cms_GA
Data source: Big Local News · About: big-local-datasette
140 rows where "filedate" is on date 2019-11-01
This data as json, copyable, CSV (advanced)
Suggested facets: inspection_date (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4289 | 4289 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2016-03-10 | 371 | F | 0 | 1 | JQUV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, it was determined that the facility staff failed to ensure opened food items were securely wrapped, labeled, and dated in the dry storage area and walk-in freezer. This deficient practice had the potential to effect one hundred and fifty seven (157) residents receiving an oral diet. Findings include: Observation on 03/7/16 at 12:16 p.m. of the dry storage area revealed 3-2Lbs 3ounce bags of frosted flakes cereal out of shipping box on four tier dry storage food shelve with no expiration date visible on food product. Observation on 3/7/16 at 12:18 p.m. observed 1-25 pound bag of Sweet Onion Hush Puppy mix by House-Autry opened on dry storage food shelve without visible date of opening on this dry food product. Observation on 3/7/16 at 12:20 p.m. observed opened 1-10 pound bag of Barilla [MEDICATION NAME] Macaroni wrapped in plastic with no opening date visible on this food product. Observation on 3/7/16 at 12:30 p.m. observed on FIFO (first in first out) can rack 1-8 pound dented can of Grape Jelly by West Creek placed on FIFO can rack for facility use. On same FIFO storage rack observed 1-6 pound 12 ounce dented can of Rice Pudding by GFS. Observation on 3/7/16 at 12:35 p.m. observe 1-20 pound opened box of Green Split Peas with all of food product exposed to open room air with no open date or no visible plastic covering of food product. Observation on 03/7/16 at 12:45 p.m. in walk-in freezer revealed 1-2 pound 8ounce bag of opened Fry and Serve Hash Puppies on top freeze shelves with no visible opening date. Observation on 3/7/16 at 1:35 a.m. during interview with kitchen manager on food storage policies stated all employees must date any and all opened food products before storing on food shelves. On 3/7/16 at 12:05 p.m. during kitchen tour which kitchen manager accompanied surveyor during inspection and verified all food storage finding and concerns. Facility staff must ensure that all food products… | 2019-11-01 |
| 4290 | 4290 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2016-03-10 | 431 | E | 0 | 1 | JQUV11 | Based on observations and staff interview the facility failed to provide expired floor stock medication was removed from the medication storage room from one (1) out of two (2) storage rooms and one out of four (4) medication cart. Findings include: Review of the facility policy and procedure for expired medications revealed the unit secretary will check medication rooms monthly for expired floor stock or any other expired items within the medication room. Medications are then removed from the facility. Observation on 3/9/16 at 12:11 p.m. of the A hall cart floor stock storage draw revealed an opened bottle of ferrosol liquid with an expiration date of 10/15 confirmation of expired date by the A hall nursing supervisor. Observation on 3/10/16 at 2:20 p.m. of one of the medication storage rooms that cover the A, B, C, and D hall revealed two (2) bottles of magnesium expired on 4/15, lactaid lactase enzyme tablets expired on 8/14 and one expired on 10/15, four (4) bottles of pro-stat liquid supplement bottles expired on 12/16/15. Staff interview on 3/10/16 with BB revealed that the bottled medications were expired and should be checked monthly and removed by the service coordinator assigned. Staff interview on 3/10/16 with CC service coordinator revealed that she and another coordinator checks the medication storage rooms and removes all expired floor stock medications by placing them in the bin for expired medications. Review of the pro-stat medications revealed that she was not sure if they were expired accounting to the way they were dated. | 2019-11-01 |
| 4291 | 4291 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2016-03-10 | 441 | D | 0 | 1 | JQUV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and resident observation during lunch dining service. It was determined that staff failed to follow infection control practices effecting for resident (#111) and resident (#120). This was evident for 2 out of 72 residents during stage 1 of survey process. Findings include: 03/08/2016 1:12:51 PM -Surveyor observed staff member #AA Certified Nursing Assistant during lunch service in dining room [ROOM NUMBER] bare hand touching resident #120 chopped meat sandwich. After surveyor intervention observed staff member #DD discarded the contaminated sandwich and replace it with a new one. This was verified with another surveyor and facility staff. 03/08/2016 1:13 PM-Interview with staff member #AA reveals staff member #AA discarded the sandwich and replaced it with a new sandwich from the kitchen. On 3/8/16 at 1:00 p.m. observed in dining room [ROOM NUMBER] observed staff member #DD touching resident (#111) ham sandwich with their bare hands. After surveyor intervention observed staff member #DD discarded the contaminated sandwich and replace it with a new one. On 3/10/16 at 10:36 a.m. during interview with infection control nurse and review of infection control handwashing policy verified that all staff members are in-service on handwashing when assisting residents during meal services. Facility must ensure all staff member continue to practice infection control standard during residents meal service. | 2019-11-01 |
| 4292 | 4292 | MILLER NURSING HOME | 115039 | 206 GRACE ST | COLQUITT | GA | 39837 | 2015-08-27 | 323 | D | 0 | 1 | TVFN11 | Based on observations, staff interview and facility water temperature monitoring tool the facility failed to maintain safe water temperature for four (4) residents rooms in two(2) of (3) three halls and one (1) of two (2) resident's shower areas. Findings include: During environmental tour of the facility with Maintenance Director conducted 08-24-15 at 10:30 a.m. using facility thermometer the following rooms were identified with water temperatures of 120 degree or above Fahrenheit(F): Room #19 - 128.5 degrees F; Room #2 - 120 degrees F; Room # 7 -122 degrees F; Room #15 - 122 degrees F; Lady's shower room - 125.2 degrees F; these temperatures were confirmed by the Director of Maintenance. Interview with Maintenance Director on 8-24-15 at 10:30 AM revealed he/she was aware the guideline for federal water temperature should be above 120 degrees. Review of Hot Water Tank temperature Check for Station 1 and Station 2 revealed that the water temperature in some instances over 120 degrees. | 2019-11-01 |
| 4293 | 4293 | MILLER NURSING HOME | 115039 | 206 GRACE ST | COLQUITT | GA | 39837 | 2016-12-02 | 159 | D | 1 | 0 | 4JJD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure liability statements were mailed each month with the balance due indicated to include any past due amounts for one (1) resident (R#4) and failed ensure that resident personal trust funds were disbursed within thirty (30) days of death for one (1) resident (R#9). The sample size was 3 residents. Findings Include: Review of resident a personal allowance account statement dated [DATE] revealed R#4 died on [DATE] and had a personal liability remaining of 1099.00-. Review of the facility general fund account invoice ,[DATE] revealed the 990.21 Trust Fund Account balance for R#4 was paid to the county hospital General Fund on [DATE]. During an interview on [DATE] at 8:15 a.m., the Nursing Home Office Director revealed the facility never sent any liability statements to the R#4 ' s responsible party and it was simply an oversight. During an interview on [DATE] at 9:10 a.m., T revealed she never received a liability statement from the facility for R#4 ' s account. Review of the resident liability statement policy dated [DATE] and revised [DATE] revealed, If check not routed to the Facility, then resident liability statements are mailed at the end of each month with the balance due indicated to include any past due amounts if applicable. 2. Review of Invoice ,[DATE] dated [DATE] revealed 79.22 was paid by check to R#9's Power of Attorney (POA) on [DATE]. Review of R#9's face sheet revealed she expired on [DATE] During an interview on [DATE] at 10:58 a.m., the Nursing Home Office Director revealed she delayed processing the trust fund refund for R#9 out of caution while she verified the mailing address. She added, she should have verified the POA address at the time of notification of death or discharge and that in hindsight, it should have been done differently. Review of the trust fund disbursement policy dated [DATE] and revised [DATE] revealed the policy is to ensure the re… | 2019-11-01 |
| 4294 | 4294 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2016-06-03 | 159 | D | 0 | 1 | Y7LY11 | Based on record review, resident, family and staff interviews the facility failed to provide quarterly account statements for five (5) residents from a sample of thirty four (34). Findings include: Interview on 6/1/16 at 8:18 a.m. with resident #59s representative for financial decisions stated that they have never received a statement from the facility. Further interview revealed that he/she have called and they would tell them over the phone how much was in the resident's account. Interview on 6/1/16 at 9:56 a.m. with resident #109s representative for financial decisions stated that they have never received an account statement. Interview on 6/1/16 at 8:17 a.m. with resident #21 stated that the facility does not let her know how much money she has in her account. Interview on 5/31/16 at 3:59 p.m. with resident #99s representative for financial decisions stated that he/she has not seen a statement in six (6) months. Interview on 5/31/16 at 5:13 p.m. with resident #111 stated that the facility does not let him/her know what their account balance is and he/she has never received a statement. Interview on 6/2/16 at 2:18 p.m. with the Resident Trust Book Keeper stated that the filing system was changed in (MONTH) (YEAR) and also stated that a balance report is provided to the switch board operator on duty and each resident that has a balance can sign for money if available and that no bank statements mailed out had been returned. | 2019-11-01 |
| 4295 | 4295 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2016-06-03 | 225 | E | 0 | 1 | Y7LY11 | Based on observation, interview and record review the facility failed to report initial findings and final investigation findings in a timely manner for three (3) out of three (3) reportable incidents. Findings include: Review of the Abuse Prohibition reporting and investigation Policy stated that the initial report would be filed immediately (within 24 hours of discovery), defined what the investigative report would contain, and that a written report of investigation would be submitted within five (5) working days to the State Office. Review of three (3) reportable incidents for resident #111, #92, and #105 revealed the following: 1) Review of the reportable incident for Resident #92. The date of the Incident was 5/4/16, Wednesday. The Initial Investigation was done on 5/9/16, Monday. The investigation revealed that Resident #92 chased Resident #116 out of her room. The final investigation was faxed to the State Agency on 5/16/16 however, it was due on 5/11/16. 2) Review of the reportable incident for Resident #105. The date of the incident was 4/22/16, Friday. The initial investigation was done on 4/26/16, Tuesday and it was due on 4/25/16. The final investigation was faxed to the State Agency on 5/3/16 however, it was due 4/28/16. 3) Review of the reportable incident for Resident #111. The date of the incident was 3/17/16. The initial investigation was on 3/18/16. The final investigation was faxed to the State Agency on 3/25/16 however, it was due on 3/24/16. Interview on 06/03/2016 at 11:26 a.m. with the Director of Nursing (DON) revealed that she thought she had two hours from the time that an incident was reported to her to report it to the state. The DON revealed that she understood that she had 5 working days from the time of the initial investigation to send in the findings for the final investigation. Interview on 06/02/2016 at 11:30 a.m. with LPN, FF, Unit Manager revealed she would report an incident to the (DON) and Social Services and she then files an incident report. If there was an incident of st… | 2019-11-01 |
| 4296 | 4296 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2016-06-03 | 241 | D | 0 | 1 | Y7LY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: Observation on 06/02/2016 at 7:58 a.m. and on 6/3/16 at 12:55 p.m. in the dining room on the Secured Unit, resident #10 was observed with his/her chin level with the table. Review of resident #10's medical record listed [DIAGNOSES REDACTED]. The 3/3/16 annual (MDS) coded resident #10 with a Brief Interview for Mental Status (BIMS) summary score of 02 which indicated severe cognitive impairment. Review of the Care plan for resident # 10 did not document an intervention for resident #10 to be seated at chin height at the dining table . Observation on 06/02/2016 at 7:58 a.m. and on 6/3/16 at 12:55 p.m. in the dining room on the Secure Unit, resident #52 was observed with his/her chin level with the table and he/she was holding the left arm with his/her right hand in order to feed his/herself. The resident scooped the food straight into his/her mouth from the plate. Review of resident #52's medical record listed [DIAGNOSES REDACTED]. Review of the 4/4/16 annual Minimum Data Set (MDS) for resident #52 coded a Brief Interview for Mental Status (BIMS) of 00 indicating severe cognitive impairment. Review of the Care plan for resident #52 did not document an intervention for the resident to be seated at chin height at the dining table . Observation and Interview on 06/03/2016 at 5:08 p.m. with the Director of Nursing (DON) confirmed that both resident #10 and #52 were seated at chin height at the dining table. During further interview on 6/3/16 at 5:32 p.m., the DON stated that new tables had recently been purchased and he/she had not realized that the tables were to tall for some of the residents. Based on observation, record review and staff interview, the facility failed to maintain dignity for three (3) residents (#75,#97 and #2 ) by failing to knock and await a response before entering residents rooms and for two (2) residents (#10 and #52) by failing to provide dining tables at appropriate height from a census sample of thirty four (34… | 2019-11-01 |
| 4297 | 4297 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2016-06-03 | 441 | D | 0 | 1 | Y7LY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings Include Observation of sacral wound care treatment for [REDACTED]. Revealed LPN AA removed scissors from his uniform pocket to cut the foam wound packing that was placed into the resident's sacral wound and then place the scissors back into uniform pocket. LPN AA then removed the scissors again from uniform pocket and cut the adhesive strips that was placed around the sacral wound and then placed scissors back into the uniform pocket. Review of resident # 9 revealed a healing stage four and a physician order [REDACTED]. Review of Wound Care/Treatment guidelines revealed supplies should be placed on a clean surface. Interview with LPN AA on 06/3/16 at 07:35 a.m. stated that the scissors were in their uniform pocket at the beginning of the wound care and throughout the wound care. Then stated that they put the scissors back into my pocket after using for treatment and stated that they always keep the sisscors in their pocket. Interview with the Director of Nurse's (DON) on 06/03/2016 3:52 p.m. revealed that I would expect LPN AA to keep the scissors clean and not put in the uniform pocket. I expect the nurse to keep the scissors clean during the wound care treatment. 2. Review on 06/03/2016 at 5:53 p.m. of Infection Control Surveillance sheets revealed that the different types of infections in the facility were being monitored however, the line listing from 03/2015 through 09/2015 was not available and the break down of infections by units was not available from 03/2015 to 05/2015. Interview on 06/03/2016 at 6:05 p.m. with the Infection Control Nurse revealed that she had documentation of each individual with an infection and how it was treated and the monitoring of the trending on the units. Further interview revealed that the previous Infection Control Nurse left the job due to illness. The current Infection Control Nurse stated that she was hired for the job in December, (YEAR) and started working on Infection Control in January, (Y… | 2019-11-01 |
