiration list posted but that they go by what the facility says, which is all Insulins expire twenty eight (28) days from the date they are opened. Observation on 04/22/15 at 11:10 a.m. of Medication Cart for B Hall revealed one (1) opened bottle of Vitamin E 400 IU with an expiration date of 3/2015. During an interview on 04/23/15 at 11:50 a.m. with the Director of Nursing (DON) revealed that the facility does not have a written policy regarding insulin and expiration dates. An interview with the DON on 5/5/15 at 2:30 p.m. via telephone revealed he/she could not explain how the nurses would know what the expiration dates were for insulin once they were opened. | 2018-10-01 |
| 5298 | 5298 | OCONEE HEALTH AND REHABILITATION | 115357 | 107 RIDGEVIEW DR | OCONEE | GA | 31067 | 2015-02-12 | 225 | D | 0 | 1 | 557N11 | Based on review of the facility's Complaint Log, Abuse Prohibition Policy and Procedure, staff and resident interviews, it was determined that the facility failed to thoroughly investigate an allegation of stolen money for one (1) resident A from a sample of twenty-two (22) residents. Findings include: Interview with resident A on 2/9/15 at 1:34 p.m. revealed that approximately three weeks ago, she was missing $15.00 from her purse and that she reported the missing money to two (2) nurses and a Certified Nursing Assistant (CNA). Resident A further revealed that staff never followed up with her about the status of the missing money. Review of the Grievance form dated 1/22/15 revealed that resident A complained to a nurse that she was missing $15.00 and that she believed she knew who took it. Further review of the Grievance form revealed that the resident stated that when a CNA was transferring her from the wheelchair to the bed, the pouch containing the money that was around her neck fell to the floor. Continued review revealed that the CNA picked up the pouch and gave it back to the resident. However, the resident complained that the money was missing from the pouch. Review of the 1/22/15 Grievance form revealed that staff searched the resident's room for the missing money but, was unable to find it. Continued review revealed that a statement would be obtained from the alleged perpetrator (CNA) and that the administrator was notified of the resident's complaint. Further review of the Grievance form revealed that on 1/23/15, the administrator informed the resident that it was her responsibility to keep up with her money and that she would not be reimbursed for the missing money. The resident was in agreement. Further review revealed that the Social Services Director (SSD) followed up with the resident on 2/2/15 and notified the resident that she could keep her money safely in the SSD's office. Review of the facility's Abuse Prohibition Policy and Procedure revealed that once a complaint was identified involving al… | 2018-10-01 |
| 5299 | 5299 | LUMBER CITY NURSING & REHABILITATION CENTER | 115404 | 93 HIGHWAY 19 | LUMBER CITY | GA | 31549 | 2015-01-22 | 371 | E | 0 | 1 | QM5O11 | Based on observation and staff interview revealed that the facility failed to properly store food items in the walk in refrigerator with valid expiration dates; failed to properly demonstrate the usage of the three compartment sink to prevent potential for food borne illness; failed to properly maintain one (1) main entree food item on the steam table above one hundred thirty five degrees Fahrenheit (135 F) to prevent food borne illness. Findings include: Observation on 01/20/15 at 11:20 a.m. of the walk in refrigerator revealed eleven (11), fifteen (15) ounce boxes of raisins with the expiration date of (MONTH) 06, 2014. Interview on 01/20/15 at 11:20 a.m. with the Dietary Manager (DM) revealed that he/she expects all food items in the kitchen to have current expiration dates. The DM confirmed that the eleven (11) boxes of raisins had an expiration date of 11/06/14 and they were all expired. Observation and interview on 01/22/15 at 10:30 a.m. of Dietary cook BB revealed that he/she was not able to properly demonstrate the proper technique for the usage of the three (3) compartment sink. Cook BB was observed washing the food processor bowl and blade in soapy water, rinsing the bowl and blade in water, and then dipping the bowl and blade in the sanitizing solution for less than five (5) seconds and putting the items on a rack to dry. Further observation of the three (3) compartment sink revealed a poster hanging above the sinks that show the proper procedure for using the sink and the poster states to submerge items in the sanitizing solution for sixty (60) seconds or longer. Interview on 01/22/15 at 10:30 a.m. with cook BB revealed that he/she washes all items in the three (3) compartment sink the way he/she demonstrated to the surveyor. The cook did not know that he/she needed to submerge items in the sanitizing solution for sixty (60) seconds or longer. Interview on 01/22/15 at 10:30 a.m. with the DM revealed that he/she gave an in-service on the proper usage of the three (3) compartment sink a few months ago. … | 2018-10-01 |
| 5300 | 5300 | LUMBER CITY NURSING & REHABILITATION CENTER | 115404 | 93 HIGHWAY 19 | LUMBER CITY | GA | 31549 | 2015-01-22 | 372 | B | 0 | 1 | QM5O11 | Based on observation and staff interview the facility failed to properly maintain the area surrounding two (2) of two (2) dumpsters to prevent pests. Findings include: Observation on 01/20/15 at 11:30 a.m. revealed that there were two (2) dumpsters located on bare ground behind the facility. Continued observation revealed that the dumpster on the right hand side had two (2) crinkle cut French fries located on the ground four (4) inches from the dumpster and a piece of bread like item that was five (5) inches in length and one (1) inch in width and light brown in color. Interview on 01/20/15 at 11:30 a.m. with the Dietary Manager (DM) that he/she is responsible for the maintenance and condition of the dumpsters and the dumpster area. The DM revealed that he/she inspects that area surrounding the dumpster's one to two (1-2) times a day. The DM revealed that he/she had inspected that dumpster area earlier and did not notice any food debris. The DM revealed that it is important to keep the area surrounding the dumpsters clean and verified that there was food debris on the ground next to the dumpsters. | 2018-10-01 |
| 5301 | 5301 | LUMBER CITY NURSING & REHABILITATION CENTER | 115404 | 93 HIGHWAY 19 | LUMBER CITY | GA | 31549 | 2015-01-22 | 441 | D | 0 | 1 | QM5O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation , record review the facility failed to ensure infection control procedures were followed for the care of linen for residents on isolation from a sample size of twenty three (23) and a census of seventy six (76) residents. Findings include: Observation and record review revealed there was one (1) resident on contact isolation for Clostridium Difficile (C-diff) at the facility. An interview on 1/22/15 at 8:58 a.m. with the Laundry employee on the 7 a.m. to 2 p.m. shift revealed that he/she was informed yesterday that a resident was on contact isolation for[DIAGNOSES REDACTED] and was told to allow the bin to filled up and then wash laundry separately. Continued interview revealed that the Laundry employee was unable to explain about Personal Protective Equipment (PPE) used during isolation or the location of PPE in the laundry room. Continued interview at this time revealed he/she has not worn a gown when sorting any kind of soiled linen, other than gloves. An interview on 1/22/15 at 9:23 a.m. with the account manager/laundry supervisor revealed that he/she has not been able to in-service the new laundry employee on isolation linen and was not able to provide an in-service sheet. He/She revealed that the new employee was informed to allow the isolation linen to fill up and wash them all at once separately from other laundry items. He/She also revealed that laundry staff should wear PPE, such as a gown, when sorting the linen for residents but especially for those on contact isolation. Staff Interview on 1/22/14 at 10:14 a.m. with the Assistant Director of Nursing (ADON) Infection Control Manager revealed that he/she was unaware of the laundry's precaution for handling isolation linen but that staff was expected to use PPE equipment. An interview on 1/22/14 at 10:19 a.m. with housekeeping worker AA revealed that he/she was instructed to change the water bucket after ever two (2) rooms even if the resident is on isolation. Co… | 2018-10-01 |
| 5302 | 5302 | HARBORVIEW HEALTH SYSTEMS JESUP | 115414 | 1090 W ORANGE ST | JESUP | GA | 31545 | 2018-08-23 | 568 | D | 0 | 1 | ZLSU11 | Based on resident and staff interview and review of facility policy, the facility failed to provide proof that one resident, (R#15) received quarterly statements for her personal fund account that the facility manages. The census sample size was 32 residents. Findings include: Resident Interview on 8/20/18 at 1:30 p.m. with R#15 revealed that she did not receive a quarterly statement for her personal funds account. R#15 had a Brief Interview for Mental Status score of 15 on her Quarterly Minimum Data Sets dated 5/24/18. Interview on 8/21/18 at 11:57 a.m. with the Business Manager and the Administrator revealed that the facility process for personal fund accounts was that the Administrator hand delivers the quarterly statement to each resident. The facility process for personal funds of residents that were not cognitively intact revealed that those quarterly statements were mailed or handed to the responsible party. When asked if she had proof that the residents had received their statements or that statements were mailed, the Administrator said that she did not have proof that they had received their statement or that statements were mailed. Review of facility policy titled Quarterly Accounting of Resident Funds documented that the facility was to provide each resident, who had funds managed by the facility on his or her behalf, with a quarterly accounting of such funds. | 2018-10-01 |
| 5303 | 5303 | PINE KNOLL NURSING & REHAB CTR | 115443 | 156 PINE KNOLL DRIVE | CARROLLTON | GA | 30117 | 2015-04-02 | 278 | D | 0 | 1 | E7DK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of two (2) resident (#20 and #51) from a sample of twenty-five (25) residents. Findings include: 1. Record review for resident #51 revealed a Significant Change MDS dated [DATE] which assessed the resident as having limited range of motion for one (1) side in the upper and lower extremities. Review of the quarterly MDS dated [DATE] revealed that the resident was impaired on both sides in the upper and lower extremities. Review of the Joint Range-of-Motion and Mobility Screen dated 2/2/15 revealed that the resident is limited on the upper left side for wrist flexion and extension, but has full flexion and extension on the right upper for wrist and finger; however, on the lower extremities (hip flexion/extension, knee flexion/extension, and ankle dorsa flexion/plantar flexion) revealed limited on both sides. Interview with the MDS Coordinator AA on 4/1/15 at 11:20 a.m., revealed that both MDS's were coded incorrectly, because only the upper left side was impaired and both lower sides were impaired. Continued interview revealed that this form is filled out upon admission, readmission and yearly and that this is the only form that is used for Range Of Motion (G400A and G400B). 2. Record review for resident #20 revealed the resident was admitted to the facility on (MONTH) 27, 2014 status [REDACTED]. Review of the Admission MDS assessment dated [DATE], Section G0400 Functional Limitation in Range of Motion indicated the resident had impairment on one (1) side for Lower Extremity (hip, knee, ankle, foot). Review of the Joint Range-of-Motion and Mobility Screen dated 11/27/14 revealed that the resident had no range of motion for lower extremities due to the bilateral amputation of both the knee. Interview with the MDS Coordinator AA on 4/1/15 at 2:30 p.m. revealed that the Admission MDS Assessment was coded incorre… | 2018-10-01 |
| 5304 | 5304 | PINE KNOLL NURSING & REHAB CTR | 115443 | 156 PINE KNOLL DRIVE | CARROLLTON | GA | 30117 | 2015-04-02 | 371 | D | 0 | 1 | E7DK11 | Based on observation, staff interview, and review of facility policy, the facility failed to store food under sanitary conditions. Findings include: During initial tour on 03/30/15 at 09:45 AM, observation of the walk in freezer revealed the following: A pork roast wrapped in clear wrap, lying on an unsealed, opened bag of frozen okra. Unsealed, open bag of frozen, pre-cooked chicken breasts. A loaf of frozen sliced white bread was opened and did not have an open date. Nineteen (19) spices were noted on a rolling cart. Thirteen (13) out of the 19 spices had been opened and used. None of the spices were label with an opened date. Interview with the Dietary Manager on 4/1/2015 at 10:00 AM revealed that the spices should have an open date indicated on the container Interview with Head Cook EE 4/2/2015 at 1:45 PM revealed that the policy for returning opened, unused items to the freezer is to label the item with an open date and use by date. She puts the items in the original container or bag when possible and seals it. Review of the facility's Policy and Procedure for Dietary revealed that all food will have a label to include date prepared and the use by date, there will be no exceptions. Any questions on when a product was made or no label, it must be discarded. | 2018-10-01 |
| 5305 | 5305 | HERITAGE INN OF BARNESVILLE HEALTH AND REHAB | 115447 | 946 VETERANS PARKWAY | BARNESVILLE | GA | 30204 | 2015-02-19 | 441 | D | 0 | 1 | 8H6B11 | Based on observation and staff interview the facility failed to ensure acceptable infection control practice for one (1) resident (#148) from forty-three (43) sampled residents. Findings include: Observation conducted during wound care for resident #148 on 2/18/15 at 10:00 AM, revealed that the resident had a wound vac for wound suctioning. Further observation revealed the wound vac machine and its tubing was on the floor. The nurse providing the wound care was asked about this and she indicated that she guess it should not be kept on the floor. Interview with resident care coordinator AA on 2/18/15 at 3:15 PM revealed that the wound vac and tubing should not be on the floor. Interview with the Director of Nurses on 2/19/15 at 3:19 PM revealed that according to standards of infection control nothing should be on the floor. | 2018-10-01 |
| 5306 | 5306 | MADISON HEALTH AND REHAB | 115457 | 2036 SOUTH MAIN STREET | MADISON | GA | 30650 | 2015-01-08 | 309 | D | 0 | 1 | QN3M11 | **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].#56) to receive a multiple vitamin mineral (MVI) supplement as a result of the dietitian recommendation. The resident sample size was twenty-seven (27). Review of the 30 Day Minimum Data Set assessment dated [DATE] revealed that resident #56 had a weight loss of five percent (5%) or more in the last month or loss of ten percent (10%) or more in the last six (6) months. His weight was one hundred and thirty-six pounds (136 lbs), and he was receiving a therapeutic diet. Review of the clinical records revealed a dietitian note dated 12/9/14 for resident #56 with a referral to the physician for MVI as well as House supplement twice daily one (1) container. Further review revealed that the physician responded and accepted the dietitian's recommendations on 12/11/14. Review of the physician's orders [REDACTED]. There was an order dated 11/21/14 for No concentrated sweets (NCS) house shake twice daily 10:00 a.m. and 3:00 p.m. on snack cart. Further review of the Physicians Telephone Orders dated 1/6/15 revealed that an order was obtained to start MVI with minerals once daily and diet change: House supplement twice daily. Interview with the Director of Nursing (DON) on 01/08/15 at 8:50 a.m. revealed that once the dietitian makes recommendations they are submitted in writing to the DON, Assistant Director of Nursing (ADON), or Treatment nurse. The DON further revealed that the nurse that receives the dietitian's recommendation faxes the recommendation to the physician's office for review. Once the physician reviews the recommendation the nurse is responsible for writing the dietitian's recommendation as a telephone order. Continued interview revealed that the MVI and house supplement did not get ordered and that it was an over site by the licensed nurse. The DON confirmed that the recommendations were made by the dietitian on 12/9/14 and were accepted… | 2018-10-01 |