| 4298 | 4298 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2016-06-03 | 514 | D | 0 | 1 | Y7LY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure clinical records were complete and accurately documented for one resident #9 for Negative Pressure Wound Treatment setting (NPTW). The Census sample size was thirty-four (34) residents. Findings include: Review of resident's #9 clinical record revealed a healing stage four pressure ulcer to the sacrum. Further review of the clinical record revealed a Physician order [REDACTED]. - An observation of the pressure ulcer treatment on resident #9 on 6/2/16 at 09:40 a.m. by two (2) Licensed Practical Nurse's (LPN) AA and BB revealed LPN AA place the setting on the Genadyne XLR8 [DEVICE] System at 125 millimeter of Mercury (mmHg). LPN AA stated this was a general setting that the wound care Physician wanted for his residents and this was the only setting he was aware of and it was a standing order. Interview with the Wound Care Physician by telephone on 6/3/16 at 08:55 a.m. revealed that the [DEVICE] setting was a general communicated rule for a setting at 125 mmHg and would write an addendum for the resident #9 to clarify the order. Interview with the Administrator on 06/03/2016 at 3:27 p.m. revealed the only information on the Genadyne XLR8 [DEVICE] System was printed information from the product's web site. The Administrator revealed that was no policy or procedure regarding the [DEVICE] system. Interview with the Director of Nurse's (DON) on 06/03/2016 6:22 p.m. revealed that we do not have a policy for NPWT and we go by the doctors orders for the [DEVICE] setting. During the interview the DON confirmed that no order or standing order was written for the NPWT setting until surveyor inquired. | 2019-11-01 |
| 4299 | 4299 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2016-11-07 | 157 | J | 1 | 0 | HU6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility's Medication Discrepancy/Errors Guideline and staff interview, it was determined that the facility failed to notify the physician and responsible party that a Licensed Practical Nurse (LPN) had administered an incorrect dose of [MEDICATION NAME] to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/16, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that the medication error should be reported to the Director of Nursing (DON) or acting supervisor immediately and the physician promptly. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her fasting blood sugar level (FSBS) was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. She was discharged back to the facility on [DATE]. Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of I… | 2019-11-01 |
| 4300 | 4300 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2016-11-07 | 281 | J | 1 | 0 | HU6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility's Orientation Policy, review of the facility's Medication Discrepancies/Errors Procedural Guidelines, review of the National Council of State Boards of Nursing, Georgia Practical Nurses Practice Act (Chapter 410-10) and interview, it was determined that the facility failed to ensure that services provided met professional standards. The facility failed to ensure that licensed nursing staff administered Insulin correctly and safely to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Orientation Period policy revealed that the first three (3) calendar months of employment was considered an orientation period for newly hired employees. Continued review revealed that During this time the associate's job performance should be observed by the supervisor. Review of the facility's Medication Discrepancy/Errors Procedural Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in th… | 2019-11-01 |
| 4301 | 4301 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2016-11-07 | 282 | J | 1 | 0 | HU6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to follow the care plan to administer insulin as ordered by the physician for one (1) Resident (R) (R10) of six (6) residents reviewed for insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer insulin as ordered. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that the resident was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Review of the Emergency Department Nursing Record dated 9/2/16 at 12:25 a.m. revealed that the resident was assessed due to an accidental overdose of Insulin. Continued review revealed that the resident's blood sugar level was 38 upon EMS arrival to the nursing home. Cross refer to F333) Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that LPN CC, who was a new nurse orientee, had inaccurately administered 100 units of … | 2019-11-01 |
| 4302 | 4302 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2016-11-07 | 333 | J | 1 | 0 | HU6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, it was determined that the facility failed to ensure that one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin was free of a significant medication error from a sample of sixteen (16) residents. This failure resulted in harm for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer Insulin as ordered. review of the resident's medical record revealed [REDACTED]. [REDACTED]. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m.… | 2019-11-01 |
| 4303 | 4303 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2016-11-07 | 514 | J | 1 | 0 | HU6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure that the clinical record for one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration was complete and accurately documented from a sample of sixteen (16)residents. The facility failed to ensure that a factual description of the medication error and the on-going monitoring of the condition for 24 to 72 hours was accurately and completely documented in the medical record as per facility policy for R10. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R#10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review … | 2019-11-01 |
| 4304 | 4304 | APPLING NURSING AND REHABILITATION PAVILION | 115262 | 163 EAST TOLLISON STREET | BAXLEY | GA | 31513 | 2015-07-23 | 287 | C | 0 | 1 | E39D11 | Based on review of the state agency (SA) Minimum Data Set (MDS) Missing OBRA Assessment Report and staff interview, the facility failed to ensure that eight (8) MDS Assessments were transmitted to the SA in a timely manner. Findings include: Review of the SA MDS Missing OBRA Assessment Report having a run date 6/29/2015, revealed that as of that date, the facility had eight (8) missing MDS Assessments. During an interview on 07/22/15 at 12:40 p.m. with the MDS coordinator, he/she acknowledged there were late or missing MDS assessments. | 2019-11-01 |
| 4305 | 4305 | APPLING NURSING AND REHABILITATION PAVILION | 115262 | 163 EAST TOLLISON STREET | BAXLEY | GA | 31513 | 2015-07-23 | 371 | E | 0 | 1 | E39D11 | Based on observation, staff interview and review of facility policy, the facility failed to dispose of expired food products in a timely manner and to refrigerate items that required refrigeration to prevent food-borne illness on two (2) of three (3) halls with a total of sixty-two (62) residents receiving oral alimentation. Findings include: Observation on B-hall on 07/22/15 at 12:16 p.m. in the pantry refrigerator, where resident snacks were kept, revealed three (3) expired milks. Interview on 07/22/15 at 12:18 p.m. with Registered Nurse DD , unit manager confirmed that the milks were expired. Observation on C-hall on 07/22/15 at 12:21 revealed a bottle of Ranch Dressing sitting on the counter at room temperature in the pantry that contains resident snacks. The bottle of Ranch Dressing was approximately 1/3 to 1/4 full with the label stating to refrigerate after opening. Review of Policy regarding storage of foods revealed that perishable food items were to be stored in the refrigerator in dated and labeled containers between thirty-eight (38) and forty-one (41) degrees Fahrenheit. Interview conducted with Licensed Practical Nurse EE, at the time of the observation confirmed that the ranch dressing was sitting on the counter and should have been refrigerated. | 2019-11-01 |
| 4306 | 4306 | APPLING NURSING AND REHABILITATION PAVILION | 115262 | 163 EAST TOLLISON STREET | BAXLEY | GA | 31513 | 2015-07-23 | 441 | D | 0 | 1 | E39D11 | Based on observation, record review, and staff interview, the facility failed to provide care during wound care in a manner to help prevent the development of infection for one (1) resident (#30) from a survey sample of twenty-four (24) residents. Findings include: Observation of wound care for resident #30 on 07/23/15 at 10:10 a.m. with Treatment Nurse BB revealed during the wound dressing change BB cleansed the wound and apply applied clean dressing and failed to change dirty gloves or wash he/she hands throughout this proceedings. Review of Policy for Dressing changes showed that gloves were to be removed, hands washed and a clean pair were to be donned aseptically after removal of a dirty dressing, and before treatment performed as ordered, and hands were to be washed after discarding of waste. Interview with the Director of Nursing (DON) on 07/23/15 at 10:32 a.m. revealed that he/she would expect that hands would be washed before starting treatment, with removal of a dressing, and with cleansing of wound, etc. as appropriate for infection control. | 2019-11-01 |
| 4307 | 4307 | CALHOUN NURSING HOME | 115264 | 265 TURNER STREET | EDISON | GA | 39846 | 2016-12-07 | 363 | D | 1 | 0 | ECT611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to follow the planned mechanical soft diet menu for meat for two (2) resident (R#A3 and R#7) from six (6) residents observed on a mechanical soft diet. This deficient practice had the potential to effect 16 residents receiving a mechanical soft diet. Findings include: 1. Observation for the supper meal on 12/ 06/16 from 5:20 p.m. to 5:40 p.m. for R#A revealed that she had received a whole piece of cubed steak on her plate. She further stated that she could not eat the piece of meat. Record review for this resident revealed that she had a current order at least since 11-24-2015 for a mechanical soft diet with chopped meats. The resident had [DIAGNOSES REDACTED]. Review of the Diet Spread Sheet for the supper meal of 12-6-16 revealed that it had planned for chopped cube steak for Mechanical Soft diets. 2. Observation for the lunch meal on 12-7-16 at 12:55 p.m. for R#7 revealed that she had received a whole piece of fried chicken (thigh) on her plate. Record review for this resident revealed that she had a current order order at least since 6-24-2014 for a liberalized mechanical soft diet. Review of the Diet Spread Sheet for the lunch meal of 12-7-16 revealed that it had planned for chopped chicken for Mechanical Soft diets. During an interview with the Dietary Manager (DM) on 12-7-16 at 5:15 p.m. and after review of the Diet Spread Sheets for 12-6-16 and 12-7-16 and surveyor review of the observed meals for R#A during the supper meal on 12-6-16 and for R#7 during the lunch meal on 12-7-16, the DM confirmed that the meats for these two residents should have been chopped. Review of the Diet Listing by Resident revealed that 16 residents were receiving a mechanical soft diet in the facility. | 2019-11-01 |
| 4308 | 4308 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 584 | E | 1 | 1 | I5PG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in seven resident rooms (rooms 200, 201, 203, 206, 209, 210, 227), common shower room and supply storage room, on one of two units. The census was 108. Findings include: Observation on 7/21/19 at 11:20 a.m., revealed on second floor, A Hall supply/storage fluorescent room light out, making room dark during retrieval of supplies. Observation on 7/21/19 at 11:30 a.m., revealed in room [ROOM NUMBER] light bowl sitting on sink counter; ripped wallpaper strip above bed A; peeling particle board on sink counter; hole in ceiling, between two beds, with electrical face plate partially covering opening; hole in ceiling tile in bathroom, approximately two inches in diameter; light in bathroom missing globe fixture; hole in ceiling tile in bathroom, approximately one inch circular around sprinkler head. Observation on 7/21/19 at 12:51 p.m., revealed in room [ROOM NUMBER], electrical outlet in wall with broken face plate. Observation on 7/21/19 at 12:55 p.m., revealed in room [ROOM NUMBER], a hole in ceiling tile in bathroom, approximately two inches in diameter; call light reset button missing on wall unit; chair rail missing around room on bed B side of the room. Observation on 7/21/19 at 2:16 p.m., revealed in room [ROOM NUMBER], hole in ceiling, between two beds, with electrical face plate partially covering opening. Observation on 7/21/19 at 2:18 p.m., revealed common shower room on second floor, with strong, unidentifiable and gagging odor. Observation on 7/22/19 at 11:04 a.m., revealed in room [ROOM NUMBER], bathroom had very strong urine odor; male urinal in clear plastic bag hanging on grab bar, with dark discolored ring around urinal opening. Observation on 7/22/19 at 12:11 p.m., revealed in room [ROOM NUMBER], hole in ceiling, between two beds, with electrical face plate partially covering opening. … | 2019-11-01 |
| 4309 | 4309 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 156 | D | 0 | 1 | XJQ911 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), to allow the beneficiary to make an informed decision related to continuance of Medicare skilled services and the financial responsibility for those services if Medicare does not reimburse. This notice was not provided for three (3) of three (3) residents (#97, #110, and #224). From a sample size of thirty-three (33). The reviewed were the resident's discharged from skilled Medicare services and remained in the facility. Findings include: A review of the Liability Notices for residents #97, #110, and #224 was conducted and revealed that they were discharged from skilled Medicare services and remained in the facility. Further review revealed the only notice provided to the residents was the Notice of Medicare Non-Coverage. There was no evidence that the facility had issued an SNFABN (Centers of Medicare/Medicaid Services - CMS form ) notice to the residents, providing the opportunity to continue with skilled services, at their cost, if Medicare did not reimburse. Interview on 06/17/16 at 9:20 a. m. with the Case Manager (CM)/Discharge Planner revealed that he/she was not familiar with the CMS form . Continued interview revealed that he/she provided residents with a verbal notice of their right to appeal. The CM confirmed that no training on providing CMS form had been provided by previous CM. The CM confirmed that the three (3) residents reviewed were only provided the non-coverage form and were not provided the SNFABN form. The CM confirmed that there is no facility policy on providing the CMS form . | 2019-11-01 |
| 4310 | 4310 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 157 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the physician according to facility policy, Medication Administration General Guidelines for a resident who refused sliding scale insulin administration for one (1) resident (#234) of twelve (12) residents receiving sliding scale insulin. The census sample was thirty-three (33). Findings include: Review of the facility's policy and procedure for Medication Administration General Guidelines revealed the following: If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the Medication Administration Record [REDACTED]. If two consecutive doses of a medication are withheld or refused, the physician should be notified. Review of the 5/28/16 admission Minimum Data Set (MDS) assessment for R#73, noted in section I the following [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Fingerstick Blood Sugar (FSBS) before meals (AC) and hour sleep (HS). Sliding Scale Humalog 100 u/milliliter (ml) Notify Medical Doctor (MD) / Nurse Practitioner (NP) if blood sugar less than 60 or greater than 400. 200-250=4 units, 251-300= 6 units, 301-350=8 units, 351-400=10 units, 401-450=12 units. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the back of the (MONTH) (YEAR) MAR indicated [REDACTED].m Further review of the MAR indicated [REDACTED]. During an interview on 6/15/16 at 7:45 p.m. with (LPN), LL she stated that the resident refuses the Sliding Scale Insulin at 9:00 p.m. and stated that she usually documents the refusal on the back of the MAR. Further interview revealed that the resident refused the ordered sliding scale insulin when she attempted to administer the insulin for FSBS's 200 or greater on 6/2, 6/7, 6/10, 6/11, 6/12 and 6/14 . Continued interview with LPN LL revealed she did not notify the Medical Doctor (M.D.), or Nurse Practitioner (NP) of the resident refu… | 2019-11-01 |
| 4311 | 4311 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 280 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review the facility failed to revise the Fall Intervention Plan (FIP) to reflect fall interventions for two (2) residents #224 and #233 from a total sample of thirty three (33) residents. Findings include: 1. Resident #224 was a ninety six (96) year old long term care resident that was admitted to the facility on [DATE] after a hospitalization for general weakness. Her [DIAGNOSES REDACTED]. Review of the Admission Minimum Date Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) Score of 6 which indicates serve cognitive impairment. Continued review of the MDS revealed that the resident required extensive assistance with transfers, Activities or Daily Living (ADL) and Walking. The resident was assessed as total dependent for locomotion on and off of the unit. Review of the Fall Intervention Plan (FIP) revealed that the following interventions were initiated on 06/06/16: Low bed, call light in reach, educate how to use call light, encourage to call for assistance to toilet at first urge to void, encourage use of non-skid shoes/socks, foot wear, provide non-skid socks, hydration - fluids of choice within reach, medications - consider medication side effects, medications - review regimen and times given, and vision - keep glasses available. The following interventions were initiated on 06/07/16: Alarm, pressure sensitive on bed and fall mat at one side of bed. Review of the Comprehensive Falls Assessment revealed that nursing staff signed the form on 06/06/16 and only indicated that the resident was a new admit. Further review of the assessment form revealed the boxes that were to be checked regarding the resident risk for falls were blank. Review of the medical record revealed that an SBAR was completed on 06/13/16 due to a fall, Vital signs were obtained. The nurse ' s notes revealed that resident was heard calling for help and upon staff entering the… | 2019-11-01 |
| 4312 | 4312 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 282 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the careplan for one (1) resident (#73) recieving anticoagulant medication and one (1) resident (resident #43) receiving treatment for [REDACTED]. Findings include: 1. Review of R#73's Plan of Care dated 6/2/16 revealed a Problem Resident at risk for abnormal bleeding and may bruise easily related to anticoagulant therapy. The interventions included to give anticoagulant medications as ordered. However, review of the resident's 6/3 Physician orders [REDACTED]. Further review of the MAR indicated [REDACTED]. During an interview with the Director of Nurses (DON) on 6/17/16 at 9:30 a.m. the DON confirmed the nurses failed to follow the Plan of Care for the Problem identified to administer medication as ordered. 2. Review of resident #43 Treatment Record dated 6/3/16 revealed a pressure ulcer to the Sacrum that measured 1x0.5x0.1 centimeter . Observation on 06/15/2016 at 12:44 p.m. of dressing change of resident #43 with Registered Nurse (RN), AA revealed that she cleaned the wound with Normal Saline, placed calcium alginate over the wound bed and covered with Allevyn Foam Dressing. RN, AA verified during the observation that she cleaned the wound with Normal Saline, placed calcium alginate on the wound bed and covered Allevyn Foam Dressing. Interview also revealed that there was approximately 40 % slough covering the wound and it measured 1.0 x0.5 x 0.1 cm. RN, AA was uncertain about staging the wound. Interview on 06/15/2016 at 1:02 p.m. with Wound Care Nurse, RN, AA revealed that she thought that Calcium Alginate and collagen dressing were the same product. Interview on 06/15/2016 at 2:00 p.m. with Wound Care Nurse, RN, AA revealed that she spoke with the Wound Care Nurse who held the full-time position and after speaking with this nurse, she was able to locate the collagen dressing. She stated that she had removed the dressing that she initially applied during th… | 2019-11-01 |
| 4313 | 4313 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 309 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the Facilities Medication Administration Policy, the facility failed to follow the Physician order's for administration of an Anticoagulant medication for one (1) resident (#73), administration of Sliding Scale Insulin and one (1) resident (#234) a pressure wound dressing for one (1) resident (#43) from a total sample of thirty-three (33) residents. Findings include: Review of the facilities Medication Administration General Guidelines revealed the following: Medications are administered in accordance with written orders of the attending physician. 1. Review of resident #73's 5/21/16 Physician order's revealed [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [MEDICATION NAME] 3.5 mg by mouth (po) every day. Recheck International Normalized Ratio (INR) 6/6/16. Review of the INR control sheet dated 6/3/16 revealed INR 1.2, [MEDICATION NAME] dose at time of test 3.0 mg po every day. Increase 3.5 mg. Review of the (MONTH) Medication Administration Record [REDACTED]. However review of the physician's orders [REDACTED]. During an interview with the Director of Nurses (DON) on 6/15/16 at 6:28 p.m. she confirmed the nurses failed to follow the 6/3/16 physician's orders [REDACTED].The DON revealed that the [MEDICATION NAME] 3.5 mg po should have been started on 6/3. The DON further revealed it is her expectation the nurses follow the Physician orders. 2. Review of resident #234's History and Physical dated 6/6/16 revealed [DIAGNOSES REDACTED]. Review of the (MONTH) Admission Physician orders [REDACTED].=4 units, ,251-300=6 units,301-350=8 units, 351-400 =10 units, 401- 450 =12 units. Review of the physician's orders [REDACTED].=4 units, 251-300=6 units ,301-350=8 units, 351-400 =10 units, 401- 450 =12 units. Less than 60 or greater than 400 call Medical Doctor(MD) . Humalog 100 units/milliliter (ml) Give 16 units sq three times a day before meals at 0730 a.m., 11:30 a.m., 4:30 p.m.… | 2019-11-01 |
| 4314 | 4314 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 314 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to apply the correct treatment dressing during observation of wound care treatment for one (1) resident (#43) from a total sample of thirty-three (33) residents. Findings include: Review of Quarterly Minimum Data Sets (MDS) revealed that resident #43 had an unhealed pressure ulcer that was unstageable and one pressure area that was a stage three (3). [DIAGNOSES REDACTED]. Review of the Medical record for resident #43 revealed that the Braden Scale was done quarterly and was last done on 3/11/16 with the resident being assessed to have a Braden Score of 12, indicating that the resident was at high risk for developing a pressure ulcer. Review of the Treatment Record for resident #43 dated May, (YEAR) revealed that the sacral pressure ulcer was being staged as a stage three (3) and the wound base tissue type was granulation tissue. The treatment record documented that the sacral pressure ulcer was responding to treatment. The treatment record revealed treatment was started on 3/2/16. Review of measurements for the month of (MONTH) documented no change in size of wound. On 5/4/16 wound measured 0.5 x 0.2 x 0.1 centimeters. On 5/25/16 the wound measured 0.5 x 0.2 x 0.1 centimeters. Review of the (MONTH) 2106 physician order [REDACTED].#43 revealed a physician's orders [REDACTED]. Review of the Careplan for resident #43 revealed that the resident had a stage three (3) pressure ulcer to the sacrum. Review also revealed that the physician's wound orders were to be followed. Review of resident #43s Treatment Record dated 6/3/16 revealed a pressure ulcer to the Sacrum that measured 1 x 0.5 x 0.1 centimeter. An observation on 06/15/2016 at 7:45 a.m. revealed resident #43 was asleep in bed, lying on her back in a low bed with an air mattress and a fall mat beside the bed. Observation and interview on 06/15/2016 at 12:44 p.m. of dressing change for resident #43 with Registered Nu… | 2019-11-01 |
| 4315 | 4315 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 323 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review of the facities Policy, Fall Management at a Glance the facility failed to ensure interventions were in place to prevent falls for one (1) resident (#233) from a total sample of thirty- three (33) residents. Findings include: Review of the facility Policy Fall Guidelines provided by the facility revealed: 1. Intent: The Falls program is an interdisciplinary approach to the management of patients at high risk for falls. 2. Goal: Our goal is to be proactive in our efforts to identify risk factors that reduce the frequency of falls and serious injuries. 3 .Program Process : a. Comprehensive Falls Assessment to be completed on Admission, Readmission, Quarterly, Annually and as clinically indicated. b. Falls Intervention Plan (FIP)- Based on the findings from the Comprehensive Falls Assessment , implement appropriate interventions on the FIP. c. Should a Fall occur: Event management form will be completed. Investigation and assessment of fall circumstances needs to be captured on the Event Management form. Nursing documentation will reflect the following, complete Situation, Background , Assessment, Recommendation(SBAR) if applicable: i. Circumstances of the fall to paint an accurate picture(who,what,when,where and why) will be described in the Interdisciplinary Team (IDT) note, along with head to toe nursing assessment, immediate intervention(s) initiated and documentation of the effectiveness of that intervention for seventy- two (72) hours to ensure effectiveness. ii. The nurse responsible for the patient's care at time of a fall needs to implement an immediate intervention on the FIP targeted to protect patient safety and /or serious injury. iii. Subsequent documentation for the next seventy - two (72) hours, or longer if indicated, should address: complete head to toe nursing assessment , site of injury if applicable, interventions initiated related to current fall event, effectiveness … | 2019-11-01 |
| 4316 | 4316 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 371 | F | 0 | 1 | XJQ911 | Based on observation, staff interview, and record review the facility failed to ensure the meat slicer was cleaned and sanitized after usage to prevent cross contamination. This deficient practice had the potential to effect all fifty four (54) residents receiving an oral diet. Findings include: Observation on 06/16/16 at 10:30 a. m. in the kitchen, the meat slicer revealed that it was covered with a white frosted plastic bag. The plastic bag was removed from the slicer which revealed food particles, tan and brown in color on the underside of the blade. The Dietary Manager (DM) removed the top blade guard which revealed more food substance that covered the inside top of blade which was tan and brown in color. Interview on 06/16/16 at 10:30 a. m. with Dietary Manager revealed she confirmed that the meat slicer had a plastic bag covering the machine. She confirmed that when a plastic bag is placed over a piece of equipment it indicates that the equipment is clean and ready for use. The DM confirmed that there was tan and brown food particles on the top and bottom of the slicer blade. She expects staff to properly clean and wash the slicer and inspect the slicer before placing the plastic bag over the top. The DM revealed that turkey was sliced last evening and expected the cook to clean the slicer better. She revealed that she does not have a policy for kitchen cleaning and that the cleaning schedule was the policy. Further interview with the DM revealed that she confirmed that evening dietary staff have not initialed on the daily cleaning schedule when tasks have been completed for the past three (3) days. She expects staff to complete cleaning tasks and initial the form when they are completed. Review of the Daily Cleaning Schedule for the week of (MONTH) 13-19th revealed that the evening dietary sheet was blank, staff had not initialed any kitchen equipment had been cleaned for the week. Review documentation revealed that the dietary staff had an in-service conducted on 03/31/16 and staff were educated on the sl… | 2019-11-01 |
| 4317 | 4317 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 514 | E | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately document medication administration leaving blanks/holes on the Medications Administration Records (MARs) for seven (7) residents (#236, #71, #234, #1, #80, #73, and #135) out of 12 residents receiving sliding scale insulin. The census sample size was thirty-three (33). 1. Resident #135 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]., Vitamin B12 deficiency, [MEDICAL CONDITION]/[MEDICAL CONDITIONS] Disease, [MEDICAL CONDITION], and [MEDICAL CONDITION], Review of the medical record revealed that the physician had ordered for the resident to have Finger Stick Blood Sugar (FSBS) completed at 6:30 a. m. and 4:30 p. m. The physician ordered [MEDICATION NAME], ten (10) units subcutaneously at bedtime daily as well as [MEDICATION NAME] Sliding Scale Insulin: 201-250 four (4) units, 251-300 six (6) units, 301-350 eight (8) units, and 351-450 10 units. Review of the (MONTH) (YEAR) Medical Administration Record (MAR) revealed on 06/13/16 at 4:30 p. m. the Finger Stick Blood Sugar (FSBS) check the resident had a blood sugar reading of two hundred forty four (244). Continued review of the MAR revealed the units of sliding scale insulin for that blood sugar reading was blank. Review of the (MONTH) (YEAR) MAR revealed that the resident Fasting Blood Sugar (FSBS) on 05/07/16 at 4:30 p. m. was blank. Continued review of the (MONTH) MAR revealed on 05/08/16 at 4:30 p. m. the resident had a FSBS of two hundred seventy (270), the MAR was blank for the amount of sliding scale insulin the resident was to receive. Further review of the (MONTH) MAR revealed on 05/22/16 the FSBS for 6:30 a. m. was blank. Review of the (MONTH) (YEAR) MAR revealed on 04/17/16, 04/25/16, and 04/30/16 the MAR was blank. Review of the laboratory results in the medical record revealed the resident had a Hemoglobin A1C (HbA1C) lab completed on 04/26/16. The results of (9.3) which indicated high (r… | 2019-11-01 |