| 5307 | 5307 | MADISON HEALTH AND REHAB | 115457 | 2036 SOUTH MAIN STREET | MADISON | GA | 30650 | 2015-01-08 | 314 | D | 0 | 1 | QN3M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to appropriately assess a pressure sore for one (1) resident (#76) from a sample of twenty-seven (27) residents. Findings include: Review of the Medical Record revealed that resident #76 was admitted to the facility on [DATE] from the hospital after the surgical repair of a right [MEDICAL CONDITION]. The resident also had [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance with bed mobility and was totally dependent for transfers. The resident was assessed as being totally incontinent of bowel and bladder. Review of the Admission Clinical Assessment, dated 12/08/14, indicated the resident was admitted with a stage two (2) pressure ulcer on her sacrum, however there were no measurements or detailed wound descriptions documented on the assessment. Review of an entry in the Nurses note dated 12/08/14 at 7:00 p.m. indicated that resident had a Stage 2 pressure ulcer on her sacrum. There were no measurements, description of the surrounding tissue or staging of the pressure ulcer documented. Review of the Wound/Skin Tracking Form dated 12/8/14-12/15/14 indicated an entry for Resident #76. The entry indicated the resident had a pressure sore to the top of the buttocks which measured 6.8 centimeters (cm) by 7.2 cm. and a pressure sore to the bottom of the buttocks which measured 2.6 cm by 1.2 cm. The stage of the pressure ulcer was not documented. There was no actual date of the assessment on the form, only a date range. Further review of the clinical record revealed an entry on the Treatment Record by the Treatment Nurse dated 12/10/14. This entry addressed a change in the treatment to the pressure sore and had measurement, however they were marked through. There was no evidence of staging or a description of the pressure sore. Review of the Treatment Record revealed an entry dated … | 2018-10-01 |
| 5308 | 5308 | MADISON HEALTH AND REHAB | 115457 | 2036 SOUTH MAIN STREET | MADISON | GA | 30650 | 2015-01-08 | 371 | E | 0 | 1 | QN3M11 | Based on observations and staff interview the facility failed to properly label and date food items in one (1) of two (2) freezers in the dietary department; failed to properly label and date food items in the resident nourishment refrigerator and freezer for three (3) days of the survey; and failed to properly cover food items on resident meal trays while on an open cart while pushed through a common area to prevent contamination. Findings include: 1. Observation on 01/05/15 at 8:50 a.m. revealed that the chest freezer in the dietary department had three (3) clear plastic bags full of steak fries with no date identifying when they were opened. Interview with the Dietary Manager (DM) on 01/05/15 at 8:50 a.m. revealed that she expects dietary staff to label and date all food items before placing them back into the freezer of the refrigerator. She confirmed that the three (3) clear plastic bags did not have a label or a date. 2. Observation on 01/05/14 at 1:20 p.m. of the centrally located resident nourishment room and nourishment refrigerator revealed a foam plate covered with foil on the bottom of the refrigerator with no label or date. Continued observation revealed a twelve (12) ounce uncovered foam cup with a brown liquid, the cup was not labeled. Further observation revealed the following; a plastic twenty-four (24) ounce polka-a-dot tumbler on the bottom shelf which contained a liquid it had no label or date, and also an open unlabeled bag of Barbeque (BBQ) potato chips in the door of the refrigerator. The freezer contained Marie Chandler Fettuccine Alfredo frozen meal with no label or date as well as a Jimmy Dean Grilled Steak frozen meal with no label or date. Continued observation of the freezer revealed that there was a Hershey Cookies and Cream candy bar also with no label or date. Observation on 01/06/15 at 10:30 a.m. of the resident nourishment room refrigerator revealed that the open unlabeled bag of BBQ potato chips remained in the refrigerator door. Continued observation revealed that there was a t… | 2018-10-01 |
| 5309 | 5309 | MADISON HEALTH AND REHAB | 115457 | 2036 SOUTH MAIN STREET | MADISON | GA | 30650 | 2015-01-08 | 372 | C | 0 | 1 | QN3M11 | Based on observation and staff interview the facility failed to properly maintain the condition of two (2) of two (2) dumpsters; one (1) dumpster with leakage and the other with a broken lid to prevent the potential for pests and leakage of biohazard waste. Findings include: Observation on 01/05/15 at 9:05 a.m. revealed that the facility had two (2) large general dumpsters sitting side by side on a concrete pad. Observation of the dumpster on the left side revealed that the flip top lid was cracked and broken which had caused the lid to fall inside the dumpster exposing garbage to the elements. Further observation revealed that the dumpster on the right side had 2 leaks, one from the bottom right back corner and another coming from the bottom front right corner. The leak coming from the bottom back right corner was milky white in color and was eight (8) inches in length and six (6) inches in width. This leak had three (3) small streams of milky white substance running toward the left side of the concrete pad towards the bare ground. The leak at the bottom front right corner was milky white in color and was 6 feet in length and 1 foot in width. This leak was running towards the left side of the concrete pad and was going over the edge forming a pool of milk white fluid that was twelve (12) inches in length and 6 inches in width. Observation of the dumpsters with the Dietary Manager (DM) on 01/05/15 at 9:10 a.m., she confirmed that the dumpster lid was broken and not functioning properly. The DM further confirmed that the other dumpster was leaking from 2 separate areas. Interview with the Director of Maintenance on 01/08/15 at 11:00 a.m. revealed that he was responsible for making sure that the dumpsters are free from leaks. He confirmed that the one dumpster had a broken lid that needed repair and confirmed that the other dumpster did have leaks. He further revealed that when he identifies that the dumpster has a leak, or is in need of repair he would contact the city's waste disposal for service. Continued inter… | 2018-10-01 |
| 5310 | 5310 | MADISON HEALTH AND REHAB | 115457 | 2036 SOUTH MAIN STREET | MADISON | GA | 30650 | 2015-01-08 | 431 | E | 0 | 1 | QN3M11 | Based on observation, record review and staff interview, the facility failed to ensure that medications stored in one (1) of one (1) medication room refrigerators were kept at the recommended temperature range of 36 to 46 degrees Fahrenheit (F). The facility census was seventy (70), and the sample size was twenty-seven (27) residents. Findings include: On 01/06/15 at 10:24 a.m., the temperature of the medication refrigerator located in the medication storage room was observed to be 20 degrees F. This was verified during interview with the Director of Nurses (DON), who revealed that the temperature should be between 36 and 46 degrees. The DON further revealed that the night shift nurses were responsible for checking the refrigerator temperatures nightly, for recording the temperatures on a log kept in the medication room, and that she was not aware there was a problem with the temperatures. The contents of the medication room refrigerator was checked with the DON at this time, and contained the following medications, with the manufacturer's recommendation for storage temperatures listed if it could be observed on the packaging: 5-Mantoux Tubersol vials. Store between 36-46 degrees. 2-Risperdal Consta vials. Store between 36-46 degrees. 1-Humalog Insulin 75/25 vial for resident #58. 3-Promethazine vials. 4- Lorazepam vials. 2-Levalbuterol Hydrochloride Inhalation Solution boxes. Store between 68-77 degrees. The locked emergency box inside the refrigerator contained the following medications: [REDACTED] 2-Ativan vials. 1-Novolin 70/30 Insulin vial. 1-Novolin NPH Insulin vial. 4-Phenergan suppositories. Review of the medication room refrigerator temperature logs from (MONTH) 2014-January (YEAR) revealed the following, and were verified by the DON: October: The temperature was 34 degrees 13 times. November: The temperature was below 36 degrees 8 times. December: The temperature was below 36 degrees 1 time. January: The temperatures were 20 degrees, 18 degrees, 22 degrees, and 20 degrees through 01/04/15. Review of the… | 2018-10-01 |
| 5311 | 5311 | MADISON HEALTH AND REHAB | 115457 | 2036 SOUTH MAIN STREET | MADISON | GA | 30650 | 2015-01-08 | 441 | E | 0 | 1 | QN3M11 | Based on observations, review of the facility's Meal Service Policy and Procedure, Hand Washing Handout, and staff interview the facility failed to properly distribute and set-up residents meal in a sanitary manner for two (2) meals observed. Findings include: Observation on 01/05/15 at 12:15 p.m. revealed the Administrator assisting with distributing and set-up of the resident's lunch meals. The Administrator was observed touching the resident's as well as touching their wheelchairs. She did not use hand sanitizer before or after touching residents, or before she began distributing meals. The administrator was observed touching several residents' food items such as the baked potato with her bare hands. Observation on 01/05/15 at 12:20 p.m. revealed a male Certified Nursing Assistant (CNA) assisted a resident with set-up of their lunch meal and touched the resident's baked potato with his bare hands. He did not sanitize his hands before or after touching the food. Observation of the breakfast meal served on 01/07/2015 at 7:15 a.m., revealed Certified Nursing Assistant (CNA) AA served four (4) resident's sitting at two (2) separate tables. The CNA touched the food (toast) of the resident's with her bare hands after pushing the service cart, pushing wheelchairs and touching the coffee dispenser. The CNA did not wash or sanitize her hands before or after contact with the resident's food. Further observation revealed the administrator touched a resident's food (toast) with her bare hands after touching the back of the chair in the dining room. She also failed to wash or sanitize her hands before or after touching the food. In addition, Dietary Aide BB, touched the food (toast) of two (2) residents with her bare hands after touching the service cart, the wheelchair of a resident and the coffee dispenser. She also failed to wash or sanitize her hands before or after touching the food. Interview with the Director of Nursing (DON) on 01/08/15 at 9:15 a.m., revealed that when staff pass meal trays to the resident's, they … | 2018-10-01 |
| 5312 | 5312 | MADISON HEALTH AND REHAB | 115457 | 2036 SOUTH MAIN STREET | MADISON | GA | 30650 | 2015-01-08 | 463 | E | 0 | 1 | QN3M11 | Based on observations, record review and staff interview the facility failed to maintain a functioning call system for three (3) of thirty-four (34) resident rooms (Rooms 111, 130 and 134) and two (2) of twenty (20) resident bathrooms (Rooms 114 and 127) Findings include: 1) During an observation on 1/5/15 at 10:54 a.m., the call light at the bed of resident #20 was not functioning when pressed. This was verified at this time by Certified Nursing Assistant (CNA) EE and CNA FF verified that the resident was capable of using the call light. 2) During an observation on 1/5/15 at 11:03 a.m., the call light at the bed of resident #65 was not functioning when pressed. This was verified by LPN DD at 11:19 a.m. who also verified the resident was capable of using the call light. 3) During an observation on 1/5/15 at 1:45 p.m. the call light at the bed of resident #62 was not working when the button on the cord was pressed. Licensed Practical Nurse (LPN) CC verified at this time the call light was not functioning and notified the Maintenance Director 4) During an observation on 1/7/15 at 9:14 a.m., the call light in the bathroom of room 114 was not functioning. Interview at this time with the Maintenance Director, he confirmed that the call light was not working. He further revealed that he was unaware that the call light was not functioning and he would need to check the bulb. Continued interview on 01/07/15 at 9:20 a.m., the Maintenance Director revealed that he checks the call lights all over the building weekly. Interview on 1/7/15 at 10:10 a.m., CNA GG confirmed that one of the resident's living in the room was able to ambulate to the bathroom with staff assistance. 5) During an observation on 1/7/15 at 9:30 a.m., the call light in the bathroom of room 127 was not functioning. Interview at this time, the Maintenance Director confirmed the light was not working and he needed to replace the panel in the bathroom. Interview on 1/7/15 at 10:13 a.m., CNA GG verified one of the residents residing in the room was capable of … | 2018-10-01 |
| 5313 | 5313 | TRADITIONS HEALTH AND REHABILITATION | 115473 | 2816 EVANS MILL ROAD | LITHONIA | GA | 30058 | 2015-08-20 | 371 | E | 0 | 1 | 244X11 | Based on observation and staff interview the facility failed to demonstrate the proper technique for sanitizing kitchen equipment when using the three (3) compartment sink and failed to maintain food temperatures above one hundred thirty-five degrees Fahrenheit (135 F) for two (2) of 2 steam tables to prevent the potential of a food borne illness. This deficient practice had the potential to effect one hundred forty1one (141) residents receiving an oral diet. Findings include: 1. Observation on 08/19/15 at 11:20 a.m. of AA , the cook use the 3 compartment sink revealed that she washed, rinsed, and submerged the food processor bowl, blade, and lid properly. Continued observation revealed that once the items came out of the sanitizing solution the Dietary Manager (DM) handed the cook clean paper towel to dry the items in order for them to be used again to complete lunch food preparation. Further observation revealed a poster was hung above the 3 compartment sink and stated to allow items to air dry after immursed in sanitizing solution. Interview on 08/19/15 at 11:22 a.m. with AA , the cook revealed that she had not been in-serviced on the proper usage of the 3 compartment sink. The cook revealed that she did not know how long to submerge items in the sanitizing solution she just keeps them in there for a while. She further revealed that she did not know that items should air dry before use. Interview on 08/19/15 at 11:22 a.m. with the DM revealed that she told staff that they can wipe items dry after they were in the sanitizing solution. She revealed that she was told the by the department of health that they can wipe dry equipment after it has been in the sanitizing solution. The DM could not explain why she was not following manufactures recommendations that were indicated on the EcoLab poster hung on the wall. Continued interview revealed that it has been a while since dietary staff had an in-service regarding the proper usage of the 3 compartment sink. Interview on 08/19/15 at 1:30 p.m. with the Regional Dieti… | 2018-10-01 |