| 4318 | 4318 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2016-12-04 | 282 | D | 1 | 0 | RXE811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interviews, the facility failed to follow care plan interventions for one (1) resident Z related to incontinent care out of three (3) residents on the sample of thirteen (14) residents. Refer F312 Findings include: Resident Z was interviewed at 12:20 p.m. on 12/04/16, and the resident informed the Surveyor that staff had not changed the resident since 12/03/16 at 10:00 p.m. During an observation on 12/04/16, at 12:25 p.m., the CNA LL changed the resident's adult brief and resident Z, during the change, was noted to be saturated with urine and brown stains. The CNA LL informed the Surveyor that the resident's adult brief was changed last at 9:00 a.m., 12/04/16. Review of resident Z's care plans identified the resident was dependent for ADLs , bilateral leg [MEDICAL CONDITION] and incontinent of bladder and bowel, revealed that the resident was dependent on staff for all of their ADLs and that interventions included on the revised care plan dated 7/15/16, was to check the resident frequently and give the resident incontinent care as needed. During an interview with the Director of Nursing (DON) on 12/04/16, at 2:00 p.m., she informed the Surveyor that the CNA LL told her that she was confused and that she had not changed the resident's diaper since she came on to her shift at 7:00 a.m. The DON informed this surveyor during the interview that staff CNA should check the residents every two hours and change the residents if needed. | 2019-11-01 |
| 4319 | 4319 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2016-12-04 | 312 | D | 1 | 0 | RXE811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interviews, observation, record review and staff interviews, the facility failed to provide incontinence care as per the resident's comprehensive care plan for one (1) resident (Z) from a sample of three (3) residents. Findings include: Record review for resident Z revealed a Minimum Data Set 3.0 ((MDS) dated [DATE], documenting a BIMS score of 12 with the resident assessed for their activities of daily living as needing extensive assistance for toileting/personal hygiene with an admitted to the facility of 2/17/15. Review of the comprehensive care plan for activity of daily living (ADL) dated 7/15/16, revealed that the resident was assessed as dependent for bed mobility, transfers, incontinent of bladder and bowel related to [MEDICAL CONDITION] and bilateral above the knee [MEDICAL CONDITION]. Interventions included to anticipate ADL needs and assist the resident with all bathing, dressing, personal hygiene, transfers, positioning and incontinent care. During resident interviews with alert and oriented residents, resident W on 12/4/16 at 11:05 a.m. revealed that a resident (resident Z) was not receiving incontinent care from Certified Nursing Staff in a timely manner. At 12:20 p.m. on 12/4/16, this Surveyor interviewed resident Zwho was able to answer all screening questions and was found to be alert and oriented. Resident Z informed the Surveyor during the interview that he/she had not been cleaned and changed since 12/3/16, at 10:00 p.m. At 12:25 p.m. on 12/4/16, resident Z put her call light on and the CNA assigned to the resident answered the call light and resident Z asked the CNA LL to change her adult brief. The resident was sitting in her wheel chair and two CNAs put resident back into her bed. The CNA LL then began to change her diaper and resident Z was observed to have a diaper saturated with urine and some brown stains. The CNA LL cleaned the resident and put on a dry diaper. This surveyor then asked CNA LL wh… | 2019-11-01 |
| 4320 | 4320 | BERRIEN NURSING CENTER | 115343 | 405 LAUREL AVE. | NASHVILLE | GA | 31639 | 2016-12-08 | 469 | F | 1 | 0 | OO2Z11 | > Based on observation, staff interview, contracted pest control services interview and record review, the facility failed to maintain an effective pest control program that effectively sealed 10 of 13 doors leading directly outside which allowed the potential for insects and rodents to enter the facility. The investigation was part of a complaint allegation that the facility had roaches and rats in the resident rooms and the potential to affect all the residents within the facilty. Facility reported census of 95 (MONTH) 5, (YEAR). Findings include: On 10/7/16 at 11:30 AM, CNA (Certified Nursing Assistant) EE stated during an interview, I work nights and I just saw a roach the other night in the hallway. If we see any insects or rats, we tell maintenance and they take care of it. I have seen rat droppings in the closets and cockroaches in the halls and the resident rooms at least once a month. On 12/8/16 at 9:45 AM, a cockroach scurrying along a baseboard in the West Wing hall, close to Room 145 and the service hallway was observed. On 12/8/16 at 11:15 AM, during a tour with the Maintenance Supervisor DD, an observation of all the exterior doors leading directly to the outside areas, revealed 10 of 13 doors had a space at the threshold large enough for sunlight to shine through and for insects and rodents to enter the building. An interview, at this time, the Maintenance Supervisor DD indicated, (Local pest control service) comes out once a month to spray for insects, including roaches and ants, once a month. When I get work orders that insects or rodents have been seen, I call them and they come and spray again. I would say I get 2 work orders a month on average. If mice are seen, I put non-toxic wafers in the areas that they have been seen and (local pest control service) comes and places traps around the outside of the building. The doors need shims under the thresholds and door sweeps for a good seal. On 12/8/16 at 11:40 AM, a telephone interview with the pest control service technician that the facility used… | 2019-11-01 |
| 4321 | 4321 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD STREET | ROME | GA | 30161 | 2016-12-15 | 157 | D | 1 | 0 | YN3U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and family interviews, it was determined that the facility failed to immediately notify a resident's family member of significant changes in the resident's physical status, regarding the death of one resident (RA) from a complaint survey sample of six residents. Findings include: Complainant A was interviewed at 10:15 a.m. on [DATE], and informed the Surveyor that staff failed to notify her and/or other family members of her husband, RA death for more that 30 hours after he expired at the facility. She was only informed of his death the following afternoon when she called the facility to check on his progress in therapy. During an interview with the Director of Nursing (DON), at 1:06 p.m. on [DATE], she revealed the family was not notified of R A s death because because facility staff failed to update the computer to include all of the family emergency contact numbers provided during the 72 hour care plan meeting held after the resident was admitted . Review of the resident's care plan revealed interventions to inform resident and/or healthcare decision maker of any change in status or care needs and provide resident/healthcare decision maker with sufficient information to make an informed decision. During an interview with the Director of Nursing (DON) at 3:30 p.m. on [DATE], she informed the Surveyor that her expectation would have been for the nurse on duty to pass the information of the resident' s death on to the nurse on the next shift if she was unable to contact the family. It was a failure from admission on to nursing. It is our fault because we had a 72 hour meeting with his wife and did not confirm the family's numbers and the nurse did not follow-up. During an interview with the Admissions Director CNA BB at 12:25 p.m. on [DATE] who revealed she completed the resident' s initial admission but did not have all four of the contact numbers when the admission paperwork was faxed to her on [DATE]. CNA BB… | 2019-11-01 |
| 4322 | 4322 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD STREET | ROME | GA | 30161 | 2016-12-15 | 282 | D | 1 | 0 | YN3U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interviews, the facility failed to follow care plan interventions for one resident (A) related to notification to responsible party of change in status or care needs out of six sampled residents. Findings include: Complainant A was interviewed at 10:15 a.m. on [DATE], and informed the Surveyor that staff had not notified her or other family members of the resident's death until she contacted the facility the day after he expired. During an interview with the Director of Nursing (DON), at 1:06 p.m. on [DATE], she revealed the family was not notified of the resident's death because facility staff failed to update the computer to include all of the family emergency contact numbers provided during the 72 hour care plan meeting held after the was admitted . Review of the resident's care plan revealed interventions to inform resident and/or healthcare decision maker of any change in status or care needs and provide resident/healthcare decision maker with sufficient information to make an informed decision. During an interview with the Director of Nursing (DON) at 3:30 p.m. on [DATE], at which time she explained that the family had not been notified of the resident's death until the next day. refer to F157 During an interview with the Admissions Director CNA BB at 12:25 p.m. on [DATE] who revealed that she had not updated the computer system with the contact information for the resident. refer to F157 Review of the facility investigation into the failure to notify incident revealed a documented statement from the Admissions Director, CNA BB dated [DATE] recounting her error in documenting all of the resident's emergency contact information in the system for it to be available to nursing staff. Review of the facility Education/In-service on Resident Contact Information signature log, dated [DATE] revealed the CNA BB as the sole attendee. Review of facility policy NSG122 Change in Condition: Notification of; e… | 2019-11-01 |
| 4323 | 4323 | DELMAR GARDENS OF GWINNETT | 115350 | 3100 CLUB DRIVE | LAWRENCEVILLE | GA | 30044 | 2015-09-11 | 502 | D | 0 | 1 | YK1U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to collect a stool specimen ordered by the Physician on 7/28/15 for one (1) resident (#49) that was experiencing diarrhea from a sample of twenty six (26) residents. Findings include: An interview conducted on 9/9/15 at 10:20 a.m. with resident #49 revealed that she has been having complications with diarrhea. A review conducted of the physician's orders [REDACTED]. A review of the Lab Log revealed on 7/29/15 a stool specimen was to be collected for Ova/Parasites Stool Studies. Upon further review the stool specimen was not signed off as being collected. A review of the clinical record Nurse's notes with reference dates 7/28/15 through 8/5/15 revealed no documentation that the stool specimen had been collected, or that the specimen was unable to be obtained. A continued review revealed no lab results for a stool specimen. An interview conducted on 9/9/15 at 12:44 p.m. with the Director of Nursing (DON) revealed there was no record the [MEDICAL CONDITION] ordered on [DATE] had been collected. The DON further revealed that the order was documented in the lab book to be collected on 7/29/15, however it was not signed off as collected and it should have been repeated in the lab log each day for at least the next three (3) days to be collected but it was not. The DON revealed that the Physician should have been notified if the stool sample was unable to be collected and there was no evidence of that being documented in the nurse's notes. She confirmed that the lab was not collected as ordered in error. | 2019-11-01 |
| 4324 | 4324 | HERITAGE INN OF SANDERSVILLE HEALTH AND REHAB | 115369 | 652 FERNCREST DRIVE | SANDERSVILLE | GA | 31082 | 2015-08-20 | 441 | D | 0 | 1 | 78J711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Centers for Disease Control (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, review of the facility's policy on administration of eye drops and staff interview, it was determined that the facility failed to ensure that a Licensed Practical Nurse (LPN) washed his/her hands and wore gloves during the administration of nasal spray and eye drops for one resident (#18) and failed to wear gloves during the administration of insulin for one resident (#68) of three residents observed for medication administration from a sample of 20 residents. Findings include: According to the CDC's 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, hand hygiene was the single most important practice to reduce the transmission of infectious agents in healthcare settings. Hand hygiene included handwashing with soap and water or in the absence of visible soiling of hands, alcohol-based products approved for hand disinfection could be used. Gloves should be used to prevent contamination when there was potential direct contact with blood or body fluids, mucous membranes, nonintact skin or other potentially infectious material Review of the facility's policy on the administration of eye drops revealed that staff should wash hands prior to the administration of eye drops. 1. During observation of medication administration on 8/19/15 at 8:25 a.m., Licensed Practical Nurse (LPN) ZZ failed to wear gloves prior to administering [MEDICATION NAME] nasal spray to resident #18. After the administration of the nasal spray, ZZ cleaned the tip of the [MEDICATION NAME] bottle with a tissue and recapped the bottle. Without washing/sanitizing his/her hands and without wearing gloves, ZZ then administered Artificial Tears eye drops in each of the resident's eyes which had the potential of introducing harmful germs from the re… | 2019-11-01 |
| 4325 | 4325 | PRUITTHEALTH - MONROE | 115379 | 4796 HIGHWAY 42 NORTH | FORSYTH | GA | 31029 | 2015-07-31 | 441 | D | 0 | 1 | XP1N11 | Based on observation, staff interview, and review of the infection control policy, the facility failed to ensure that staff sanitized their hands between serving and assisting with feeding during two (2) of 2 meal observations for one (1) or 2 dining rooms. This deficient practice had the potential to effect seventy (70) of the seventy-four (74) residents receiving oral diets. Findings include: Observation on 07/27/15 at 12:10 p.m. of the Assisted Dining Room revealed that Licensed Practical Nurse (LPN) AA was assisting a resident to the dining room by pushing them in their wheelchair. She then adjusted the wheelchair, touched and removed the foot pedals to get the resident closer to the table. The LPN then touched and distributed two resident lunch meals. She then assisted with meal set-up for one resident, sat down and began assisting another resident with feeding. AA did not wash her hands or use hand sanitizer after touching residents and before assisting with feeding of the lunch meal. Continued observation of AA revealed that during feeding a resident she got up and assisted another resident with lunch meal set-up touching the resident and their wheelchair. AA then returned to the resident she was assisting with feeding and did not sanitize or wash her hands between resident contact. Further observation of the Assisted Dining Room revealed that Registered Nurse (RN) BB was also assisting residents to the dining room by pushing them in their wheelchairs. BB then distributed a lunch tray to the resident she brought in the room, she moved the chair next to the resident and did not use hand sanitizer before she began assisting with feeding. Continued observation revealed an office staff member moving a dining chair and placed it next to a resident, she then sat down and began assisting with feeding and did not wash her hands or use hand sanitizer. Observation on 07/30/15 at 8:00 a.m. of the Assisted Dining room revealed that LPN AA distributed a breakfast meal tray to a resident, AA then touched the resident's … | 2019-11-01 |