| 5314 | 5314 | TWIN OAKS CONVALESCENT CENTER | 115513 | 301 S0UTH BAKER STREET | ALMA | GA | 31510 | 2015-04-02 | 441 | E | 0 | 1 | K5KL11 | Based on observation, staff interview, and medical record review the facility failed to ensure that staff sanitized their hands between serving residents' meal trays on two (2) of five (5) halls, and in two (2) of two (2) dining rooms during three (3) dining observations with seventy-nine (79) of eighty (80) residents receiving oral alimentation. Findings include: 1. During dining observation on 03/30/15 at 12:05 p.m. a Certified Nursing Assistant (CNA) delivered a meal tray to a resident in the restorative dining room. The CNA donned gloves and touched multiple inanimate objects including wheelchairs and tables and did not remove gloves and don a new pair of gloves or sanitize hands before serving trays and handling food during set-up of trays. The CNA was never observed to change gloves during delivery or set-up of trays in the Dining Room. Multiple CNA's in the Dining Room were noted to have donned gloves, delivering trays and setting up multiple resident trays without changing gloves or sanitizing hands between residents. . 2. During dining observation on 03/30/15 at 12:54 p.m. on A-hall during lunch revealed that CNAs donned gloves, touched the meal cart and resident table prior to delivering and setting-up resident tray without ever changing gloves and washing or sanitizing hands. 3. During dining observation on 03/30/15 at 1:00 p.m. on A-hall revealed that a CNA donned gloves, repositioned a resident in bed, removed gloves, re-donned the same gloves and did not wash or sanitize their hands before setting up the resident tray and touching the resident's bread. 4. During dining observation in the large dining room on 03/31/15 at 12:20 p.m. revealed that a CNA donned gloves and was observed touching resident wheelchairs then delivering and setting-up trays without washing or sanitizing hand or changing gloves. Observation in the large dining room on 03/31/15 at 12:28 p.m. revealed that a CNA donned gloves, touched a resident on her arm, never removed gloves, washed or sanitized hands then proceeded to deliver… | 2018-10-01 |
| 5315 | 5315 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2014-09-18 | 323 | D | 0 | 1 | WX4L11 | Based on observations, record review and staff interviews the facility failed to maintain safe water temperatures of one hundred and twenty degrees Fahrenheit (120 F) to prevent accidents in resident bathrooms on three (3) of four (4) halls. Findings include: Observations during initial tour of the facility on 9/15/14 between 7:00 p.m. and 7:30 p.m. revealed the following hot water temperatures: - The D hall common bathroom water temperature was one hundred and twenty-two (122) degrees Fahrenheit (F) -The water temperature in room B-17 was one hundred and twenty three point seven (123.7) degrees F Interview on 10/01/14 at 10:45 a.m., during the Quality Assurance process, with the Assistant Director of Nursing (ADON) revealed that there were three (3) residents in room B-17 and that all three (3) were able to use the sink in the bathroom independently. Review of the weekly water temp and equipment log revealed that water temperatures were monitored on each hall and the common bath weekly with no evidence of temperatures elevated above 120 degrees F | 2018-10-01 |
| 5316 | 5316 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2014-09-18 | 431 | D | 0 | 1 | WX4L11 | Based on observations, Medication Destruction Policy, Controlled Medication Administration Policy, and staff interview the facility failed to ensure expired medications were disposed of in a timely manner in one of two (1 of 2) medication storage rooms, and one of three (1 of 3) medication carts; and failed to ensure that Controlled Medications were reconciled accurately for two (2) random residents in one of three (1 of 3) medication carts. Findings include: 1. Observations of the medication storage room (Main Nurse Supply Room A/B Hall) on 09/17/14 between 1:30 p.m. and 2:30 p.m. revealed the following medications were found to be expired: -Four (4) unopened bottles of Certavite Multivitamin (MVI) and Mineral Liquid Supplement 236 milliliter (ml) bottles with an expiration date of July, 2014. -Four (4) unopened bottles of Aspirin Enteric Coated 325 milligram (mg) Tablets with an expiration date of July, 2014 -Two (2) unopened bottles of Senexon Liquid- Natural Vegetable Stimulant Laxative 237ml bottles with an expiration date of August, 2014 -Thirty (30) packs in one (1) unopened box of Juven Nutrition Powder with an expiration date of (MONTH) 1, 2014 During interview with Licensed Practical Nurse (LPN) AA on 9/17/14 at 2:20 p.m. she verified the medications were expired. 2. Observation of the medication cart (A/B Medication Cart) on 09/17/14 between 1:30 p.m. and 2:30 p.m. revealed one (1) opened bottle of Senexon Liquid- Natural Vegetable Stimulant Laxative 237 ml bottle which was half empty, with an expiration date of July, 2014. Review of the Facility policy titled Medication Destruction revealed that discontinued medications, medications left in the nursing center after a patient's discharge, and expired medications are to be destroyed. 3. Review of the Controlled Drug Record Form for two (2) residents receiving controlled substances revealed -one (1) resident, receiving Hydrocodone-APAP 5/325 mg, had seventeen (17) tablets available but reconciliation revealed that the medication package had a total of ei… | 2018-10-01 |
| 5317 | 5317 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2014-09-18 | 441 | F | 0 | 1 | WX4L11 | Based on observations, and staff interview, the facility failed to ensure that one of one (1 of 1) ice machine was maintained in a sanitary manner, to prevent the spread of infection. Findings include: Observations of the ice machine on 9/15/14 at 6:45 p.m. and 9/16/14 at 1:40 p.m. revealed that the facility had only one (1) ice machine which was located outside of the main dining area. It had copious amounts of a dark brown substance on the plastic shield inside the ice compartment. Observation on 9/17/14 at 9:35 a.m. with the Dietary Manager revealed copious amounts of a dark brown substance on the plastic shield inside the ice compartment. The Dietary Manager verified the presence of the dark brown substance and revealed that she is responsible for cleaning the ice machine but could not recall the last cleaning. Review of kitchen cleaning schedule revealed cleaning dates for the ice chests and carts but no evidence of a schedule for the ice machine. | 2018-10-01 |
| 5318 | 5318 | CUMMING NURSING CENTER | 115551 | 2775 CASTLEBERRY ROAD | CUMMING | GA | 30041 | 2015-03-05 | 159 | B | 0 | 1 | 5C6611 | Based on review of funds, and staff interviews, the facility failed to ensure that resident funds were available on the weekends for sixty-three (63) resident with fund accounts. Finding include: Review of resident funds revealed that the facility manages sixty-three (63) resident accounts. Interview with the Business Office Manager (BOM) on 3/4/15 at 10:45 a.m., revealed that residents has access to their account Monday through Friday from 9:00 a.m. to 5:00 p.m., but not on the weekends. She revealed that until two (2) years ago, the money was available on the weekends with the supervisor; however, no resident ever requested any money, so the Administrator decided to just make the money available Monday through Friday. Interview with the Administrator on 3/4/15 at 12:30 p.m., revealed that after the facility was cited seven to eight (7-8) years ago for not having funds available for the residents on the weekends, the facility left $50.00 with the weekend nursing supervisor. He further indicated that about three to four (3-4) years ago, this procedure was stopped because the residents were not using the money over the weekends. He indicated that no resident had complained of monies not being available on the weekends. | 2018-10-01 |
| 5319 | 5319 | CUMMING NURSING CENTER | 115551 | 2775 CASTLEBERRY ROAD | CUMMING | GA | 30041 | 2015-03-05 | 278 | D | 0 | 1 | 5C6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the assessment of one (1) resident (#24) regarding anti-depressant medication from a total sample of twenty-four (24). Findings include: Resident #24 was admitted to the facility in (MONTH) 2014 with Alzheimer's, Anxiety, and [MEDICAL CONDITION]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) and (MONTH) 2014 Medication Administration Records revealed [MEDICATION NAME] fifty (50) mg at HS starting 11/28/14 had been administered according to the physician's orders [REDACTED].>Review of the Quarterly MDS dated [DATE] revealed no evidence of antidepressant medication being completed under section N0410. Interview with the MDS Coordinator BB on 3/3/15 at 2:20 p.m., revealed that the [MEDICATION NAME] was overlooked during the seven (7) day look back period (11/27/14-12/3/14) and the resident was taking the [MEDICATION NAME] during that time. | 2018-10-01 |
| 5320 | 5320 | CUMMING NURSING CENTER | 115551 | 2775 CASTLEBERRY ROAD | CUMMING | GA | 30041 | 2015-03-05 | 279 | D | 0 | 1 | 5C6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to develop a care plan for one (1) resident (#76) regarding vision from a total of twenty-four (24) sampled residents. Findings include: Resident #76 was admitted to the facility in (MONTH) 2014 with Dementia, left side weakness, and [MEDICATION NAME] Degeneration. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that resident #76 has impaired vision yet sees large print without any corrective lenses. Further review of the Care Area Assessment (CAA) dated 10/20/14 revealed that vision triggered and would be addressed in a care plan. Review of the resident's current care plan with a continuation date of 1/22/15 revealed no evidence of vision being care planned. Interview with the MDS Coordinator AA on 3/4/15 at 9:15 a.m., revealed there was no care plan related to vision. . | 2018-10-01 |
| 5321 | 5321 | LODGE, THE | 115552 | 200 SOUTH KIMBERLY ROAD | WARNER ROBINS | GA | 31088 | 2015-01-15 | 282 | D | 0 | 1 | 5KY411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to follow the Care Plan for a personal alarm while in bed for one (1) resident (#117), with a history of falls, of twenty three (23) sampled residents. Findings Include: Review of the Care Plan for resident #117 revealed that the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed as having a Brief Interview for Mental Status (BIMS) of five (5) indicating the resident was cognitively impaired. The resident was assessed as not being a fall risk and having no falls within the last six (6) months of admission. The resident is assessed as requiring extensive assist by one (1) person for bed mobility, dressing, toileting, and personal hygiene. The resident was assessed for extensive assist by two (2) persons for transfer. Review of the Quarterly MDS assessment dated [DATE] revealed that the resident was assessed as having a BIMS of six (6) indicating the resident was cognitively impaired. The resident was assessed for one (1) person extensive assistance for bed mobility, transfer, eating, and personal hygiene and bathing the resident was totally dependent upon staff. Review of the nurses notes revealed the following falls: 11/1/14 at 2:45 p.m. resident was found on the floor of his/her room, no injuries noted. Resident states he/she attempting to go to the toilet. 11/7/14 at 2:45 p.m. resident was found on the floor of his/her room with hard stool found on floor, no injuries noted. 12/27/14 at 5:05 a.m. revealed the resident was found on the floor of his/her room and appeared to get out of bed without assistance. Noted the resident had a bowel movement in the bed, diaper and floor. No injuries were noted. Review of the resident care plan related to falls dated 8/18/14 revealed the following interventions: 1. a personal alarm on when I am in the bed. 2. Ensure oxygen nas… | 2018-10-01 |
| 5322 | 5322 | LODGE, THE | 115552 | 200 SOUTH KIMBERLY ROAD | WARNER ROBINS | GA | 31088 | 2015-01-15 | 323 | D | 0 | 1 | 5KY411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to ensure that a personal alarm was utilized for while in bed for one (1) resident (#117), with a history of falls, of twenty three (23) sampled residents. Findings Include: Review of the Care Plan for resident #117 revealed that the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed as having a Brief Interview for Mental Status (BIMS) of five (5) indicating the resident is cognitively impaired. The resident was assessed as not being a fall risk and having no falls within the last six (6) months of admission. The resident was assessed as requiring extensive assist by one (1) person for bed mobility, dressing, toileting, and personal hygiene. The resident was assessed for extensive assist by two (2) persons for transfer. Review of the Quarterly MDS assessment dated [DATE] revealed that the resident was assessed as having a BIMS of six (6) indicating the resident was cognitively impaired. The resident was assessed for one (1) person extensive assistance for bed mobility, transfer, eating, and personal hygiene and bathing the resident is totally dependent upon staff. Review of the nurses notes revealed the following falls: 11/1/14 at 2:45 p.m. resident was found on the floor of his/her room, no injuries noted. Resident states he/she attempting to go to the toilet. 11/7/14 at 2:45 p.m. resident was found on the floor of his/her room with hard stool found on floor, no injuries noted. 12/27/14 at 5:05 a.m. revealed the resident was found on the floor of his/her room and appeared to get out of bed without assistance. Noted the resident had a bowel movement in the bed, diaper and floor. No injuries were noted. Review of the resident care plan related to falls dated 8/18/14 revealed the following interventions: 1. a personal alarm on when I am in the bed. 2. Ensure oxygen … | 2018-10-01 |
| 5323 | 5323 | ROSEMONT AT STONE MOUNTAIN | 115565 | 5160 SPRING VIEW AVENUE | STONE MOUNTAIN | GA | 30083 | 2015-10-09 | 514 | D | 1 | 0 | KX8511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F514 Based on observation, interview and record review, the facility failed to accurately reflect the resident ' s current allergies in the physician's order [REDACTED]. physician's order [REDACTED]. Review of the medications on the physician's order [REDACTED]. Review of the resident ' s Medication Administration Record [REDACTED]. Review of the Telephone Orders for the resident reveal the following: 7/7/2015: D/C Allergic to [MEDICATION NAME]/NSAIDS (resident insists no allergy will monitor). Interview on 10/7/2015 at 2:25 p.m. with DON who reveals that physician's order [REDACTED]. After review of the allergies and resident ' s prescribed medications, the DON agreed that the listed allergies were incorrect and the facility had a responsibility to notify the pharmacy when the Telephone Order was received on 7/7/2015. | 2018-10-01 |
| 5324 | 5324 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2015-10-28 | 282 | D | 1 | 0 | 8M4F11 | Based on observation, interview and record review, it was determined the facility failed to implement interventions to assist one resident (#1) with his/her over-all appearance and maintain the bed in the lowest position for one resident (#7) from a total sample of 7 residents. Findings include: 1. Resident #1 had a plan of care since 5/28/13 for having a self care deficit and requiring assistance with activities of daily living (ADL's). The plan of care included an intervention for nursing staff to assist the resident with over-all appearance. However, the resident was observed with multiple stains to the front of his/her shirt and/or pants on 10/28/15 at 10:25 a.m., 11:55 a.m. and 12:40 p.m., 1:45 p.m., and 3:00 p.m. Cross refer to F 312 2. Resident #7 had a plan of care, dated 10/15/15, for being at risk for falls related to a history of falls. The plan of care included an intervention for nursing staff to ensure the bed was in the lowest position. However, the bed was observed to be in an elevated position with the resident in the bed on 10/29/15 at 9:30 a.m. and 10:45 a.m. Cross refer to F 323 | 2018-10-01 |
| 5325 | 5325 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2015-10-28 | 312 | D | 1 | 0 | 8M4F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, it was determined the facility failed to assist one resident (#1) with dressing and overall appearance from a total sample of seven (7) residents. Findings include: 1. Resident #1 had [DIAGNOSES REDACTED]. The 8/21/15 Minimum Data Set (MDS) assessment, completed by nursing staff, documented that the resident was provided with extensive assistance with dressing and total care with personal hygiene. The resident had a plan of care since 5/28/13 (and most recently reviewed on 7/23/15) for having a self care deficit and requiring assistance with activities of daily living (ADL's). The plan of care included an intervention for nursing staff to assist the resident with over-all appearance. Licensed Nurse CC stated during an interview on 10/29/15 that the resident had to be dressed by staff. However, the resident was observed with multiple stains to the front of his/her shirt and pants on 10/28/15 at 10:25 a.m., 11:55 a.m., 12:40 p.m., 1:45 p.m. At 3 p.m. the resident observed with a clean shirt but the same stained pants. During an interview on 10/29/15 at 12:05 p.m., Certified Nursing Assistant (CNA) BB stated that she had first observed the stains to the resident's clothing on 10/28/15 at lunch time and changed his shirt after lunch. She further stated she wiped the stains on his pants in an attempt to remove them and thought she had. During the same interview on 10/29/15 at 12:05 p.m., CNA AA stated he provided care to the resident on 10/28/15 that morning after breakfast and his clothes were not stained. However, he had not observed the resident after that time and before assisting CNA BB with care after lunch. | 2018-10-01 |
| 5326 | 5326 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2015-10-28 | 323 | D | 1 | 0 | 8M4F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review it was determined the facility failed to ensure that the bed of one resident (#7) was maintained in a low position to prevent falls from a total sample of seven residents. Findings include: Resident #7 had [DIAGNOSES REDACTED]. A review of the clinical record revealed a history of a fall out of bed on 8/19/15. The current plan of care, dated 10/15/15, included a problem for being at risk for falls related to a history of falls. The plan of care included an intervention for nursing staff to ensure the bed was in the lowest position. A review of the computerized Certified Nursing Assistant (CNA) smart charting system also revealed an intervention for CNA's to keep the bed in the lowest position except during activities of daily living (ADL) care. However, the bed was observed to be in an elevated position with the resident in the bed on 10/29/15 at 9:30 a.m. and 10:45 a.m. At 10:50 a.m., after surveyor inquiry, the Care Plan Coordinator lowered the level of the resident's bed to the lowest position. | 2018-10-01 |
| 5327 | 5327 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2014-11-20 | 253 | B | 0 | 1 | NWCY11 | Based on observation, it was determined that the facility failed to maintain a clean and comfortable environment in four (4) of thirty seven (37) bathrooms on three (3) of four (4)halls. Findings include: 1. Observation on 11/18/14 at 10:31 a.m. revealed the bathroom floor had a heavy build up of dust and debris especially along the edges behind the toilet in resident room 304. 2. Observation on 11/18/14 at 9:59 a.m. revealed a heavy build up of dust on the ceiling vent and the floor under the sink had a heavy build up dust and debris in the bathroom in resident room 312. 3. Observation on 11/18/14 at 8:42 a.m. revealed the metal frame on the raised toilet seat and several rusted areas in the bathroom in resident room 403. | 2018-10-01 |
| 5328 | 5328 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2014-11-20 | 441 | E | 0 | 1 | NWCY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to store urinals and washbasins in a manner to prevent possible contamination in seven (7) residents bathrooms from a total of thirty seven (37) bathrooms. Findings include: 1. During observation on 11/18/14 at 10:57 a.m. revealed in room [ROOM NUMBER] bathroom a wash basin and a bedpan were stored in the tub unmarked and not in a plastic bag. 2. During observation on 11/18/14 at 9:59 a.m. revealed in room [ROOM NUMBER] bathroom a wash basin unmarked and not in a plastic bag. stored on the back of the toilet. 3. During observation on 11/18/14 at 3:35 p.m. revealed in room [ROOM NUMBER] bathroom, which is shared with room [ROOM NUMBER], one wash basin on back of toilet and two wash basins on the floor beside the toilet unmarked and not in plastic bags. 4. During observation on 11/18/14 at 3:40 p.m. revealed in room [ROOM NUMBER] bathroom, which is shared with room [ROOM NUMBER], two wash basins stored on back of the toilet , both unlabeled and not in plastic bag. 5. During observation on 11/18/14 at 4:35 p.m. revealed in room [ROOM NUMBER] bathroom, which is shared with room [ROOM NUMBER], a wash basin, a bedpan and a urine measurement container, all items were unlabeled and not bagged appropriately. 6. During observation on 11/17/14 at 12:15 p.m. revealed in room [ROOM NUMBER] bathroom, which is shared with room [ROOM NUMBER], there were three wash basins stacked inside each other, none of the items were labeled nor in a plastic bag. 7. During observation on 11/17/14 at 3:31 p.m. revealed in room [ROOM NUMBER] bathroom, which is shared with room [ROOM NUMBER], a urinal, two wash basins stacked inside each other and two emesis basins, all unlabeled and not bagged. During an interview and tour with the Maintenance Director on 11/20/14 at 8:30 a.m., he confirmed the above concerns. During an interview with the Director of Nursing on 11/20/14 at 8:45 a.m. revealed that the facility d… | 2018-10-01 |
| 5329 | 5329 | HERITAGE INN HEALTH AND REHABILITATION | 115597 | 307 JONES MILL ROAD | STATESBORO | GA | 30458 | 2015-10-28 | 272 | E | 1 | 0 | SGS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete the facility's Comprehensive Falls Assessment form per facility policy to aid in the development of resident interventions related to falls for three (3) of three (3) residents reviewed. Review of the facility Falls Management at a Glance: Intent revealed the Falls program was an interdisciplinary approach to the management of patients at high risk for falls. The Goal was to be proactive in efforts to identify risk factors that reduce the frequency of falls and serious injuries. Program progress included a Comprehensive Falls Assessment to be completed on Admission, Readmission, Quarterly, Annually and as clinically indicated. Appropriate interventions were implemented on The Falls Intervention Plan (FIP) based on the findings from the Comprehensive Falls Assessment. The Director of Nursing (DON) and/or designee would ensure updates occurred for the FIP, 24 hour report and Accunurse. Review of the medical record for resident #1 revealed were was admitted in 04/2015 after a hospital stay for altered mental status and urinary tract infection. Other [DIAGNOSES REDACTED]. Resident #1 Required extensive assistance with transfers and walking. Further review revealed that no Comprehensive Falls Assessments completed on admission in (MONTH) (YEAR) with falls occurring on 06/20/2015 and 06/21/2015. Review of the medical record for resident #2 revealed admitted in (MONTH) of 2012. [DIAGNOSES REDACTED]. Further review revealed no Comprehensive Falls Assessments completed with Quarterly assessments dated 04/08/2015 and 07/11/2015 or Annual assessment dated [DATE]; with falls occurring 08/07/2015, 08/19/2015, 09/28/2015 and 09/29/2015. Review of Medical record for resident #3 revealed she was admitted in (MONTH) of 2014. [DIAGNOSES REDACTED]. She required supervision with transfers and walking. Further review revealed no Comprehensive Falls Assessment completed with Quarter… | 2018-10-01 |
| 5330 | 5330 | HERITAGE INN HEALTH AND REHABILITATION | 115597 | 307 JONES MILL ROAD | STATESBORO | GA | 30458 | 2015-10-28 | 279 | E | 1 | 0 | SGS711 | Based on observation, interview and record review the facility failed to develop and/or update care plans related to individual risk factors and interventions related to falls for three (3) out of three (3) residents reviewed. Observation on 10/27/2015 at 3:55 p.m. revealed resident #2 up in her room bending over her bottom dresser drawer with tall striped socks on. Observation on 10/27/15 at 4:00 p.m. Observation of resident #2 sitting in recliner in bedroom (reclined) with same socks on, not non-skid. Observation on 10/27/2015 at 4:05 p.m. revealed a sign over the recliner of resident #2 to offer to assist the resident in reclining her chair and to round on resident every hour. Interview on 10/27/2015 at 4:10 p.m. with Physical Therapist CC revealed resident #1 had an unsteady gait and poor safety awareness. He was unable to utilize a walker independently due to his cognition. His was discharged to a functional program that included walking with staff assistance 125-150 feet. He was not an appropriate candidate for restraints due to poor cognition. He became agitated when asked to sit down. He was blind and hard of hearing. He pulled up on what he could reach. He had walked at home by holding on to things and tried to continue to do so. Interview on 10/27/2015 at 5:19 p.m. with the DON revealed that on admission residents were evaluated for fall risk and given a FIP. New admissions were considered at risk due to their new environment. If a fall occurred the nurse filled out an incident report and placed it in the Falls Program Coordinators box who assessed the resident and did a follow through on the fall. The falls were then discussed in the weekly PAR meeting and reviewed for appropriate/effective interventions and care plans were updated as needed. Interview on 10/28/2015 at 6:30 a.m. with the Falls Program Coordinator revealed every resident was considered at risk for falls when they were admitted to the facility. This was explained to the families on admission. Everyone then got a FIP on the chart and inte… | 2018-10-01 |
| 5331 | 5331 | WESTWOOD NURSING CENTER | 115601 | 101 STOCKYARD ROAD | STATESBORO | GA | 30458 | 2015-08-20 | 325 | D | 0 | 1 | 4OPQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, it was determined that the facility had failed to follow up timely on the Registered Dietician's recommendations for one (1) residents (#31) at nutritional risk from a sample of thirty (30) residents. Findings include Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Physician Recommendation Sheet from the Registered Dietician for 6-8-15 for Resident #31 revealed a recommendation to start a multivitamin one daily and to discontinue the zinc sulfate. There was no evidence of follow-up by the physician. During an interview with the unit manager, she stated on 8-19-15 at 4:00 pm that the recommendation was sent to the physician on 6-8-15; however, as of 8-19-15, there had been no response from the physician for that recommendation. Review of the current physician's orders [REDACTED]. | 2018-10-01 |
| 5332 | 5332 | WESTWOOD NURSING CENTER | 115601 | 101 STOCKYARD ROAD | STATESBORO | GA | 30458 | 2015-08-20 | 329 | D | 0 | 1 | 4OPQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, it was determined that the facility had failed to ensure that one resident (#12) was free from an excessive dose of an antipsychotic, from a total sample of thirty (30) residents. Findings include: For Resident #12 the Consulting Report (CR) done by the Registered Pharmacist on 2-10-15 had a recommendation to provide a [DIAGNOSES REDACTED]. However, the physician failed to respond until 3-18-15 to the CR report of 2-10-15, at which time he agreed to the [DIAGNOSES REDACTED]. Review of the physician's telephone order (PTO) for 3-18-15 revealed that an order was written for [DIAGNOSES REDACTED]. However, there was no PTO written for the reduction of the [MEDICATION NAME] 50 mg at bedtime to 25 mg at bedtime. Review of the physician's telephone orders (PTO) for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and review of the physician's orders [REDACTED]. [REDACTED]. A recommendation was made by the consultant Registered Pharmacist (RPh) on the 4-22-15 Consulting Report (CR) to re-evaluate the need for the continued use of [MEDICATION NAME], perhaps considering a gradual dosage reduction to 25 mg at bedtime, with the end goal of discontinuation of therapy if possible. The physician did not respond to this recommendation until 5-10-15, at which time he accepted the recommendation to reduce the dosage of the [MEDICATION NAME] from 50 mg to 25 mg. There was a PTO sheet documenting an order to reduce [MEDICATION NAME] 50 mg at bedtime to 25 mg at bedtime on 5-11-15. There was a delay of three months, from 2-10-15 until 5-11-15, in the reduction of the [MEDICATION NAME] 50 mg. at bedtime to [MEDICATION NAME] 25 mg at bedtime. | 2018-10-01 |
| 5333 | 5333 | WAYCROSS HEALTH AND REHABILITATION | 115605 | 1910 DOROTHY STREET | WAYCROSS | GA | 31501 | 2015-05-21 | 371 | E | 0 | 1 | WZWW11 | Based on observation and staff interview, the facility failed to hold food at the proper temperature during lunch service. This had the potential to effect a census of 70 residents. Findings include: On 05/21/2015 at 12:20 p.m., observation of the steam table temperatures with the Dietary Manager, using a facility thermometer that was calibrated between food items, revealed the following food items were not being held at the proper temperature: chopped chicken - 110 degrees Farenheit pureed squash - 100 degrees Farenheit candied yams - 110 degrees Farenheit pureed chicken, individually pre-packaged - 132 degrees Farenheit On 05/21/2015 at 1:00 p.m. the Dietary Manager (DM) questioned the cook, AA who revealed that there was no warmer, so after being cooked food sat on the top of the stove, with no burners on, until being transferred to the steam table. The cook further revealed that the timing of taking the steam table temperatures for meal services varied. The DM revealed that she had had a problem with the right side of the steam table about two months ago but had not had any problems since. A review of the facility Safe Food Handling Practices: Food Temperatures Section I. D. revealed The danger zone for the growth of bacteria is 41 degrees Farenheit (F.) to 140 degrees F. and that foods should be kept at temperatures either above or below the danger zone. Section I.G. revealed Keep hot foods hot. Hot foods should be kept at 140 degrees F. or higher. #1. Place foods on the steam table no more than 20 minutes before serving. Heat food to at least 140 degrees F. before putting it on steam table. Section I.H. revealed .Never allow foods to stay at room temperature or place on a warm range or griddle Section I.I. revealed Heat leftovers to an internal temperature of at least 165 degrees F. before placing on the serving line. Interview with the Dietary Manager on 05/21/2015 at 12:40 p.m. revealed that the holding table temperatures should have been at least 135 degrees Farenheit. | 2018-10-01 |
| 5334 | 5334 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2015-05-21 | 253 | D | 0 | 1 | 1S4H11 | Based on observation, staff interview and facility policy, the facility failed to provide effective housekeeping/maintenance service on (2) two of (6) six halls. Findings include: Observation on 05/18/15 at 11:59 a.m., 05/19/15 at 12:03 p.m., 05/20/15 at 7:42 a.m., and on 05/21/15 at 1:19 p.m. revealed that in room B-11 bathroom there was a large circular black stain around base of toilet on the floor. Observation on 05/18/15 at 11:54 a.m., 05/19/15 at 12:00 p.m.,and 05/20/15 at 7:35 a.m. revealed that in room A-8 bathroom there was a leaking pipe under the sink with a black stain with build-up of black residue on the shelf. The residue was approximately 3-4 inches thick. Observation also revealed clear liquid dripping off of the pipe and collecting on the shelf below the pipe. Interview with Assistant Director of Maintenance on 05/21/15 at 1:23 PM confirmed that there was a large circular black stain around base of toilet on floor in bathroom of room B-11. Interview on 05/20/15 at 10:43 a.m. with Administrator reveals that the facility has a Guardian Angel Program for Quality Assurance. During the interview it was revealed that the purpose of the Guardian Angel Program is the routine weekly checking of a variety of issues, including but not limited to housekeeping and maintenance issues, that are to be reported by the staff member assigned to audit that room and resident. Interview and tour with the Administrator on 05/20/15 at 10:43 a.m. confirmed that there was a large black stain around the base of the toilet on floor in bathroom for room B-11 and a leaking sink pipe with build-up of residue on shelf below pipe in bathroom of room A-8. | 2018-10-01 |