| 4326 | 4326 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2015-09-24 | 221 | E | 0 | 1 | 60C511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, review of the facility policy and procedure entitled Restraint Use, Long Term Care, and staff interviews, the facility failed to ensure residents were free from restraints unless medically necessary. This affected five (5) residents, (#72, #15, #186, #199, and #108) from a sample of twenty-one (21) residents who were observed wearing a self-releasing Velcro waist band the duration of the survey. Findings include: On 09/23/15 at 10:15 a.m., an interview with HH , Licensed Practical Nurse, (LPN), Unit Manager, revealed morning rounds are made inclusive of the following employees; Director of Health Services (DHS), Minimal Data Set (MDS) Coordinator, Social Services Director, Education Coordinator, and all of the Unit Managers. During these rounds, recent falls and wandering episodes are discussed. Self -releasing Velcro waist bands are placed on certain residents as a safety intervention on an as needed basis. After placement of the physical device, there is not a systematic way each resident is re-assessed to determine if the waist band is still required; determination is made on a case by case basis. The determination is based on staff observations if the resident attempted to get up from the wheelchair or fidgeted with their waist belt. On 09/23/15 at 11:00 a.m., an interview with II , Assistant Director of Health Services (ADHS), stated she would provide the survey team with a list of all residents that use the self-releasing Velcro waist band and the rationale basis for each device. This surveyor asked the ADHS to please include on the list those that can release it themselves ; ADHS responded, I hope they all can. On 09/24/2015 4:03 p.m. an interview with the DHS stated her definition of a restraint was Anything that impairs body movements. When asked her to define limitation of movement, she responded, it's in the policy. 1. Resident #72 (R #72) was an eighty-six (86) year old Caucasian female admit… | 2019-11-01 |
| 4327 | 4327 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2015-09-24 | 241 | D | 0 | 1 | 60C511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review the facility failed to provide service with dignity evidence by provide privacy by ensuring that the privacy curtain was closed during care for one (1) # 28 resident from a total resident sample of forty-six (46). Findings include: Resident # 28 ( R #28), a ninety-nine year old resident was admitted to this facility on (MONTH) 16, 2009 with [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS) reference date (MONTH) 10, (YEAR), revealed the resident has a Basic Intellectual Mental Status (BIMS) of 99 and has a history of combative physical and verbal behaviors. Observation revealed that during peri-care on 09/13/15 at 11:30 a.m. Resident #28 was exposed from the waist down while staff provided pericare. During this observation resident privacy curtain was not fully closed exposing her to two (2) roommates who was present in the room during care. One of Certified Nursing Assistants (CNA) walked to the side of the bed between the bed and the privacy curtain. As she walked, she brushed against the curtain, opening it more than half way, exposing Resident #28 to her room mates. The CNA made no effort to cover the resident or pull the curtain around the bed. Review of facility policy and procedures Perineal Care of the female patient states provide privacy Interview with Director of Health Services (DHS) on 9/23/15 at 4:00 PM stated staff are educated annually and through compliancy demonstration. She provided the facility (YEAR) Skills Checklist Perineal Care of the female patient that includes provide privacy. Interview with Assistant DHS on 09/24/15 at 7:00 p.m. revealed that her expectation is for all employees when providing peri-care to provide privacy by closing the door, pulling the curtain and to have all supplies ready prior to beginning peri-care. | 2019-11-01 |
| 4328 | 4328 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2015-09-24 | 247 | D | 0 | 1 | 60C511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to give notice to two (2) B & C of 3 sampled residents when there was a roommate change. The findings include: 1. During an interview on 9/23/15 at 10:00 AM, Resident C stated her most recent room mate came to her room several months ago. She stated she did not know if she got notice she would be getting a new roommate. Record review revealed Resident #66 was moved on 4/27/15 to room [ROOM NUMBER] C. Record confirmed Resident C did not have notice that she was getting a new roommate. 2. Interview with Resident B on 9/24/15 at she stated I have been here 10 weeks and have had numerous roommates and was never given notice. During discussion with Social Worker (SW) confirmed that Resident B was not given notice that she would be getting a new roommate. The SW stated she did not realize it was necessary because the new roommate was a new admit and not being transferred from within the facility. The SW stated it was her impression since rehab had such a turn over, it was not required. | 2019-11-01 |
| 4329 | 4329 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2015-09-24 | 272 | E | 0 | 1 | 60C511 | Based on observations,review of individual Minimum Data Set Assessments and staff interviews, the facility failed to adequately assess residents for restraint use. This affected five (5) residents, (#72, #15, #186, #199, and #108) from a sample of twenty-one (21) residents who were observed wearing a self-releasing Velcro waist band the duration of the survey. Findings include: 1. Resident #72 (R #72) was observed sitting in the hallway in her wheelchair with a self-releasing Velcro waist band secured in place on the following dates and times: 09/21/15 at 10:30 a.m. 09/21/15 at 02:30 a.m. 09/22/15 at 11:00 a.m. 09/22/15 at 02:00 p.m. 09/22/15 at 04:30 p.m. 09/23/15 at 07:30 a.m. On 09/23/15 at 04:37 R#72 was asked if she could undue her belt for this surveyor, the Center Medicaid/Medicare (CMS) Federal surveyor and the DHS; the resident is non-verbal and did not respond verbally or physically. The resident gave no indication she cognitively understood the request. Review of the Quarterly Minimal Data Set (MDS), reference date 09/02/15, Section P. Restraints revealed no documented use of restraints. Section G 0400: A: Upper Extremities, one (1) impairment on one side B: Lower Extremities, two (2) impairment on both sides Review of the Census & Condition completed by the facility at the onset of the survey revealed that they have documented 0 restraints. 2. Resident #15 (R #15) was observed in the hallway seated in her wheelchair with a self-releasing Velcro waist band secured in place throughout the survey. On 09/24/2015 10:48 a.m. R#15 was observed seated in her wheelchair with a self-releasing Velcro waist band secured. R #15 was asked if she could undue her belt for this surveyor, the CMS Federal surveyor and the DHS; the resident was unable to release the Velcro secured belt. Review of the Quarterly MDS, reference date 08/27/15, Section P. Restraints revealed no documented use of restraints. Section G 0400: No impairment upper and lower extremities Review of the Census & Condition completed by the facility at … | 2019-11-01 |
| 4330 | 4330 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2015-09-24 | 279 | D | 0 | 1 | 60C511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to develop a care plan for one (1) resident (#100) having been assessed as edentulous from a sample of forty six (46) residents. Findings include: A record review for resident #100 revealed an Annual Minimum Data Set (MDS) assessment having an Assessment Reference Date of 3/15/15 which documented in Section L- Dental/Oral Status the resident has no natural teeth/edentulous. In Section V- Care Area Assessment (CAA) which triggered Dental with the decision to be care planned. A review conducted of the care plans revealed no evidence of a Dental Care Plan. A Review of the Nursing Monthly Observation Form dated 9/3/15 documents Dental Status: Dentures/Removable Bridge they are using daily. An observation conducted on 9/21/15 at 3:39 PM of the resident revealed she has no natural teeth with upper dentures in use. An Interview conducted on 9/23/15 at 11:05 AM with the MDS Coordinator AA confirmed the MDS assessment dated [DATE] identified the resident is edentulous with upper but no lower dentures. She confirmed the CAA triggered dental status with the decision to be care planned, however, no care plan had been developed for Dental Status. She said a modified care plan would be developed for Dental Status. | 2019-11-01 |
| 4331 | 4331 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2015-09-24 | 312 | D | 0 | 1 | 60C511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to ensure residents received the help needed for Activities of Daily Living (ADLs) affecting two (2) residents ('A' and #28) from a sample of forty six (46) residents. Findings include: 1. Resident 'A' complained on 9/21/15 at 2:41pm that her roommate had to help her pull up her pants every morning, that staff were supposed to, but never did. Review of the most recent Quarterly assessment dated [DATE] indicated the resident needed ADL supervision and set up help only. Review of the Care plan updated 7/29/15 indicated resident required limited assist with daily care, including daily grooming and toilet assist. Further review of the Certified Nursing Assistant (CNA) Care Record indicated that resident needed assistance at all times for dressing and grooming. On 9/23/15 at 8:16 am resident observed sitting at bedside in wheel chair fully dressed. Stated roommate assisted with pulling up pants that morning as she did every morning. On 9/24/15 at 8:53 am interview with resident revealed that her roommate had helped pull up her pants that morning. Interview with CNA BB on 9/24/15 at 9:56 am revealed she checked the Care Record on the back of resident's closet door for interventions needed. Also had change of shift report with previous shift. Checked with charge nurse as well to ensure nothing was missed. Feels like resident would probably need help with pulling up pants because she had to hold on with both hands when standing up or transferring, it would be hard to pull up pants while using both hands for balance, but she had not dressed her in a very long time. Night staff usually got resident up. 2. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION],severe dementia. Resident is cognitively impaired. Interview with facility staff QQ nursing assistant on 9/22/15 at 8:42 confirmed the resident does not speak often. He stat… | 2019-11-01 |
| 4332 | 4332 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2015-09-24 | 315 | D | 0 | 1 | 60C511 | Based on observation, record review and interviews, the facility failed to to provide appropriate peri-care for 1 ( #28) of 5 sampled residents to prevent urinary tract infections. The findings include: 1. Peri care was observed for Resident # 28, bed 616 A, at 09/13/15 at 11:30 a.m. Performed by staff FF and EE, both CNA's. The Resident was lifted from wheelchair by both CNA's; each CNA placed their arm under her armpit and lifted her. Staff FF grabbed the back of her pants at the waist band to assist with lifting the resident. During lift, red quarter size stain noted on the right buttock of the resident ' s pants. Resident moved to bed on top of clean draw sheet. Curtains & door closed. Staff EE moved to the side of bed, and in doing so, moved the divider curtain more than half the way open. She never re-closed the curtain. The resident was partially exposed to her other roommates throughout the entire peri care observation. Staff EE unfastened the resident ' s briefs, instructed resident to grab the side rail to her right, using a draw sheet she turned the resident onto her right side and lowered brief. While she did this,staff FF removed his gloves and searched for Peri wash throughout the room. After FF found Peri wash in resident ' s bin, he washed hands and pulled gloves on. Staff EE sprayed Peri wash on the wipes & pulled wipes from the container and began wiping the resident from under side of peri area up her buttock. She did not change her gloves. Staff FF assisted the resident to grab the opposite side rails and turned her and lowered her brief and removed her brief. Peri care was never performed on her frontal peri area, red excoriated area in the resident ' s inner thigh folds noted. Resident was very combative, cursing and clawing at her perineum. Her brief was completely removed, noted a 3 x 3 circular purplish area on her right ischium. A 5 x 5 purplish circular area with yellow halo observed on her right trochanter, on left hip area, 3 separate .5 x .5 circular purplish area with long yellow ar… | 2019-11-01 |
| 4333 | 4333 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 157 | J | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews the facility failed to notify the physican when insulin was withheld or were not within acceptable ranges (70-100) for resident (R7) and; failed to notify the physician of a Speech Therapy (ST) recommendation which indicated nothing by mouth (NPO) for R35. On (MONTH) 2, (YEAR) at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents on 8/21/16 at 6:00 a.m. and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. On 11/22/16 the current interim Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. At the time of exit on (MONTH) 23, (YEAR), an acceptable Allegation of Compliance (AoC) had not be… | 2019-11-01 |
| 4334 | 4334 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 221 | J | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and staff interviews, it was determined that the facility failed to provide a restraint free environment for one (1) resident (R15); failed to assess the use of a lap tray, failed to re-assess the use of the lap tray when the resident was at risk for serious harm related to entrapment when the lap tray was in use, failed to follow the facility policy related to Restraint Management and Evaluation and failed to educate the staff related to the manufactures recommendations for applying the use of the lap tray. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, remains on-going. On (MONTH) 25, (YEAR) at 6:10 p.m. the previous Administrator, previous DON and Corporate Registered Nurse were notified of IJ that was determined to existed on 8/21/16 when R15 was observed sitting in a wheel chair with a lap tray applied to the wheel chair, R15 slid down in the wheelchair with his chin resting on the lap tray which had been applied inappropriately to the wheelchair. R15 consistently slid underneath the lap trap, the staff was not educated on the proper application of the lap tray, the staff incorrectly tied the straps to the lap tray behind the chair, failed to have R15 assessed, re-assessed and continued the use of the use of the lap tray for R15 with known sliding behavior placing R15 at risk of entrapment. At the time of exit on (MONTH) 23, (YEAR), an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: Resident (R15) was admitted to the … | 2019-11-01 |