| 5335 | 5335 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2015-05-21 | 282 | D | 0 | 1 | 1S4H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow the Plan of Care regarding the administration of medications as ordered for one (1) resident (#16) receiving anticoagulant therapy requiring laboratory monitoring from a total sample of twenty-one (21) residents. Findings include: Record review for resident #16 revealed the resident with a [DIAGNOSES REDACTED]. Review of the resident's Plan of Care with a revision date of 3/25/14 for Anticoagulant therapy revealed an intervention to report laboratory (lab) results and notify the physician of the results. Review of the physician's orders [REDACTED]. Review of the laboratory results for 04/17/15 revealed the [MEDICATION NAME] time (PT) and International Normalized Ratio (INR) was collected but no results were available. During an interview on 05/21/15 at 5:50 p.m. with the Director of Nursing (DON) he/she revealed that the 04/17/15 PT and INR was collected as ordered but the test was not done and therefore, the results were not reported to the physician as specified in the residents Plan of Care. The DON stated it was her expectation the plan of care be followed and the staff failed to follow the residents plan of care. Refer to F309 | 2018-10-01 |
| 5336 | 5336 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2015-05-21 | 309 | D | 0 | 1 | 1S4H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews the facility failed to ensure that the physician orders [REDACTED].#16) receiving anticoagulant therapy of twenty-one (21) sampled residents. Findings include: Resident #16 had [DIAGNOSES REDACTED]. Record review revealed the resident was receiving oral anticoagulant therapy requiring laboratory monitoring of the resident's [MEDICATION NAME] time (PT) and International normalized ratio (INR) as ordered by the physician. Record review of the physician's orders [REDACTED]. Review of the nursing progress note written by the unit manager dated 04/04/15 revealed the dosage change, check PT and INR in two (2) weeks on Friday 04/17/15. Record review of lab results revealed a PT of 15.5 and INR of 1.28 dated 04/07/15 although no results were available for 4/17/15. An interview with the Director of Nursing (DON) on 05/21/15 at 12:30 p.m. revealed that the PT and INR was collected on 04/17/15, as ordered, but no results were available. The DON revealed the 04/17/15 PT and INR should have been followed up on and results followed up on but the staff failed to do so. The DON further stated the Unit manager does a weekly audit and should have caught that the lab was not done on 4/17/15. The DON cannot explain how this occurred. | 2018-10-01 |
| 5337 | 5337 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2015-05-21 | 329 | D | 0 | 1 | 1S4H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to document monitoring of behaviors and side effects for antipsychotic drugs, per shift, for one (1) resident #51, per the physician's orders [REDACTED]. Findings include: Review of the clinical medical record revealed that resident #51 was admitted to facility on 7/26/13 with [DIAGNOSES REDACTED]. Review of Resident #51 Order Summary Report revealed that an order dated 03/30/15 for nursing staff to document behaviors and number of behaviors,outcomes of interventions and side effects every shift. Review of Electronic Behavior Monitoring record for (MONTH) (YEAR) revealed nursing staff failed to document on (MONTH) 1 ,2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 27, and 28. Further review of (MONTH) (YEAR) revealed nursing staff failed to document on 2, 3, 6, 8, 11, 13, 14, and 15. During an interview with the DON on 05/20/15 at 10:55 a.m. revealed that he/she expected the nurse to document on the Behavior Monitoring for behavior and side effects every shift as ordered, and expected the nurse to document a zero or number for code. The DON confirmed that nursing staff failed to document behaviors on the (MONTH) (YEAR) and (MONTH) (YEAR) Behavior Monitoring. | 2018-10-01 |
| 5338 | 5338 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2015-05-21 | 431 | D | 0 | 1 | 1S4H11 | Based on observation, staff interview, and record review the facility failed to ensure that expired medications were properly disposed of in a timely manner in one (1) of two (2) medication rooms. Findings include: Observation on 05/21/15 at 11:15 a.m. revealed that there were three (3) expired medications in the medication storage room for A, B, and C-halls. Sodium Bicarbonate (1000) one thousand tablets unopened, expired March, (YEAR), Niacin 50 mg. (100) one hundred tablets unopened, expired March,2015, and Acetaminophen Liquid 160 mg./5 ml. a (16) sixteen ounce bottle unopened, expired January, (YEAR). Interview with Licensed Practical Nurse AA, Unit Coordinator on 05/21/15 at 11:20 a.m. confirmed that medications were expired. Review of the facility policy for medications showed that medications are to have the expiration date visible on the medication container and that expired medications are to be disposed of appropriately. Interview with Director of Nurses on 05/21/15 at 11:29 a.m. revealed that it is the responsibility of both Central Supply and night shift nurses to check medications in medication room for expired dates and to ensure that they are disposed of properly. | 2018-10-01 |
| 5339 | 5339 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2015-02-26 | 166 | D | 0 | 1 | W0TU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interviews, and record review, the facility failed to promptly resolve grievances related to one (1) resident (B) from a sample of twenty- two (22) residents. Findings include: On 2/25/15 at 12:25 p.m., a family member of resident B stated that resident B had been having repeated Urinary Tract Infections [MEDICAL CONDITION] and dehydration since (MONTH) of 2014. She further stated that she had made the concerns known on many occasions to multiple nurses and the Assistant Director of Nursing (ADON). An interview was conducted on 2/25/15 at 2:50 p.m. with the Social Worker revealing the process for filing a complaint/grievance is as follows: When a staff member receives a complaint from a family member or a resident, they are to report it to their immediate supervisor. The complaint is then forwarded to Social Services. If a department head receives a complaint/grievance directly, they can file the grievance themselves and then forward it to the Social Worker. The grievance is then brought to the Administrator and it is signed by the Administrator. All complaints/grievances are investigated by the appropriate department and all complaints/grievances related to care, are investigated by nursing. The Social Worker is responsible for logging all complaints in the grievance log. Every complaint/grievance is followed up with the complainant once the investigation has been completed. An interview conducted on 2/16/15 at 10:40 a.m. with the Administrator revealed all grievances are brought to the morning meetings. The investigation process is discussed with the department heads and the Social Worker logs the grievance. The social worker or appropriate department head will follow up with the complainant of the investigated findings either in person or by courtesy telephone call. A record review of the Grievance Log with reference dates of (MONTH) 2014 through (MONTH) (YEAR), indicates there is no evidence of any formal … | 2018-10-01 |
| 5340 | 5340 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2015-02-26 | 167 | B | 0 | 1 | W0TU11 | Based on observations, resident interview and interview with the Administrator, the facility failed to make survey results available and accessible to the residents without having to ask. Findings include: During an initial tour and observation of the facility conducted on 2/23/15 at 11:28 a.m., there was no evidence of accessible survey results. An interview conducted on 2/25/15 at 9:20 a.m. with resident A revealed she was not aware that survey results were available to her or where the survey results were located. An observation on 2/25/15 at 9:40 a.m. with the Administrator revealed that survey results were not posted in the facility. An interview with the Administrator at that time confirmed no survey results were currently posted or accessible to the residents. | 2018-10-01 |
| 5341 | 5341 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2015-02-26 | 282 | D | 0 | 1 | W0TU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to implement intervention per the plan of care for two (2) residents B and #39 from a sample of twenty-two (22). Findings include: 1. Record Review revealed that resident B had a Quarterly Minimum Data Set (MDS) assessment on 11/19/14 revealed the resident did not have a Brief Interview for Mental Status (BIMS) due to being unable to complete the interview due to severe impairment. [DIAGNOSES REDACTED]. The initial Care Plan for resident B was dated 06/16/14 and was reviewed and revised and updated on 09/24/15 and 12/05/14. The plan of care instructed staff to cleanse the perineal area with soap and water following bowel incontinence. During an observation of perineal care for resident Bon 02/25/15 at 1:25 p.m. by Certified Nursing Assistant (CNA) FF revealed he/she did not demonstrate the technique as instructed by the facility's policy. The CNA failed to turn the resident and clean from the posterior vaginal opening, from front to back, where there was a moderate amount of feces/stool left intact on the resident's perineum. On conclusion of the observation, CNA FF verified that the feces/stool was not properly cleaned off the resident. 2. An observation of perineal care for resident #39 on 02/25/15 at 2:10 p.m. with CNA EE revealed that the CNA cleaned the resident's anal and scrotal area with a wash cloth and then used the same wash cloth to retract the foreskin and cleaned the top of the penis. Following the observation, CNA EE verified that the wash cloth that was used to clean the resident's foreskin and top of penis was contaminated with feces/stool. An interview on 02/26/15 at 10:14 a.m. with the Assistant Director of Healthcare (ADOH) verified that the facility had not initiated skills check on perineal care. | 2018-10-01 |
| 5342 | 5342 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2015-02-26 | 315 | D | 0 | 1 | W0TU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility's Policy and Procedure for Perineal care, the facility failed to use appropriate technique, per the Policy, to prevent the potential for infection during perineal care for two (2) residents B and #39 of twenty-two (22) sampled residents. Findings include: Review of the facility's Policy and Procedures Lippincott Procedures (Revised: (MONTH) 04, 2013). The procedure promotes cleanliness and prevents infection. Using gentle downward [MEDICAL CONDITION] from the front to the back of the perineum to prevent intestinal organisms from contaminating in the urethra or vagina. Avoid the area around the anus, and use a clean section of wash cloth for each stroke by folding each use section inward. This method prevents the spread of contaminated secretions or discharge. Turn the patient on his/her side to the Sims position, if possible, to expose the anal area. Clean, rinse, and dry the anal area, starting at the posterior vaginal opening and wiping from front to back. 1. During an observation of perineal care with resident B on 02/25/15 at 1:25 p.m. Certified Nursing Assistant (CNA) FF did not demonstrate the technique as instructed by the facility's policy. The CNA failed to turn the resident and clean from the posterior vaginal opening, from front to back, where there was a moderate amount of feces/stool left intact on residents #47 perineum. CNA FF verified that the feces/stool was not properly cleaned off of resident B. A review of the resident's clinical record indicated a history of numerous abnormal Urinalysis with resulting antibiotic therapy. 2. An observation of perineal care on resident #39 on 02/25/15 at 2:10 p.m. with CNA EE revealed that CNA EE cleaned resident #39 anal and scrotal area with a wash cloth and then used the same wash cloth to retract the foreskin and cleaned the top of the penis. CNA EE verified that the was cloth that was used was contaminated with feces/sto… | 2018-10-01 |
| 5343 | 5343 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2015-10-28 | 279 | D | 1 | 0 | QQCM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility failed to develop a plan of care to address the care and treatment of [REDACTED]. Findings include: Resident #1 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of the 7/7/15 Admission/Nursing Evaluation Form noted the resident had a Port a Cath to the left chest. Review of the resident's comprehensive plan care dated 7/7/15 revealed there were no interventions in place to address the resident's Port a Cath. During an interview with the Assistant Director of Nursing on 10/28/15 at 12:15 P.M., she confirmed there was not a care plan to address the resident's Port a Cath. Refer to F 328 for additional information on resident #1. | 2018-10-01 |
| 5344 | 5344 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2015-10-28 | 328 | D | 1 | 0 | QQCM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to obtain a Physician's order for the care and treatment of [REDACTED].#1) of three (3) sampled residents with a Port a Cath from a total sample of seven (7) residents. Findings include: Resident #1 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. The Admission/Nursing Evaluation Form dated 7/7/15 noted the resident had a Port A Cath to the left chest. Review of the resident's comprehensive plan care dated 7/7/15 revealed there were no interventions in place to address the resident's Port a Cath. During an interview with the Assistant Director of Nursing on 10/28/15 at 12:15 P.M., she confirmed there was not a care plan to address the resident's Port a Cath. In an interview with the Director of Nursing (DON) on 10/27/15 at 2:05 P.M., she stated that during that assessment the port did not have a dressing or a needle in the device. There were also no Physician's orders for care or treatment to the port because he was going to [MEDICAL CONDITION] Center for [MEDICAL CONDITION]. She also stated that the resident's Port was monitored during the weekly body audits for any signs of infection. Weekly body audits were documented as done from 7/16/15 through 9/17/15. The documentation revealed the resident's skin was intact and there were no abnormal findings. However, during an interview on 10/28/15 at 11:15 A.M., with licensed practical nurse CC who completed the 9/17/15 body audit, stated that she had been written up because even though the resident had refused for the body audit to be done that day, she documented she had completed the body audit. She stated she would not have known if there was a needle or a dressing over the resident's port on 9/17/15 because she did not do the body audit. She further stated that she did not even know the resident had a port. Review of the 7/15/15 Skilled Daily Nurses Note revealed documentation… | 2018-10-01 |
| 5345 | 5345 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2015-10-28 | 441 | E | 1 | 0 | QQCM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to properly store basins, bedpans and urine measuring devices on three (3) of (3) halls in nine (9) out of thirty-nine rooms. Findings include: Observation on entering facility on 10/27/15 at 10:15 a.m. in room [ROOM NUMBER] showed several unbagged and unlabeled basins in the room on a shelf under sink. Observation of room [ROOM NUMBER] on 10/27/15 at 10:18 a.m. was also observed to have several unbagged and unlabeled basins in the room and an unbagged pail to a bedside commode sitting on the shelf in the bathroom that is unbagged. Observation of room [ROOM NUMBER] on 10/27/15 at 10:25 a.m. had unbagged and unlabeled basins and urine measuring devices in the bathroom. Observation of room [ROOM NUMBER] on 10/27/15 at 10:27 a.m. had unbagged and unlabeled basins on a shelf in the room. Observation of room [ROOM NUMBER] on 10/27/15 at 10:30 a.m. observed to have an unbagged bedpan in the bathroom on a shelf. Observation of room [ROOM NUMBER] on 10/27/15 at 10:35 a.m. had a bedside commode pail unbagged and sitting on the floor in the bathroom. Observation of room [ROOM NUMBER] on 10/27/15 at 10:38 a.m. had an unbagged bedpan sitting on the floor next to the toilet and an unbagged basin sitting on the shelf. Observation of room [ROOM NUMBER] on 10/27/15 at 10:42 a.m. the toilet is observed to have a dry yellow stain on the base of the toilet, black stains up under the rim of the toilet and brown debris on the bedside commode seat that is over the toilet and the outer rim of the toilet and there are unbagged and unlabeled basins on the shelf in the bathroom. Observation 2: Observation of room [ROOM NUMBER] on 10/27/15 at 12:40 p.m. showed several unbagged and unlabeled basins in the room on a shelf under sink. Observation of room [ROOM NUMBER] on 10/27/15 at 12:30 p.m. showed an unbagged bedside commode pail sitting on a shelf in the bathroom and several unbagged and unlabeled b… | 2018-10-01 |
| 5346 | 5346 | EAGLE HEALTH & REHABILITATION | 115618 | 405 S COLLEGE ST | STATESBORO | GA | 30458 | 2015-04-09 | 328 | E | 0 | 1 | 40EV11 | Based on review of the Equipment Inventory Log and staff interview, the facility failed to perform functional checks daily by analyzing the oxygen concentration for five (5) of eight (8) oxygen concentrators in use with residents (#3, #40, #45, #85, #118) in the ventilator unit. Findings include: A review conducted of the Equipment Inventory Log revealed functional checks that include the analyzing of oxygen concentration, was not performed daily and had only been checked once in the month of (MONTH) 2014 on the following oxygen concentrators in use with residents on the vent unit: SN# CON 82 in use by resident #3 SN# CON 20 in use by resident #40 SN# E 94 in use by resident #45 SN# CON 44 in use by resident #85 SN# E 18 in use by resident #118 Interview conducted on 4/7/15/ at 3:15 PM with the Respiratory Director revealed functional checks including analyzing oxygen concentration on the concentrators has only been performed once a month on all concentrators in the ventilator unit and not daily. She said she was not aware these functional checks were to be performed daily to ensure the accuracy of oxygen output from the concentrators in the ventilator unit. | 2018-10-01 |
| 5347 | 5347 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2015-01-15 | 371 | E | 0 | 1 | VJVF11 | Based on observations, review of the Daily Cleaning Schedule and staff interviews the facility failed to properly label and date food items in the walk-in freezer; failed to properly maintain sanitary conditions in the dry storage area; and failed to properly demonstrate the use of the three (3) compartment sink to prevent the potential for foodborne illness. This had the potential to effect one hundred and fourteen (114) residents receiving oral alimentation. Findings include: Observation on 01/12/15 at 1:35 p.m. of the dry storage area in the kitchen revealed that it was not clean and free from food debris, a quarter cup of dried elbow macaroni pasta was observed scattered on top of a cardboard box containing water which was sitting on the bottom shelving unit. Continued observation at 1:45 p.m. of the walk-in freezer revealed three (3) clear plastic bags located on the middle shelf near the door. The contents of the plastic bags had no label, or date and were un- identifiable. Interview on 01/12/15 at 1:35 p.m. with the Dietary Manager (DM) revealed that she expects the staff to keep the dry storage area clean and free from food debris. The DM confirmed that there was dry elbow macaroni pasta scattered on top of case of water. The DM further revealed that she had assigned a staff member to clean the dry storage area daily and once completed staff initials the cleaning sheet. Continued interview with the DM at 1:45 p.m. revealed that she expected the dietary staff to label and date all food items before placing them in the freezer or refrigerator. She confirmed that the three (3) clear plastic bags in the walk-in freezer did not have labels or dates. Review of the Cleaning Log sheets for the kitchen revealed that staff did not clean the dry storage area for the last four (4) days. Observation in the kitchen on 01/14/15 at 3:20 p.m. revealed that dietary staff AA was not able to demonstrate the proper usage of the three (3) compartment sink to clean and sanitize kitchen equipment. AA was observed washing the foo… | 2018-10-01 |
| 5348 | 5348 | CARROLLTON MANOR, INCORPORATED | 115638 | 2455 OAK GROVE CHURCH ROAD | CARROLLTON | GA | 30117 | 2015-04-23 | 167 | B | 0 | 1 | X9OS11 | Based on observations, resident and staff interviews, the facility failed to make survey results available and accessible to the residents. The facility census was ninety-seven (97) residents. Findings include: Observation conducted during initial tour on 4/20/15 at 9:45 AM revealed no survey results was posted nor a notice indicating the location of survey results. Observation conducted on 4/23/15 at 9:02 AM revealed a letter was posted on the bulletin board by the dining room entrance indicating the facility had no deficiencies on the last survey of 3/27/14. Interview conducted on 4/23/15 at 7:59 AM with resident A revealed that she was unaware of any survey results and has never seen any results. Further, she did not have any idea where it would be kept. Interview conducted on 4/23/15 at 8:03 AM with resident B revealed he knew that the state comes and does a survey but did not know that a report was sent back. He further revealed that he has never seen the report, does not know where it is located, and did not know that he could view it. Interview on 4/23/15 at 9:50 AM with the facility administrator revealed an actual statement of deficiency has been posted in the past but he was unaware that posting was required or that a notice indicating the location of survey results was a requirement. | 2018-10-01 |
| 5349 | 5349 | CARROLLTON MANOR, INCORPORATED | 115638 | 2455 OAK GROVE CHURCH ROAD | CARROLLTON | GA | 30117 | 2015-04-23 | 279 | D | 0 | 1 | X9OS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and staff interview, the facility failed to develop a comprehensive care plan for one (1) resident (#39) from sample of twenty-seven (27) residents. Findings Include: Record review Resident #39 revealed the resident was admitted on [DATE] with a Foley Catheter due to Urethral Stricture, [MEDICAL CONDITION], and Enlargement of the Prostate. An interim care plan was completed and placed on the chart on 03/03/15. Review of the admission Minimum Data Set (MDS) completed on 3/15/15 revealed the resident triggered for Urinary Incontinence and Urinary Catheter and was to be care planned. Continued review revealed no comprehensive care plan had been developed following completion of the 3/15/15 MDS. Interview was conducted with MDS Coordinator AA on 4/23/15 at 4:50pm revealed he was behind and is currently trying to catch up with developing comprehensive care plans. AA indicated that resident #39 Comprehensive Care Plan is currently thirty-one (31) days past due. Review of facility policy for Comprehensive Care Plan dated 9/6/2012 indicated that the MDS coordinator will complete a comprehensive assessment by the fourteenth (14th) day and a care plan within seven (7) days after the assessment. | 2018-10-01 |
| 5350 | 5350 | CARROLLTON MANOR, INCORPORATED | 115638 | 2455 OAK GROVE CHURCH ROAD | CARROLLTON | GA | 30117 | 2015-04-23 | 315 | D | 0 | 1 | X9OS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of facility policy, staff and resident interviews, the facility failed to ensure a urinary catheter was changed according to physician's orders [REDACTED]. Findings include: Record review for resident C revealed a [DIAGNOSES REDACTED]. Continued review revealed a current physician's orders [REDACTED]. The order indicated the last date the catheter change occurred was 2/17/15. Review of Nurses Notes revealed the resident refused catheter changes on 3/20/15 at 1:59 PM, and on 3/21/15 at 4:00 AM. Further review of nurses notes from 2/17/15 through 4/23/15 indicated there were no additional attempts to change the catheter. Interview conducted 4/23/15 at 10:30 AM resident C revealed he recalled being awakened very early in the morning approximately a month ago to have his catheter changed, and expressed his wish to have the procedure later in the day. The resident revealed no one had asked him to change the catheter again. Resident C indicated he did not object to having his catheter changed but would prefer not to be awakened. The resident could not remember his catheter being changed since February. He further indicated that the catheter is not usually secured to his leg or bed linens. and he experiences discomfort when the tubing is accidentally pulled. Observation conducted on 4/20/15 at 3:10 PM revealed resident C was sitting on side of bed with visitor in room. The Foley catheter was not secured to his leg and the drainage tubing was not secured to the bed linen. Observation conducted on during catheter care on 4/23/15 at 11:05 AM revealed the Foley catheter was not secured to the resident's thigh and tubing was not secured to the bed linen. Interview conducted on 4/23/15 at 12:15 PM with the Director of Nurses (DON) revealed the catheter should be anchored to the resident's thigh to prevent injury. Further interview with the DON conducted 4/23/15 at 3:06 PM revealed he had been unable to locate a… | 2018-10-01 |
| 5351 | 5351 | CARROLLTON MANOR, INCORPORATED | 115638 | 2455 OAK GROVE CHURCH ROAD | CARROLLTON | GA | 30117 | 2015-04-23 | 356 | B | 0 | 1 | X9OS11 | Based on observation and staff interview the facility failed to display nurse staffing data in a prominent place, readily accessible to residents and visitors. The facility census was ninety-seven (97) residents. Findings include: Observation on 4/20/15 at 9:40 AM, during the initial tour of the facility, revealed nurse staffing hours were not posted in a prominent location. A blank staffing form with the facility name was fastened to the bulletin board in the main lobby. No date or hours for any facility staff appeared on this form. Interview conducted on 4/23/15 at 9:41 AM with the facility administrator revealed a schedule with staff names, their work location, facility name and date is posted daily in the break room. The administrator indicated he was unaware staffing hours for facility staff needed to be posted in an area accessible to visitors and residents. | 2018-10-01 |
| 5352 | 5352 | LIFE CARE CENTER | 115654 | 176 LINCOLN AVE | FITZGERALD | GA | 31750 | 2015-02-12 | 161 | F | 0 | 1 | QWRE11 | Based upon record review and staff interview the facility failed to ensure the current Surety Bond was of an adequate amount to safeguard the resident Trust Funds for three (3) of the six (6) months reviewed. The total number of Trust Funds was one hundred and eighteen (118) and the Census was one hundred and twenty five (125). Findings include: Review of the facility Surety Bond revealed that the bond was for $40,000.00. Review of the Resident Trust Fund Account monthly balance revealed the following balance amounts: August 2014-Starting balance was $45,325.26 and the ending balance was $43,592.89 December 2014-Starting balance was $35,004.11 and the ending balance was $53,746.94 January (YEAR)-Starting balance was $53,746.94 and the ending balance was 40,412.60 An interview with the Business Manager, on 2/27/15 at 3:40 p.m., during the Quality Assurance review, revealed that the $40,000.00 Surety Bond is the only bond the facility has to cover the resident Trust Funds and they cannot explain why the balance exceeds the bond limit. | 2018-10-01 |
| 5353 | 5353 | LIFE CARE CENTER | 115654 | 176 LINCOLN AVE | FITZGERALD | GA | 31750 | 2015-02-12 | 167 | E | 0 | 1 | QWRE11 | Based on observation and interview with Resident B, the facility failed to ensure the results of the state inspection were available to read without asking. The census was 125. Findings: During an interview with Resident B on 2/12/15 he/she stated that the survey results were located in the front lobby under a piece of glass. During an interview on 2/12/15 at 10:15 a.m. the Administrator stated that the survey results are kept an office in the front lobby and the residents can ask for the book if they want to see the survey results. The Administrator confirmed that the survey results are not available and accessible without having to ask. | 2018-10-01 |
| 5354 | 5354 | LIFE CARE CENTER | 115654 | 176 LINCOLN AVE | FITZGERALD | GA | 31750 | 2015-02-12 | 253 | D | 0 | 1 | QWRE11 | Based on observation and interview the facility failed to maintain a clean environment on two (2) of four (4)halls. Findings include: Observation in room W1A on 2/09/15 at 1:44 p.m. revealed that the air conditioning unit vent cover had a heavy build up of dust/debris. Observation in room S17A on 2/10/15 at 10:45 a.m. revealed the wall beside the bed with brownish areas on the center of the wall. Observation in room W15B on 2/09/2015 at 2:20 p.m. revealed rust at the bottom of the door frame in the bathroom and the presence of a brown discoloration on the toilet paper roll sitting on the bathroom floor. Observation in room W12A on 2/9/15 at 1:58 p.m. revealed the heater/air conditioner unit was cracked at the top of the unit, the bathroom floor had wet area around the toilet on the floor and the baseboard was not attached to the wall in the bathroom. Observation in room W12A on 2/10/15 at 11:10 a.m. and on 2/12/15 at 8:15 a.m. revealed a gap in the flooring in the bathroom next to the wall and bathroom floor had a wet area around the toilet. During an interview and tour with the Maintenance Director on 2/12/15 at 1:30 p.m. he/she confirmed the above areas of concern. During an interview and tour with the Housekeeping Director on 2/12/15 at 2:00 p.m. he/ she confirmed the following concerns of room W12A the bathroom floor with liquid around the base of toilet and in room W15B the presence of brown discoloration on a toilet paper roll that was sitting on the bathroom floor. | 2018-10-01 |