| 4335 | 4335 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 224 | L | 1 | 0 | C00C11 | **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 provide care in a manner which prohibited neglect by not providing care and services to residents, including: adequate supervision including on 7/20/16 when resident (R17) fell resulting in a laceration to his head while there was no nurse on duty; failed to ensure the LN who was assigned to the secured unit was not impaired; failed to have a licensed nurse (LN) on the secured unit to administer medications and blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents (7, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 32 and 33) on 8/21/16 at 6:00 a.m.; on 10/10/16, R7 sustained a fall and suffered a subarachnoid hemorrhage, and nasal fracture, with a blood sugar of 567 and a [DIAGNOSES REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, remains on-going. 1. On (MONTH) 2, (YEAR) at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications … | 2019-11-01 |
| 4336 | 4336 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 278 | J | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews the facility failed to ensure that the Minimum Data Set (MDS) was coded accurately including pressure sores (PSores), indwelling urinary catheter and weight loss for one (1) resident (R35). The failure of inaccurate coding of the MDS resulted in a lack of care planning. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 11/22/16 the current interim Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: Record review of the Quarterly MDS dated [DATE] revealed that R35 was coded to have one (1) Stage II PSores. R35 was discharged to the hospital on [DATE] with 1 Stage II PSores. R35 was re-admitted to the facility on [DATE]. Review of the wound physician notes dated 9/7/2016 revealed R35 had five (5) PSores at this time including: two (2) stage II and one (1) unstageable on the coccyx; 2 fluid filled blisters to the heels one each heel. Howeve… | 2019-11-01 |
| 4337 | 4337 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 279 | J | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, it was determined that the facility failed to develop a comprehensive plan of care to include the use of a lap tray and the risk of negative outcomes including entrapment of the device for one (1) resident (R15). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On (MONTH) 25, (YEAR) at 6:10 p.m. the previous Administrator, previous DON and Corporate Registered Nurse were notified of IJ that was determined to existed on 8/21/16 when R15 was observed, by the surveyor, sitting in a wheel chair with a lap tray applied to the wheel chair, R15 slid down in the wheelchair with his chin resting on the lap tray which had been applied inappropriately to the wheelchair. R15 consistently slid underneath the lap trap, the staff was not educated on the proper application of the lap tray, the staff incorrectly tied the straps to the lap tray behind the chair, failed to have R15 assessed, re-assessed and continued the use of the use of the lap tray for R15 with known sliding behavior placing R15 at risk of entrapment. At the time of exit on (MONTH) 23, (YEAR), an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: Resident (R15) was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [REDACTED]. Review of the Clinical Programs Manual for Restraint Management and Evaluation revealed the interdisciplinary team, re-evaluate the use of a restraint and/or enabler at least quarterly or with change in resident condition during Care Management Meeting and to review and revise the care plan … | 2019-11-01 |
| 4338 | 4338 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 280 | J | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and record review, (Standards of Practice) the facility failed to revise the care plan to include self-injurious behaviors with interventions to prevent injury and failed to revise the care plan after falls with injuries to prevent further falls and/or injuries for one resident (R7). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. On (MONTH) 2, (YEAR) at 5:00 p.m., the Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. On 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. At the time of exit on (MONTH) 23, (YEAR), an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan was developed on 6/1/16 that documented R7 was at risk for verbally, physically, and socially inappropriate behavior related to a [DIAGNOSES REDACTED]. The care plan problem also documented t… | 2019-11-01 |
| 4339 | 4339 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 281 | K | 1 | 0 | C00C11 | **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 ensure that services being provided by a licensed practical nurse (LPN) and a registered nurse (RN) met professional standards of quality as referenced in Rules and Regulations of the State of Georgia, Chapter 410-10 Standards of Practice, including: leaving the secured unit without an nurse, therefore not administering medications as ordered by the physician to twenty-two (22) residents (7, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 32 and 33), in addition on 7/20/16, R17 fell resulting in a laceration to his head while there was no nurse on duty on 7/27/16 the RN was impaired while on duty on the secured unit, failed to ensure that Narcotic keys were not left with Certified Nursing Assistant or left unsecured on the Secured unit and; failed to obtain a physician order [REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. 1. On (MONTH) 2, (YEAR) at 5:00 p.m., the Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, only one nurse onsite in the facility and the LN was leaving the Narcotic keys with a Certified Nurse Assistant or leaving the keys unsecured area on th… | 2019-11-01 |
| 4340 | 4340 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 282 | K | 1 | 0 | C00C11 | **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 follow the care plans indicating to document the administration of routine and sliding scale insulin per physician orders [REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. On (MONTH) 2, (YEAR) at 5:00 p.m., the Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. At the time of exit on (MONTH) 23, (YEAR), an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: 1. Resident (R10) had a [DIAGNOSES REDACTED].(MONTH) (YEAR). Continued review of the MARs revealed that licensed nursing staff failed to obtain and document the Accucheck as care planned twenty four (24) times in (… | 2019-11-01 |
| 4341 | 4341 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 309 | K | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, it was determined the facility failed to administer medications and finger blood sugar levels (FSBS) as ordered by the physician for fifteen (15) residents (R10, 11, 12, 16, 18, 19, 20, 21, 22, 23, 27, 28, 29, 32 and 33), on 8/21/16 at 6:00 a.m. when there was no licensed nurse scheduled to the secured unit to administer medications or FSBS. Insulin as ordered and for one resident (R7) and for medications to administered timely and not past the one hour window, allowed by Federal Regulation, on 8/20/16 at 9:00 p.m. for three residents (R17, 24 and 25). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. On (MONTH) 2, (YEAR) at 5:00 p.m., the previous Administrator and previous Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for nineteen (19) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIA… | 2019-11-01 |
| 4342 | 4342 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 323 | L | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, physician interview, record review and facility policy review, the facility failed to provide an environment that was free of accident hazards, including: one resident (R15) with a lap tray device who continuously slid down in the wheelchair under the lap tray and failed to ensure a bed alarm was functional for one resident with a history of falls; failed to ensure measures were in place to prevent injuries for one resident (R7) who had a history of [REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. 1. On (MONTH) 2, (YEAR) at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. 2. On (MONTH) 25, (YEAR) at 6:10 p.m. the previous Administrator, previous DON and Corporate Registered Nurse were notified of IJ that was determined to existed on 8/21/16 when R15 was observed, by the surveyor, sitting in a wheel chair with a lap tray applied to the wheel chair, R15 slid down in the wheelchair with his chin resting on the lap tray which had been applied inappropriately to the wheelchair. R15 consistently slid u… | 2019-11-01 |
| 4343 | 4343 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 325 | J | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, staff and family interviews the facility failed to ensure nutritional needs were met for one (1) resident (R35) who had a 24.3% weight loss in three (3) months, in addition on 10/21/16 without a physician order [REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 11/22/16 the current interim Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. At the time of exit on 11/23/16, an acceptable Allegation of Credible Compliance had not been received, therefore the IJ remains on-going. Findings include: 1. Review of the monthly weight record revealed that R35 on 8/1/2016 weighed 152 pounds. On 9/7/16 R35 weighed 131 pounds which indicated a 13.8% weight loss in one (1) month, and he was placed on weekly weights. On 10/17/2016 and upon discharge on 11/9/2016, R35 weighed 115 pounds, a 24.3 % indicating a significant weight loss in three (3) months. Record review revealed a comprehensive metabolic panel (CMP) laboratory test result dated 9/8/2016 revealed an [MEDICATION NAME] level of 1.9 (normal 3.5-5.0). Review of the physician progress notes [REDACTED]. Revie… | 2019-11-01 |
| 4344 | 4344 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 327 | J | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, staff and family interviews the facility failed to ensure that one (1) resident (R35) had enough fluids to keep the resident hydrated which resulted in hospitalization with a [DIAGNOSES REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 11/22/16 the current interim Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. At the time of exit on 11/23/16, an acceptable Allegation of Credible Compliance had not been received, therefore the IJ remains on-going. Findings include: Record review revealed that R35 was re-admitted to the facility on [DATE] after a hospital admission for Altered Mental Status (AMS), wound infection and decreased oral intake. The resident was hospitalized again 9/26/16 and discharged back to the facility on [DATE] for Anorexia, AMS and failure to thrive, pneumonia and clinical severe dehydration with [MEDICAL CONDITION] (166), hyperchloridemia (139) and acute [MEDICAL CONDITION]. R35 was placed on the ST service for dysphagia management, diet modification and linguistic retraining. Continued review revealed a ST recommendation dated 1… | 2019-11-01 |
| 4345 | 4345 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 353 | L | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, it was determined that the facility failed to provide sufficient staff on the secured unit to prevent falls for one (1) resident (R17); failed to provide sufficient staff and supervision for the residents residing on the secured unit who had cognitive impairment and/or aggressive behaviors; failed to ensure one Registered Nurse (RN) was impaired while on the job on the secured unit; and failed to provide sufficient staff to ensure for twenty-two (22) residents (7, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 32 and 33) received medications as ordered Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. On (MONTH) 2, (YEAR) at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized… | 2019-11-01 |
| 4346 | 4346 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 354 | F | 1 | 0 | C00C11 | > Based on observation, record review, and staff interview, it was determined that the facility failed to ensure the previous Director of Nursing (DON) did not act as a charge nurse. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). Findings include: Observation, by the surveyor, on 10/19/2016 at 2:00 p.m. on Unit D, the locked unit, revealed that the previous Director of Nursing (DON) was working as the Medication nurse on the locked unit for the day shift. Observation, by the surveyor, on the same day at 7:20 p.m. of the DON giving report and conducting the Narcotic count with the oncoming nurse. A telephone interview with the Consultant Pharmacist on 10/20/16 at 2:50 p.m. revealed that he was in the building last week for the Pharmacy Review. He revealed that the facility is short of staff and that the previous DON was passing medications on his visit. During a subsequent interview with the previous DON on 11/2/16 at 10:00 a.m., she stated that she is pulled to work a medication cart at least three times a week due to the facility being short staffed. She stated this has been going on for months. She stated it started when the facility was taken over by a new company back in (MONTH) (YEAR). She stated she usually is pulled to push the med cart on the D Hall (secured unit). During an interview with the previous Administrator and review of the (MONTH) (YEAR) schedule on 11/3/16 at 3:20 p.m., she confirmed the previous DON was pulled to act as a charge nurse and to pass medications on dayshift on 8/8/16, 8/9/16, 8/15/16, 8/19/16, and 8/26/16. | 2019-11-01 |
| 4347 | 4347 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 386 | E | 1 | 0 | C00C11 | > Based on record review and staff interviews the facility failed to ensure that the Physician dated all orders and to ensure that a Physician who uses a signature stamp is the only person using the stamp. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). Findings include: Record review of the Physician orders for resident #35 revealed that all orders have a signature stamp for Physician XX without a date. Dates included: 10/22/2016, 10/20/2016, 10/19/2016, 10/12/2016, 10/10/2016, 10/6/2016, 10/4/2016, 9/26/2016, 9/22/2016, 9/15/2016, 9/8/2016, 9/7/2016, and 6/6/2016. Review of the Physician Order monthly summary reveals that the (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) used the signature stamp but without a date signed. A telephone interview with Physician XX on 11/23/16 at 10:37 a.m. revealed that he doesn ' t have signature stamp and that the nurses stamp the orders. He revealed that he has done this throughout his entire time in practice and ask if that was illegal. An interview with Medical Records clerk AAA on 11/23/16 at 10:49 a.m. reveals that she takes the Physician orders to Dr. XX office to be signed. She reveals that when the orders are ready for pick up the orders come back with Dr. XX signature stamp on them. She states the Doctors stamp is not at the facility. Clerk AAA reveals that the orders are taken to Dr. XX staff member BBB and we may want to speak to her about the signature stamp. A telephone interview with staff member BBB on 11/23/2016 at 10:55 a.m. reveals that she has the Dr. XX signature stamp and stamps the orders as they come in to his office. She then gives the orders for Dr. XX to review then returns the orders to the facility. | 2019-11-01 |
| 4348 | 4348 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 431 | E | 1 | 0 | C00C11 | > Based on staff interview, record review, and facility policy review, it was determined the facility failed to ensure that medications were secure by only permitting authorized personnel to have access to the medication cart and medication room keys for two medication carts and one medication room on one hall (secured unit) of four halls. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). Findings include: Review of the policy titled Controlled Substance Management and Destruction. The policy documented that the nurse does not allow others to have access to medication cart keys during the shift. During an interview on 11/1/16 at 4:30 p.m., the previous Director of Nursing (DON) stated that the keys to the medication carts and medication room should be held by licensed nurses only. She stated that non-nursing staff, for example, Certified Nursing Assistants (CNAs), should not have the keys. During an interview with CNA VV on 10/14/16 at 3:15 p.m., she stated that on the morning of 8/21/16 Licensed Practical Nurse (LPN) MM who worked on the D unit (secured unit) had to leave early and tried to give the keys to the nurse on Unit 1 but the nurse refused to take them. CNA VV stated she took the keys from LPN MM because she needed them on the D Hall (secured unit). CNA VV revealed that she left at 6:00 a.m. and accidentally locked the medication cart keys in the nurse's station. During an interview with LPN FF on 10/19/16 at 10:00 a.m., revealed that on the morning of 8/21/16 when she came on duty, she and another nurse were locked out of the nurse's station on D hall (secured unit) because the keys were locked in the nurses station. LPN FF stated they waited nearly an hour before they could finally get in the D hall (secured unit) nurses station. She stated that several times in (MONTH) (YEAR) and (MONTH) (YEAR) when she had come on duty, there was not a night shift nurse present and the keys would… | 2019-11-01 |
| 4349 | 4349 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 490 | L | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the Administrator job description and interviews, the facility failed to be administered in a manner to ensure that residents received the necessary care and services, specifically: 1. The previous Administrator failed to provide oversight related to staffing of the secured unit therefore, R#17 on 7/20/16 at 12:10 a.m. turned off the door alarm, on the D unit, went out onto the smoking porch in order to get a soft drink and fell resulting in a laceration to the resident's head. At this time, there was no Licensed Nurse assigned to the D unit, and only one nurse onsite in the facility (cross refer to F224, F280, F281, F309, F353, F354). On 7/27/16, a licensed practical nurse supervisor on the secured unit worked while impaired. In addition, review of the (MONTH) (YEAR) schedules and actual time sheets (Punch Detail Report) for Pleasant View and the second facility, revealed that the LPN worked at these two facilities at the same time on 8/10/16, 8/11/16, 8/13/16 and 8/20/16 from 7:00 p.m. to 7:00 a.m. leaving the secured unit without a nurse and with residents unsupervised, without a nurse to assess any changes in condition, or to act in the event of a life threatening emergency including cardiac or respiratory event and/or a disaster such as a fire. 2. The previous Administrator failed to ensure that the facility was free of restraints related to R#15, who had a lap tray applied to the wheel chair when out of bed, R#15 consistently slid underneath the lap trap, the staff was not educated on the application of the lap tray, the staff incorrectly tied the straps to the lap tray behind the chair, the facility failed to have the resident assessed for the use of the lap tray (cross refer to F221 and F279). It determined to exist on 8/21/16 when R#15 was observed, by the surveyor, sitting in a wheel chair with a lap tray applied to the wheel chair, R#15 slid down in the wheelchair with his chin resting on the lap… | 2019-11-01 |
| 4350 | 4350 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 514 | J | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to maintain accurate clinical records regarding the administration of medications, scheduled Insulin, Sliding Scale Insulin and FSBS for eighteen (18) residents (10, 11, 12, 13, 14, 16, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 32). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, remains on-going. On (MONTH) 2, (YEAR) at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. Findings include: Review of the facility's policy titled General Dose Preparation and Medication Administration, revealed that nurses should document necessary medication administration (e.g., when medications are given) on appropriate forms. 1. R10 was … | 2019-11-01 |
| 4351 | 4351 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 520 | L | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, it was determined that the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed and implemented corrective action plans to correct a problem of inadequate staffing, and the falls management program for three (3) residents (R7, R17, R15). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, remains on-going. 1. On (MONTH) 2, (YEAR) at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. (Cross refer to F224, F323 and F353) The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. 2. On (MONTH) 25, (YEAR) at 6:10 p.m. the previous Administrator, previous DON and Corporate Registered Nurse were notified of IJ that was determined to existed on 8… | 2019-11-01 |
| 4352 | 4352 | WOODSTOCK NURSING & REHAB CTR | 115421 | 105 ARNOLD MILL ROAD | WOODSTOCK | GA | 30188 | 2016-01-07 | 253 | E | 0 | 1 | QV3U11 | Based on observations and interviews, it was determined that the facility failed provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on five (5) of five (5) halls. Findings include: Observation conducted on 01/06/16 beginning at 08:20 a.m. with Maintenance Director revealed the following: 100 Hall: In room 103 the door frames are scratched with chipped paint. 200 Hall: In rooms 202 and 204 the bathroom sink counter had brown stains. In room 206 there is brown stains around the toilet base. In room 212 the door frames are scratched with chipped paint. 300 Hall: In room 310 the bathroom has been closed for repairs since 10/12/15. 400 Hall: In room 405 the door frames are scratched with chipped paint. In rooms 403 and 406 there is brown stains around the toilet base. 500 Hall: In rooms 505 and 506 ere is brown stains around the toilet base. In rooms 507, 508, 512, 513 and 515 there are baseboards missing from the walls. In room 514 the wall in bathroom stripped to brown drywall near soap dispenser. Interview on 01/06/16 at 11:13 a.m. conducted with the Maintenance Director confirmed the aforementioned areas needed improvement. The Maintenance Director further stated he had been short of maintenance staff person and needed more collaboration with housekeeping. | 2019-11-01 |
| 4353 | 4353 | WOODSTOCK NURSING & REHAB CTR | 115421 | 105 ARNOLD MILL ROAD | WOODSTOCK | GA | 30188 | 2016-01-07 | 371 | E | 0 | 1 | QV3U11 | Based on observation, review of policy and procedure and staff interviews, the facility failed to ensure that cold food products were stored at or below forty-one degrees Fahrenheit (41 F) which increased the likelihood of food borne pathogen to the one hundred-fifteen (115) residents who eat orally receive meals from the kitchen one (1) of two (2) refrigerator. Findings include: Observation of the kitchen on 1/4/16 at 9:00 a.m. with dietary staff AA revealed, the temperature inside of refrigerator one (#1) was 43 F. Observation of dietary staff AA revealed the temperature of a bowl of vanilla pudding from refrigerator #1 was 43 F. Dietary staff AA acknowledged the temperature was not at or below 41 F. Observation of the kitchen on 1/6/16 at 10:50 a.m. with dietary staff AA revealed, the temperature of refrigerator #1 was 41 F. Dietary staff AA and BB were observed taking the temperature of food items from refrigerator #1. Observation of jelly was stored in drink pitcher revealed a temperature of 43 F and a bowl of applesauce revealed a temperature of 42 F. Interview with the dietary staff AA and BB acknowledged the temperatures were below 41 F. Observation of the kitchen on 1/7/16 at 8:35 a.m. with dietary staff AA revealed the temperature of refrigerator #1 was 38 F. Observation of dietary staff AA revealed a Yoplait yogurt cup and a glass of apple juice with a temperature reading of 43 F. Dietary staff AA confirmed temperatures were not below 41 F. Interview at the time of the observation with dietary staff AA revealed that he would remove all food in refrigerator #1 to refrigerator #2 which had adequate temperatures. Observation of the kitchen on 1/7/16 at 12:20 p.m. with dietary staff AA revealed maintenance adjusted the temperature on refrigerator #1. Food in refrigerator #1 revealed the chocolate pudding cup was 38 F and a glass of milk was 38 F. Review of the policy titled Dietary Services dated 2007 documented: cold food products to be kept at or below 41 F to prevent or limit microbial growth and produc… | 2019-11-01 |
| 4354 | 4354 | CEDAR VALLEY NSG & REHAB CTR | 115436 | 225 PHILPOT STREET | CEDARTOWN | GA | 30125 | 2016-05-05 | 371 | F | 0 | 1 | DTC511 | Based on observations, staff interviews, review of the Dietary Services Policy and Procedure for Personal Hygiene & Dress Code and review of the Dietary Services Policy and Procedure for Food Storage, Prep, Sanitation & Best Practice, the facility failed to ensure opened food items were properly labeled and dated in the refrigerators, freezer, and dry storage for two (2) of four (4) days of the survey; and failed to ensure that dietary staff's facial hair was covered to prevent contamination. This deficient practice had the potential to effect all eighty (80) residents receiving an oral diet. Findings include: Observation on 05/02/16 at 10:45 a. m. of the two (2) door reach-in refrigerator in the food preparation area revealed an opened eight (8) ounce glass jar of maraschino cherries, an opened one (1) gallon container of lemon juice, an opened one (1) gallon container Worcestershire sauce, an opened one (1) gallon container of white vinegar, an opened six (6) pound white plastic container of sliced strawberries, and an opened sixteen (16) ounce container of Cool Whip topping. None of those food items had dates when they were opened. Observation on 05/02/16 at 11:10 a. m. of the dry storage area revealed a clear plastic bin with a five (5) pound bag of Fudge Brownie Mix that was opened with no date. Continued observation revealed that there was a thirty-five (35) ounce bag of Rice Cereal in a green plastic tote that was opened with no date when it was opened. Further observation of the dry storage area revealed that in another green plastic bin there was an opened bag of Barilla spiral pasta that did not have an open date. Observation on 05/02/16 at 11:15 a. m. of the chest freezer revealed an opened one (1) gallon container of vanilla ice cream that did not have a date of when it was opened. Observation on 05/04/16 at 11:55 a. m. of the two (2) door reach-in refrigerator near the food preparation area revealed a white Styrofoam container. The Styrofoam contained grits, scrambled eggs, bacon, and a white plastic… | 2019-11-01 |
| 4355 | 4355 | CEDAR VALLEY NSG & REHAB CTR | 115436 | 225 PHILPOT STREET | CEDARTOWN | GA | 30125 | 2016-05-05 | 441 | E | 0 | 1 | DTC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and policy review, the facility failed to ensure that staff washed/sanitized their hands between residents when serving and setting up meals and beverages for three (3) of four (4) dining observations in the main dining room and on two (2) of two (2) halls (100 Hall and 200 Hall). The census was eighty (80) residents. Findings include: Observation on 05/02/16 at 12:35 p.m. of the first meal service in the main dining room revealed Registered Nurse (RN) DD approached a resident sitting at a dining table and touched the resident's left elbow. Continued observation of the RN revealed that DD then touched her hair and walked to the area with assembled resident lunch meal trays. Without washing or sanitizing his/her hands, DD obtained another lunch meal tray and delivered it to another resident. Observation on 05/02/16 at 1:30 p.m. of the second meal service in the main dining room revealed that three (3) Certified Nursing Assistants (CNAs) grabbed chairs from various other dining tables and moved them to assist residents with feeding. Further observation revealed that the three (3) CNAs did not wash or sanitize their hands before feeding the residents. Observation on 05/04/16 at 8:15 a.m. of Certified Nursing Assistant (CNA) CC revealed that she delivered a breakfast meal tray to the resident in room [ROOM NUMBER]-[NAME] While in the room, CC touched the resident's privacy curtain closest to the door to the hallway. CC exited the room and did not wash or sanitize her hands before she delivered a breakfast tray to the resident in room [ROOM NUMBER]-[NAME] CC touched and adjusted the resident's bedside table and did not wash or sanitize her hands prior to exiting the room. Observation on 05/04/16 at 8:20 a.m. of CNA EE revealed that EE delivered a breakfast meal tray to the resident in room [ROOM NUMBER]. While in the room, EE was observed touching two (2) empty clear plastic drinking glasses from the resident's be… | 2019-11-01 |
| 4356 | 4356 | PRUITTHEALTH - BLUE RIDGE | 115468 | 99 OUIDA STREET | BLUE RIDGE | GA | 30513 | 2015-09-03 | 252 | D | 0 | 1 | LF9511 | Based on observation, staff interview and record review the facility failed to maintain an environment free of accident hazards for one resident (#116) from a sample of twenty five (25 ) residents. Findings Include: Observation of resident #166 room conducted on 09/02/2015 8:15 AM during medication administration revealed LPN AA pushed the resident via his wheelchair from the hallway into his room A-8. Resident #166 does not have a roommate at this time. The resident had difficulty fitting his wheelchair into his room because a Sara Lift was on the right side of the room and a Hoyer lift on the left side of the room. After medication administration was completed AA was interviewed regarding the equipment storaged in the resident ' s room. She is not aware of why the lifts are in the resident ' s room. An interview with BB CNA revealed that she was told to move things from the hallway and keep the hallways clear so she moved the lifts into his room. A record review on 09/02/2015 at 9:12 AM revealed AA is coded on the MDS (Minimum Data Set) as having moderately impaired vision and at risk for falls due to his history of falls and poor safety awareness. He is assessed as having unsteady gait. The resident is care planned for his decrease in vision with an intervention to maintain uncluttered environment free of obstacles and safety hazards. He is also care planned for his potential for injury from falls due to his history of falls with a safety intervention to keep pathways clear and free of all obstacles. Interview conducted with the Administrator on 9/2/2015 at 11:15 reveals there are closets available to store lifts and other equipment as well as the maintenance shed. It is his expectation that equipment be kept out of the way and not a safety hazard. He was not aware that a resident ' s room was being used for storage. | 2019-11-01 |