| 5355 | 5355 | LIFE CARE CENTER | 115654 | 176 LINCOLN AVE | FITZGERALD | GA | 31750 | 2015-02-12 | 469 | E | 0 | 1 | QWRE11 | Based on observations and resident (A) interview the facility failed to maintain a pest free environment on three(3) of four (4) halls . Findings include: Observation on 2/10/2015 at 8:45 a.m. in room S1C revealed a roach was crawling up the door frame in the bathroom. Observation on 2/9/15 during the initial tour between 10:50 a.m. and 11:40 a.m. in room N13 a roach was observed crawling on the floor. Observation on 2/9/15 during the initial tour between 10:50 a.m. and 11:40 a.m. in room W 11 one (1) roach was observed crawling on the floor. Observation on 2/09/2015 at 1:58 p.m. in room W 12 A revealed a black insect crawling on the floor in the bedroom under the bed, a black insect was observed crawling in the bathroom on the wall and a black insect was observed crawling on the toilet seat. Observation on 2/10/2015 at 11:10 a.m. in room W 12 A revealed a black insect crawling on the floor in the bathroom. Observation on 2/12/2015 at 1:30 p.m. in room W 12A revealed two (2) insects were observed crawling under the bed. Observation on 2/12/15 at 2:00 p.m. in room W12A revealed that insects were crawling under the residents bed. Observation on 2/9/15 at 1:30 p.m. in room W 20 revealed two (2) roaches were crawling up the bathroom door. Observation on 2/11/2015 at 3:45 p.m. at the nurses station on the North wing revealed a small brown roach was observed crawling under the desk. During an interview on 2/10/2015 at 8:21 a.m. with resident A he/she stated that there was a roach problem and that he/she killed three (3) to five (5) roaches the night before. Resident A further stated that some were crawling up the wall, some were crawling on the floor and the building was bombed recently for roaches. On 2/12/2015 at 1:30 p.m. the Maintenance Director confirmed the presence of two (2) insects crawling under the bed in W12A. On 2/12/2015 at 2:00 p.m. the Housekeeping Director confirmed the presence of insects crawling under the residents bed in W12 A. The Ecolab Pest Elimination records were reviewed with the last service… | 2018-10-01 |
| 5356 | 5356 | VERO HEALTH AND REHAB OF WADLEY | 115679 | 10200 U.S. HWY 1 SOUTH | WADLEY | GA | 30477 | 2018-08-23 | 695 | D | 0 | 1 | VLTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record and facility data review, the facility failed to include a water drainage bag to a [MEDICAL CONDITION] collar set up for one resident (R) (#83) with a [MEDICAL CONDITION]. The sample size was 34 residents. Findings include: A record review reflects R#83 was admitted with a [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE], revealed the resident was severely cognitively impaired; was totally dependent on staff for all activities of daily living (ADLs); had active [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE]; in Section B documented the resident as comatose. Section O Special Treatments and Programs documented resident is receiving oxygen, suctioning and [MEDICAL CONDITION] care. A review of the care plan, initiated 5/11/18 related to [MEDICAL CONDITION] care, revealed that the resident had a [MEDICAL CONDITION] (a surgically created hole (stoma) in the windpipe (trachea) that provides an alternative airway for breathing. A [MEDICAL CONDITION] is inserted through the hole using an obturator as a guide and secured in place with a strap around the neck) related to impaired breathing due to an [MEDICAL CONDITIONS] and a vegetative state. The resident has oxygen therapy related to an [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Oxygen (02) saturations per order and as needed. Interventions dated 5/11/18 include: give humidified oxygen as prescribed. Review of the Physician Skilled Nursing Orders, dated 4/28/17, documents an order to clean [MEDICAL CONDITION] filters weekly on Thursday and to [MEDICAL CONDITION] each shift. To change the [MEDICAL CONDITION] cannula size #4 daily for secretions. Provide 02 via [MEDICAL CONDITION] (TC) at 28% FIO2 (Fraction of Inspired O2) continuously, suction [MEDICAL CONDITION] needed for excess secretions. Change [MEDICAL CONDITION] as needed, clean [MEDICAL CONDITION] with normal saline (NS), apply a dry gauze dressing and … | 2018-10-01 |
| 5357 | 5357 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2015-04-09 | 167 | B | 0 | 1 | TLR211 | Based on observations, resident and staff interviews, the facility failed to ensure that the most recent facility survey results were available and accessible to the residents. The facility census was fifty-six (56) residents. Findings include: During an initial tour and observation of the facility conducted 4/6/15 at 10.45 a.m. there was no evidence that any survey results were posted in the facility. An interview conducted on 4/8/15 at 4.04 p.m. with the resident X revealed she was not aware that the survey results were to be posted or where the survey would be located. An observation and interview with the Administrator on 4/8/15 at 4.28 p.m. revealed that no survey results were not posted/available in the facility. | 2018-10-01 |
| 5358 | 5358 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2015-04-09 | 253 | E | 0 | 1 | TLR211 | Based on observations, and staff interviews the facility failed to provide housekeeping and maintenance services to maintain a clean, and comfortable interior for three (3) of three (3) wings (North, South, and West). Findings include: During tour on North wing on 4/7/15 from 9:15am to 10:00am the following conditions were observed: Room 12 had four (4) twelve (12) by twelve (12) tiles in the room that were badly cracked and broken. Room 14 had had ten (10), twelve (12) by twelve (12) tiles at the sink area that were cracked, loose, and broken. The sink hot water handle would not shut completely off. The bathroom floor had a six (6) to eight (8) inch build up of a black substance around all baseboards. Room 17 the bathroom door way had twelve(12), four (4) by four (4) missing tiles. The adjoining bathroom door had a big irregular chunk of bare floor, and three (3) four (4) by four (4) tiles missing. Room 18 had a missing the wooden dowel that held the toilet paper. One (1) four (4) by four (4) tile was missing, other tiles were cracked on the bathroom floor. Bed 1 had a bed side table that had two (2) drawers that would not close. Bed 3 had a strip torn off of the over bed table. The closet doors were scraped with chipped paint. Room 21 there was no over bed, or bed side table present for bed 1. Bed 3 had soiled black smudges on the wall. Observation conducted on the South Hall with the Maintenance Director on 04/07/2015 at 10:50 AM revealed that in bathroom shared by rooms 6 and 8 the sink was full of water and would not drain. The Maintenance Director spoke to a Maintenance Assistant and requested the problem be corrected. A second observation conducted with the Maintenance Director on 04/09/2015 at 10:45 AM revealed that the bathroom sink, shared by rooms 6 and 8, remained full of water, not draining, water was dripping from under the sink on to the floor, and a towel on the floor under the sink was saturated with water. Observation conducted on 04/09/2015 at 2:06 PM on the North Hall with the Director of Nurs… | 2018-10-01 |
| 5359 | 5359 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2015-04-09 | 312 | D | 0 | 1 | TLR211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to ensure one (1) resident ('M') received baths according to schedule or as needed from a sample of twenty-eight (28) residents. Findings include: During an interview with resident 'M' on 4/7/15 at 10:10am he revealed he frequently did not get a bath, but felt they should be at least every other day. Resident observed to be unshaven, and 'M' further revealed that he preferred to be shaved, and did not want hair on his face. Interview with resident 'M' on 4/8/15 at 4:00pm revealed he did not have a shower yesterday or today. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] indicated the resident needed assistance of one (1) with bathing and personal hygiene. Review of the Care Plan dated 4/2/15 revealed the resident is care planned for self care deficit. Interventions are for showers as per schedule, and when ever necessary; and for staff to assistance with bathing, dressing, hygiene, and grooming as needed. Review of the Revised Bath Schedule, effective 11/3/14 indicated resident 'M' was scheduled for showers on Tuesdays, Thursdays, and Saturdays. Review of the monthly bathing schedules for showers that were completed as scheduled, revealed the following: January (YEAR) resident 'M' refused a shower four (4) days, was in the hospital three (3) days, there was no evidence for six (6) days, received a shower two (2) days, leaving sixteen (16) other days the resident should have received a shower. February (YEAR) resident 'M' refused a shower two (2) days, was in the hospital one (1) day, no evidence for seven (7) days, received a shower three (3) days, leaving fifteen (15) other days the resident should have received a shower. March (YEAR) resident 'M' refused a shower three (3) days, was in the hospital two (2) days, no evidence for seven (7) days, and received one (1) shower, leaving eighteen (18) other days the resident should have received a sho… | 2018-10-01 |
| 5360 | 5360 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2015-04-09 | 323 | D | 0 | 1 | TLR211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of facility's protocol, the facility failed to follow it's Neurological protocol for one (1) resident (#51) from a sample of twenty-eight (28) residents and failed to maintain safe hot water temperature for resident personal use in two (2) resident rooms ( 15 and 21 on North Hall) from twenty-two (22) resident rooms. Findings include: Record review for resident #51 revealed the resident was admitted [DATE] and was assessed as being a high risk for falls. Review of Nurses Notes indicated resident #51 fell on [DATE] while in her room. The resident's fall was unobserved and resulted in a one (1) centimeter (cm) laceration above her right eye (OD). Review of the Neurological Record revealed four (4) Neurological Assessments performed in the twenty-four (24) hour period following the fall. Further review revealed no evidence that any further Neurological Assessments were conducted. Interview conducted with the Director of Nurses (DON) on 04/08/2015 at 10:17 AM revealed that the facility policy for Neurological Assessments was that assessments are done for seventy-two (72) hours after a resident sustains a fall. She further revealed Neurological Assessments should have continued until 03/13/2015 at 6:00 AM, but were not continue after 03/11/2015 at 3:00 AM. Observations conducted on 04/07/2015 at 10:50 AM, with the facility maintenance director, using the facility temperature probe, on the North, South and West Halls revealed: North Hall Room 15 sink temperature was 120 degrees Fahrenheit (F) Room 21 sink temperature was 120 F. | 2018-10-01 |
| 5361 | 5361 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2015-04-09 | 441 | E | 0 | 1 | TLR211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to properly store personal care items for eleven (11) of nineteen (19) residents requiring the use of bedpans and urinals. The facility also failed to follow acceptable Infection Control Center for Disease Control (CDC) guidelines for two (2) of fifteen (15) Diabetic residents, (#2 and #11), requiring finger stick blood glucose monitoring. Findings include: 1. Observations of resident bathrooms conducted 04/07/2015 at 12:16 PM with the Director of Nursing (DON) revealed the following: North Hall Bathroom shared by rooms [ROOM NUMBERS]: Two (2) urinals were hanging on the hand rail beside toilet, one labeled with room and bed, but no label on the second. Neither were not in bags. Bathroom shared by rooms [ROOM NUMBERS]: One (1) unlabeled bedpan on the floor beside the toilet. South Hall Bathroom shared by rooms [ROOM NUMBERS]: One (1) unlabeled bedpan on the floor behind toilet. Bathroom shared by rooms [ROOM NUMBERS]: Two (2) unlabeled bedpans on the floor to left of toilet. West Hall Bathroom shared by rooms [ROOM NUMBERS]: One (1) unlabeled urine specimen hat in a bag on the floor beside toilet. Bathroom shared by rooms [ROOM NUMBERS]: One (1) unlabeled urinal on the floor in bag beside toilet. One (1) bedpan, unlabeled, in bag, on the floor beside toilet. Review of facility policy for Bedpans/Urinals revealed that bedpans and urinals are not to be left in the bathroom or on the floor. 2. Observation conducted 04/08/2015 at 11:32 AM revealed Licensed Practical Nurse (LPN) BB cleaned one (1) of two (2) glucometers on the medication cart with alcohol after performing the finger stick blood sugar on resident #11. The glucometer was left to air dry. Observation on 04/08/2015 at 4:37 PM Licensed Practical Nurse (LPN) DD cleaned one (1) of two (2) glucometers on the medication cart before and after performing a finger stick blood glucose on resident #3, with alcohol pad… | 2018-10-01 |
| 5362 | 5362 | PEBBLEBROOK HEALTH CENTER AT PARK SPRINGS | 115694 | 5610 NEW BERMUDA ROAD | STONE MOUNTAIN | GA | 30087 | 2015-01-22 | 328 | D | 0 | 1 | KE3111 | Based on observations, staff and resident interviews and review of facility policy for Oxygen Safety and Procedure of Nebulizer Treatment, the facility failed to store one (1) nebulizer correctly, and properly maintain two (2) oxygen concentrators from a sample of six (6) residents receiving Respiratory Therapy. Findings include: On 01/20/15 at 09:30 a.m., resident 'A' was observed with an air compressor for his nebulizer treatment stored on his bedside chair. Attached to the air compressor was his nebulizer stored in a plastic bag dated 01/04/15 with liquid inside the nebulizer cup. Interview with the resident, at the time of the observation, revealed that he received treatments several timer per day and after each treatment the nurse removed the nebulizer and stored it in the bag. On 01/20/15 at 9:45 a.m., resident 'B' was observed sitting in his wheelchair wearing an oxygen cannula. The oxygen concentrator had a humidifier bottle on it that was dated 11/20/2014. Interview with the resident, at the time of the observation, revealed that he used his oxygen all the time. Observation of resident C on 01/20/15 at 10:40 a.m. revealed that the oxygen concentrator in the room had a filter that contained a thick coating of gray dust which would impede air flow into the machine, and the humidifier bottle was not dated. Interview on 01/20/15 at 11:15 a.m. with Licensed Practical Nurse (LPN) AA revealed that nebulizers should not be stored on the bedside chairs. Proper storage would be on the bedside table. She also revealed that the nebulizer should be changed weekly and always be cleaned after use and stored with no liquid in it. AA also indicated that humidifier bottles on oxygen concentrators should be changed every seven (7) days and filters cleaned. Review of the facility procedure for Nebulizer Treatment indicated that after each treatment, the nebulizer should be taken apart, washed, dried and then stored. All equipment should be changed out every seven (7) days, and stored in a bag with the date on it. Review of … | 2018-10-01 |
| 5363 | 5363 | PEBBLEBROOK HEALTH CENTER AT PARK SPRINGS | 115694 | 5610 NEW BERMUDA ROAD | STONE MOUNTAIN | GA | 30087 | 2015-01-22 | 371 | E | 0 | 1 | KE3111 | Based on observations, staff interview, and review of facility policies for food storage, and hair net use, the facility failed to properly store and prepare food. The facility census was thirty eight (38) residents. Findings include: Observations of the kitchen on 01/20/15 at 8 a.m. with the Kitchen Manager revealed ham slices in the freezer wrapped in Saran Wrap dated 12/31/14 with signs of freezer burn and ice crystals. The Kitchen Manager reported that any food with freezer burn should be discarded. Observation of the refrigerator revealed buttermilk ranch dressing dated 11/04/14, reconstituted lemon juice dated 11/27/14, chicken base dated 11/27/14, and an open tartar sauce dated 01/02/15. The Kitchen Manager reported that all of the items should have been discarded per their policy. Continued observation of the kitchen with the Kitchen Manager on 01/20/15 at 8:20 a.m., revealed three (3) Food/Beverage staff were observed in the kitchen distributing food with their hair nets covering a portion of their hair. These Food/Beverage Servers were all observed with their bangs exposed and uncovered by their hair nets, all three (3) were observed having direct contact with the food in the kitchen, and serving it to the eight (8) residents in the dining room. Interview with the Dietary Manager on 01/21/15 at 10:30 a.m. revealed that all of the items found in the freezer and refrigerator should have been discarded, and that staff should not have any hair that is greater than one (1) inch uncovered. Review of the facility policy for Discard of Food Items dated 01/2014 revealed that all foods will be discarded within three (3) days of preparation date and/or opened with the exception of shelf stable foods. Review of the facility policy Food Storage dated 01/2013 revealed that any signs of freezer burn or foods re-frozen will be thrown out. Review of the facility policy for hair net use dated 04/2009 revealed that food service employees with hair greater than one (1) inch must wear either a hair net or hair covering. | 2018-10-01 |
| 5364 | 5364 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2014-11-13 | 241 | D | 0 | 1 | XGJP11 | Based on observations and staff interview, the facility failed to promote care in a manner that maintained dignity for one (1) resident (#26) and a random observation of two (2) other residents for a total of three (3) residents with indwelling catheters from thirty five (35) sampled residents. Findings include: Observations of resident #26 on 11/11/14 at 1:56 p.m. and at 3:50 p.m., on 11/12/14 at 7:10 a.m., 10:05 a.m., 2:01 p.m. and 3:55 p.m. and on 11/13/14 at 7:10 a.m. revealed that the resident did not have a dignity bag covering the catheter bag. During a random observations on 11/13/14 at 9:50 a.m. of the other two (2) residents in the facility with indwelling catheters revealed their drainage bags were not in a dignity bag. An interview on 11/13/14 at 2:45 p.m. with the Director of Nursing revealed that staff are to use dignity bags for all residents with indwelling catheters. She further stated that if the facility runs out of dignity bags then staff can use a pillow case to cover the drainage bags. She confirmed that there were dignity bags in the store room and the she did not know why staff had not used one for resident #26's drainage bag or the other two residents with indwelling catheters. | 2018-10-01 |
| 5365 | 5365 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2014-11-13 | 281 | D | 0 | 1 | XGJP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Nursing Standards of the Practice for License Practical Nursing (LPN) and staff interviews, facility failed to ensure that physician orders [REDACTED].#22 and #38) from a total sample of twenty-eight (28). Findings include: 1.) Resident #22 was admitted to the facility in (MONTH) 2008 with a [DIAGNOSES REDACTED]. Review of the (MONTH) 2014 Physician Medication Orders revealed and order for Accucheck's three times a day (TID) before meals (AC) with a [MEDICATION NAME] Insulin Sliding Scale coverage of the following: 0-100:0, 101-150: 1 unit (u), 151-200: 3u, 201-250: 6u, 251-300: 9u, 301-350: 11u, 351-400: 13u and 400: 15u. Review of the Physician order [REDACTED]. Interview with the Director of Nursing (DON) on 11/12/14 at 4:45 p.m., revealed that the nurse did not clarify the returning order to the facility on [DATE], and used the pre-printed Medication Administration Records (MAR's) from the pharmacy, which did clarify the dosage and units to be given; however, for (MONTH) 2014, there was no clarification. 2.) Resident #38 was admitted to the facility in (MONTH) 2010 with [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Further review reveals a Physician order [REDACTED]. Review of the (MONTH) 2014 Medication Administration Record [REDACTED]. An interview with Licensed Practical Nurse (LPN) BB on 11/12/14 at 3:50 p.m. revealed that a verbal order from the physician was taken although the order was not transferred to the physician order [REDACTED]. Interview with the DON on 11/12/14 at 5:10 p.m., confirmed that the [MEDICATION NAME]/Atrovent is listed as every six (6) hours while awake for the Nebulizer treatment although she could not confirm there was a physician's orders [REDACTED]. Review of the Standard of Nursing Practice for License Practical Nurse (LPN) under Section 2 LP/VN # E. Seeks clarification of orders when needed. Cross refer to F309 | 2018-10-01 |
| 5366 | 5366 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2014-11-13 | 282 | E | 0 | 1 | XGJP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility failed to follow the care plan related to diabetic medication for three (3) resident (#22, #11 and #43) from a total sample of twenty-eight (28) residents. Findings include: 1.) Resident #22 was admitted to the facility in (MONTH) 2008 with a [DIAGNOSES REDACTED]. Review of the care plan dated 9/25/14 revealed that resident #22 has DM with an intervention of diabetes medication as ordered by doctor, and to monitor/document for side effects and effectiveness. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that in the last seven (7) days the resident has taken insulin. Review of the (MONTH) 2014 Physician Medication Orders revealed Accuchecks three times a day (TID) before meals (AC) with a [MEDICATION NAME] Insulin Sliding Scale of the following: 0-100:0, 101-150: 1 unit (u), 151-200: 3u, 201-250: 6u, 251-300: 9u, 301-350: 11u, 351-400: 13u and 400: 15u. Review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 11/12/14 at 4:45 p.m., confirmed that the resident's care plan was not followed when the nurses did not give the sliding scale as ordered. 2.) Resident #43 was admitted to the facility in (MONTH) 2012 with a [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED]. The resident was not receiving the correct dosage of insulin mulitple times in (MONTH) 2014. Review of the care plan dated 9/24/14 revealed that resident #43 has DM with an intervention of diabetes medication as ordered by doctor, and to monitor/document for side effects and effectiveness. 3. Resident #11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. Review of the care plan dated 9/22/14 revealed an intervention for staff to administer diabetic medication as ordered. However, review of the November, (MONTH) and (MONTH) 2014 MARS revealed several times that nursing staff… | 2018-10-01 |
| 5367 | 5367 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2014-11-13 | 309 | E | 0 | 1 | XGJP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to administer insulin as ordered for ten (10) resident (#11, #69, #68, #22, #43,#12,#31,#36,#5,#33 ) f thirty five (35) sampled residents. Findings include: 1. Resident #11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. The formula for nursing staff to follow was the blood sugar minus 100 and then divided by 30 equals the number of units of insulin to be administered. However, during review of the resident's Medication Administration Records (MAR)s revealed that nursing staff failed to administer the correct amount of insulin in (MONTH) 2014 for 18 out of 48 times, in (MONTH) 2014 for 36 of 124 times and in (MONTH) 2014 for 30 of 89 times. 2. Resident # 69 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. The formula for nursing staff to follow was the blood sugar minus 100 and then divided by 30 equals the number of units of insulin to be administered. However, during review of the resident's Medication Administration Records (MAR)s revealed that nursing staff failed to administer the correct amount of insulin in (MONTH) 2014 for 18 times out of 37 times. 3. Resident #68 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. The formula for nursing staff to follow was the blood sugar minus 100 and then divided by 30 equals the number of units of insulin to be administered. However, during review of the resident's Medication Administration Records (MAR)s revealed that nursing staff failed to administer the correct amount of insulin in (MONTH) 2014 for 5 times out of 50 times. During an interview with the Director of Nursing (DON) on 11/13/14 at 3:35 p.m., she confirmed the nursing staff failed to administer the correct amount of insulin on the above times. 4. Resident #12 was admitted to facility 5/28/1… | 2018-10-01 |
| 5368 | 5368 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2014-11-13 | 332 | E | 0 | 1 | XGJP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews,and staff interviews the facility failed to maintain a medication error rate of (5) percent % or less on one (1) of two (2) halls, by two (2) of three (3) nurses, and with twenty-seven (27) opportunities,resulting in two (2) errors. The medication error rate was 7.4%. Findings Include: 1. Observation during medication administration on 11/12/14 at 11:20 a.m. with Licensed Practical Nurse (LPN) CC revealed her giving Resident #15, [MEDICATION NAME] [MEDICATION NAME] 440 milligrams (mg) and [MEDICATION NAME] 100 mg two (2) capsules opened and the administration of four hundred (400) milliliters (ml) of water via enteral feeding tube. Review of resident #15's physician's order dated 12/5/14 revealed there was no physician's order for the four hundred (400)ml of water via enteral feeding tube. Review of the Enteral Sheet for (MONTH) 2014, revealed documentation the resident had been receiving four hundred (400) ml of water four (4) times a day since 11/1/14. During an interview with Director of Nurses (DON) on 11/12/14 at 12:05 p.m. confirmed that the order for four hundred (400) ml of water was discontinued on 12/5/13. The order was not discontinued on the (MONTH) 2014 Enteral Sheet. 2. Observation during medication administration on 11/12/14 at 3:34 p.m. revealed Licensed Practical Nurse (LPN) DD giving Resident #6, [MEDICATION NAME] three (3) fifty (50) milligrams (mg) tablets crushed in applesauce. Review of Resident #6's Physician Orders dated 10/30/14 revealed to give [MEDICATION NAME] one hundred and fifty (150) mg by mouth twice a day. Review of the (MONTH) 2014 Medication Administration Record [REDACTED]. During an interview with Assistance Director of Nurses (ADON) on 11/12/2014 4:27 p.m. confirmed that the order for [MEDICATION NAME] one hundred and fifty (150) mg by mouth twice day that was written on 10/30/14 was not transcribed correctly to the (MONTH) 2014 MAR. The ADON confirmed that the resid… | 2018-10-01 |
| 5369 | 5369 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2014-11-13 | 371 | F | 0 | 1 | XGJP11 | Based on observations, facility policy review, review of the trayline temperature record, review of the weekly cleanup duties, review of facility work order and staff interviews, facility failed to maintain holding temperature for cold food to prevent a potential forborne illness, and failed to ensure that the dishes, which were being washed at the 3-compartment sink, were being dried in a sanitary condition. The total census was fifty-nine (59) with eight (8) tube feeders. Findings include: During the kitchen tour observation on 11/12/14 between 11:08 a.m.-11:27 a.m., revealed that the 3-compartment sink staff was observed stacking three (3) long pans in the front, two (2) short pans to the left and right sides, and two (2) muffin pans in the back, all were nesting together wet at the end of the 3-comparent sink to the left of the sanitizing bin. During the observation of the tray line temperatures, which were taken with Cook AA, on 11/12/14 between 11:28 a.m.-11:55 a.m., revealed that the mixed fruit was at 65.1. There was twelve (12) fixed in small clear plastic bowls and placed on a metal sheet tray to the left of the tray line; however, none had been placed on any of the five (5) already fixed trays. Interview with the Cook AA on 11/12/14 between 11:28 a.m.-11:55 a.m., while taking the tray line temperatures, she revealed that the fruit should be at 40 or below; however, did not remove the fruit and/or place the fruit on ice. During interview with the Dietary Manager (DM) at 11:57 a.m. on 11/12/14, he removed the fruit from the tray line after he was made aware of the concerns in the kitchen by the surveyor, not by the staff. Continued interview he revealed that the fruit should be at 40 or below, and the pans should not be drying wet, they should be spread out to dry. During kitchen tour on 11/13/14 between 8:15 a.m.-8:25 a.m., revealed ten (10) long metal sheet pans stacked on top of each other at the end of the 3-compartment sink, which all were wet, the microwave had green flakes of unknown substance on … | 2018-10-01 |
| 5370 | 5370 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2014-11-13 | 441 | D | 0 | 1 | XGJP11 | Based on observations, record review, facility policy review and staff interviews, facility failed to ensure that kitchen staff washed hands appropriately to prevent possible cross contamination, failed to ensure that one resident (#38) had a nebulizer mask stored accordingly to prevent possible contamination. The census was fifty nine (59) with eight (8) residents on tube feedings. Findings include: 1.) During the initial observational kitchen tour on 11/10/14 at 11:15 a.m., revealed that the three (3) compartment sink staff was washing his hands and was observed turning the left handle of the sink off after he was finished washing and rinsing his hands, he then pulled down the paper towel to dry his hands, and threw away the paper towel. During a kitchen observational tour on 11/12/14 between 11:08 a.m.-11:27 a.m., revealed that the 3-compartment sink staff was washing his hands and was observed turning the left handle of the sink off after washing and rinsing his hands, then pulling on the paper towel rack to dry his hands, and then threw away the paper towel. Interview with the Dietary Manager (DM) on 11/12/14 at 11:57 a.m., revealed that when staff are washing their hands, they should sing the birthday song however, they should wash and rinse their hands and turn off the faucet with a paper towel. Review of the Policy for Sanitation and Infection Control: Hand Hygiene dated 5/95 with revision date of 1/14 revealed that staff should use a paper towel to turn off the faucet to avoid contact with faucet germs. Review of Infection Control Attendance Verification Sheet dated (MONTH) 2014 revealed an inservice on Infection Control: Protecting Ourselves and Others (Personal Protection Equipment-PPE). | 2018-10-01 |
| 5371 | 5371 | OAKS HEALTH CTR AT THE MARSHES OF SKIDAWAY ISLAND | 115715 | 95 SKIDAWAY ISLAND PARK ROAD | SAVANNAH | GA | 31411 | 2015-02-05 | 329 | D | 0 | 1 | LJ4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and staff interviews, the facility failed to monitor for potential side effects for one (1) of two (2) residents (#5) receiving an Antipsychotic medication from a sample of seventeen (17) residents. Findings include: Resident #5 was admitted to the facility on (MONTH) 1st, 2013 with [DIAGNOSES REDACTED]. Review of (MONTH) (YEAR) physician orders [REDACTED]. (an Antipsychotic) 25 milligrams (mg) daily. Review of the Electronic Medical Record (EMR) for resident #5 revealed no evidence of monitoring for potential side effects of an Antipsychotic medication. Interview with the Assistant Director of Nursing (ADON) on 2/3/15 at 3:50 p.m. revealed that there was no form in the EMR for monitoring potential side effects of Antipsychotic medications. Interview with the Director of Nursing (DON) on 2/4/15 at 1:00 p.m. confirmed that there was no consistent monitoring for potential side effects of an Antipsychotic medication performed for resident #5. Interview on 2/4/15 at 1:45 p.m. with the ADON confirmed no consistent monitoring for potential side effects of an Antipsychotic medication was conducted for resident #5. The ADON, who is also the Minimum Data Set (MDS) coordinator, stated that Abnormal Involuntary Movement Scale ( AIMS ) were conducted on 1/3/14, 3/7/14, 4/22/14, 7/22/14, and 2/3/15 on resident #5. On 2/5/15 at 8:35 a.m. the ADON produced a facility policy on Antipsychotic Medication Use which stated in #14 of the Policy Interpretation and Implementation that Nursing staff shall monitor and report any of the following side effects to the Attending Physician: Sedation, Orthostatic [MEDICAL CONDITION], Lightheadedness, Dry mouth, Blurred vision, Constipation, [MEDICAL CONDITION], Increased psychotic symptoms ([MEDICATION NAME]), Extrapyramidal effects, Akathisia, [DIAGNOSES REDACTED], Tremor,Rigidity,Akinesia, or tardive dyskinesia. | 2018-10-01 |
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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 );