| 4357 | 4357 | PRUITTHEALTH - BLUE RIDGE | 115468 | 99 OUIDA STREET | BLUE RIDGE | GA | 30513 | 2015-09-03 | 282 | D | 0 | 1 | LF9511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and staff interviews, the facility failed to follow the plan of care related to vision one (1) resident (#38) from a sample of twenty-five (25) residents. Findings include: Review of the medical record for resident #38 revealed the resident was admitted to the facility on [DATE]. Further review revealed the plan of care initiated 12/8/14 listed : Decreased vision as evidenced by (AEB) diagnosis (Dx) Diabetes Mellitus (DM), aging process, resident states that she has reading glasses at home. Interventions: Ensure a safe obstacle free environment. Eye exam as indicated. Obtain eyeglasses for patient. Provide assistance to patient with maintaining cleanliness of eyeglasses. Maintain uncluttered environment free of obstacles and safety hazards. Use large-print material with patient. Place frequently used items within easy reach and visual field of patient. Provide assistance with Activities of Daily Living (ADLs), dining and transfers as needed. Continued review revealed that the care plan was updated as: on 2/17/15 met goal and continue plan of care with target date 5/27/15, on 3/27/15 met goal and continue plan of care with target date 6/27/15, on 6/23/15 met goal and continue plan of care with target date 9/23/15 and on 8/25/15 met goal and continue plan of care with target date of 11/25/15. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had vision impairment, see large print, with no corrective lenses. Review of the Social Worker History Form updated 8/19/15 revealed resident #38 loved to paint pictures and work word puzzles. Resident is able to read and able to participate in care plan. Interview conducted on 9/3/15 at 11:20 am with the Social Worker NN revealed she was unable to get the resident's glasses. She further revealed that she has talked with resident #38 and resident has never mentioned her glasses to NN and she is not sure the residen… | 2019-11-01 |
| 4358 | 4358 | PRUITTHEALTH - BLUE RIDGE | 115468 | 99 OUIDA STREET | BLUE RIDGE | GA | 30513 | 2015-09-03 | 313 | D | 0 | 1 | LF9511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to assist one (1) resident (#38) obtain personal assistance devices to maintain visual abilities from a sample of twenty-five (25) residents. Findings include: Review of the medical record for resident #38 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review revealed resident #38 was the responsible party and had one friend listed under contacts who had passed away. Review of the Occupational Therapy Plan of Care assessment completed on [DATE] indicated resident is expected to remain long term resident in Skilled Nursing Facility. Further, under section titled Underlying Impairments Other the resident stated that she wears glasses, but does not have them in facility. Review of the TridentUSA Mobile Clinical Services request for Eye Evaluation dated [DATE] revealed TridentUSA Mobile Clinical Services recently screened the above resident and found pre-existing eye conditions or reduced visual acuity ( Review of the Social History Form completed [DATE] revealed resident #38 loved to paint pictures and work word puzzles. Speech was clear, hearing adequate, vision impaired. Potential psychosocial needs acquiring interventions: Not Applicable (N/A) . Own responsible party. No other contacts. Resident is able to read and able to participate in care plan. Review of the care plan for resident #38 with problem onset dated [DATE] revealed: Decreased vision as evidenced by (AEB) Diagnosis (DX) Diabetes Mellalitis (DM), aging process, resident states that she has reading glasses at home. Under Approaches lists: Obtain eyeglasses for patient, provide assistance to patient with maintaining cleanliness of eyeglasses, and eye exam as indicated. Follow up documented [DATE] indicated Social Services (SS) reports that residents' landlord person who has key to her home stated that they will bring her stuff, including her glasses. As of this date, we have not received any of h… | 2019-11-01 |
| 4359 | 4359 | PRUITTHEALTH - BLUE RIDGE | 115468 | 99 OUIDA STREET | BLUE RIDGE | GA | 30513 | 2015-09-03 | 441 | E | 0 | 1 | LF9511 | Based on observations, staff interview, and facility policy review, the facility failed to wash hands and/or sanitize hands and failed to change gloves during dining and dining tray distribution to prevent the transmission of a possible infection. The total census was one hundred and one (101) with two (2) residents receiving enteral feeding. Findings include: 1. Observation of the lunch meal on the Hall D on 08/31/15 at 12:20 p.m., revealed that the trays were distributed to the residents by OO , DD , Certified Nursing Assistants (CNA). During the observation the staff wore gloves and touched the residents on the shoulders, adjusted their chairs, touched the table linens, light switches, opened milk cartons, uncovered drinking glasses, buttered potatoes with the residents utensils, then returned to the cart, and retrieved another resident's tray and assisted the next resident in the same manner. Continued observation revealed that OO pulled the screen covering the linen cart back, retrieved a towel and used the towel to cleanup a spilled drink on the floor. Further observation revealed DD went into room D2, used the electric bed control to adjust the head of the bed for one resident, moved the resident 's pillow, touched the linens, buttered the baked potato, set up the tray, and unfurled the silverware from the napkin. All of this was done without removing or changing the gloves or sanitizing and/or washing hands between residents. 2. Observation of the lunch meal served in the dining room on 09/01/15 at 12:05 p.m., revealed that the trays were distributed to the residents by CNA's EE , FF , and GG . During the observation the staff wore gloves and gripped the sides of the rolling cart as they propelled it throughout the dining room. In addition, as they assisted the residents the CNA's touched the residents table linens, moved chairs to different tables, pushed residents closer to the table in their chairs, fastened the resident ' s clothing protectors, opened milk cartons, uncovered drinking glasses, buttered… | 2019-11-01 |
| 4360 | 4360 | MCRAE MANOR NURSING HOME | 115494 | 160 SOUTH FIRST AVENUE | MC RAE | GA | 31055 | 2015-09-30 | 159 | D | 0 | 1 | C7TC11 | Based on resident interviews, record review and staff interview, the facility failed to have resident's personal funds available on the weekends and holidays for five (5) residents from a sample of twenty five (25) residents. During Stage 1 interviews, residents #19, #80, #108 and #92 all reported that they were unable to get money from their personal funds accounts on the weekends and holidays when no business office personnel were in the building. Interview with employee BB on 9-29-15 at 2:30 p.m. revealed that if a resident asks about money on the weekends he/she tells them they have to wait until Monday when the business office is here to give them money. Interview with resident #107, on 9-29-15 at 2:45 p.m. revealed that he/she is unable to get money out on the weekend. Stated he/she has to wait until Monday. Interview with employee CC, on 9-29-15 at 2:55 p.m. revealed that if the resident doesn't get money out on Friday they have to wait until Monday. He/she stated that if they want money on the weekend for the vending machines he/she will give them some money. Interview with employee DD on 9-29-15 at 3:00 p.m. revealed that there is money available that the RN keeps. Did not know where it was kept or how to access the money. Interview with employee AA on 9-29-15 at 3:30 p.m. revealed that residents do have access to their personal funds on the weekends. Money is left in a locked cabinet and the RN has a key. Employee AA confirmed that it is not posted in the facility that money is available on the weekends and how to access it. Interview with the Administrator on 9-29-15 at 3:50 p.m. revealed that there was no notice posted in a clear and noticeable place to inform resident's that funds are available on the weekend. | 2019-11-01 |
| 4361 | 4361 | MCRAE MANOR NURSING HOME | 115494 | 160 SOUTH FIRST AVENUE | MC RAE | GA | 31055 | 2015-09-30 | 441 | E | 0 | 1 | C7TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to follow infection control practices on two (2) of four (4) halls, in six (6) of sixty-three (63) rooms and during wound care treatment for one (1) resident #103 from a sample of twenty-five (25). Findings include: An observation of wound care treatment for resident #103 on 9/30/25 at 7:51 a.m. with Licensed Piratical Nurse (LPN) FF revealed that (LPN) FF did not remove the donned gloves or wash his/her hands after removing the soiled dressing. He/she was then observed to apply a clean dressing during. At the end of the wound care treatment during interview, LPN FF revealed that he/she did not wash their hands or apply new gloves after removing the soiled dressing and applying the new dressing to resident #103. Record review for resident #103 revealed a healing stage three to the coccyx and a physicians order written (MONTH) (YEAR) to cleanse wound to coccyx with normal saline and apply medi honey alginate and dry dressing daily. Review of the facilities infection control policy for wound care revealed; remove soiled dressing and place in bag. Remove gloves and discard in bag. Wash your hands. Put on clean gloves. During initial tour on 9-28-15 at 9:30 a.m. in the bathroom of room [ROOM NUMBER] a basin stored on a shelf was not labeled nor stored in a plastic bag. During initial tour on 9-28-15 at 9:32 a.m. in the bathroom of room [ROOM NUMBER], a basin stored on a shelf was not labeled nor stored in a plastic bag. During initial tour on 9-28-15 at 9:35 a.m. in the bathroom of room [ROOM NUMBER], a basin stored on a shelf was not labeled nor stored in a plastic bag, and a bedside toilet was not labeled with residents name. During initial tour on 9-28-15 at 9:40 a.m. in the bathroom of room [ROOM NUMBER], a basin and a urinal were stored on a shelf not labeled nor stored in a plastic bag. During initial tour on 9-28-15 at 9:45 a.m. in the bathroom of room [ROOM NUMB… | 2019-11-01 |
| 4362 | 4362 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 157 | K | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify family and/or the physician of incidents or changes in resident status. Specifically: the facility failed to notify the family in a timely manner of an allegation of abuse for one (1) resident (R6); the facility failed to ensure timely notification of responsible parties/family members when the resident developed a pressure ulcer for one (1) resident (R22); and the facility failed to notify the physician when the blood sugars of R10, R19 and R24 were below 70. The sample was seventy-seven (77) residents. Refer F223, 225, 226, 309 and 314 A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ). An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F157 was lowered to an E, while the facility develops and implements the Plan of Correction (PoC). Findings include: 1. Review of R6's clinical record revealed a [DIAGNOSES REDACTED]. R6 was verbally, physically and emotionally abused on 6/9/16. The facility staff became aware of the abuse on 6/9/16, however they did not notify the physician until a day or two later, nor the responsible party until 6/17/16. Interview conducted with the family during complaint triage on 7/18/16 at 9:10 a.m. revealed that the family was not notified of the abuse which occurred on 6/9/16 incident until 6/17… | 2019-11-01 |
| 4363 | 4363 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 164 | D | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, resident interviews and record review the facility failed to provide privacy for two (2) residents (R30 and R10) during activities of daily living (ADL's) and personal care, and; failed to respect the privacy for one (1) resident (R4) with an uncovered indwelling catheter bag. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Findings include: 1. R30, according to the 8/16/16 face sheet, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS - a comprehensive assessment completed by facility staff that drives the care planning process), with an Assessment Reference Date (ARD) of 7/28/16, documented R30 had a [DIAGNOSES REDACTED]. Section G0110 1. Activities of Daily Living (ADL's) documented that R30 required extensive assistance of one to perform dressing, bed mobility, transfer and personal hygiene. On 8/10/16 at 10:15 a.m., this surveyor knocked on room [ROOM NUMBER] and entered the room. R30 was observed lying on her bed in just a brief and the RCS (Resident Care Specialist (Nurse Aide) was assisting R30 with activities of daily living (ADLs). The privacy curtain was not pulled completely around, leaving R30 exposed to her roommate (R10) and anyone entering the room. On 8/11/16 at 11:45 a.m., R30 stated she was not aware that she was exposed. She stated she has not been feeling very well. When asked if she recalled lying on the bed with only a brief on, she stated, No, I don't want people to see me like that, I would never allow others to see me half-dressed. She apologized for having exposed herself. On 8/11/16 at 11:55 a.m., R10 (R30's roommate) stated that sometimes it bothers her that nursing staff will not close the curtain between the beds and when they don't close the curtain and someone walks in during personal care that is embarrassing. She stated she does not always care about being exposed to … | 2019-11-01 |
| 4364 | 4364 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 223 | J | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to assure that one (1) resident (R6) was free from verbal, rough handling abuse on 6/9/16 by a Certified Nursing Assistant (CNA) 68. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. This failure caused actual harm to R6. The facility failed to prevent R6 from verbal, emotional and physical abuse by staff, failed to investigate the allegation of abuse in a timely manner, failed to take immediate action to suspend the alleged perpetrator and protect other residents during the investigation, according to the facility policy, placed other residents at risk for serious injury or harm. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ). An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F223 was lowered to a D, while the facility develops and implements the Plan of Correction (PoC). Cross refer to F225 and F226 Findings include: Review of a facility policy, dated 7/16/16, received on 8/8/16 at 4:40 p.m., from the Corporate Nurse as current, indicated: Each Resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Any observations or allegations of abuse, neglect, or mistreatment must be imme… | 2019-11-01 |
| 4365 | 4365 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 225 | J | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to investigate an allegation of abuse, failed to report to the State Survey Agency (SSA) within twenty-four (24) hours, failed to protect residents from during the investigation of alleged abuse, failed to report the findings of a substantiated allegation of verbal and physical abuse, which occurred on 6/9/16, within 24 hours for one (1) resident (R6) reviewed for abuse. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ). The facility failed to report to the State Survey Agency (SSA) in a timely manner, a substantiated allegation of verbal and physical abuse, which occurred 6/9/16. The facility incident report was not sent to the SSA until 6/17/16, which was eight (8) days after the incident. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F225 was lowered to a D, while the facility develops and implements the Plan of Correction (PoC). cross refer to F223 and F226 Findings include: Review of a fax sent to the SSA Complaint and Intake Unit, dated 6/22/16, indicated: a report was discovered on 6/16/16 from a new Certified Nursing Assistant (CNA) ZZ who reported an incident that happened involving her preceptor CNA68 during her orientat… | 2019-11-01 |
| 4366 | 4366 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 226 | J | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to follow their policy and procedure for investigation of allegations of abuse, reporting allegations to the state agency (SSA) within twenty-four (24) hours, failed to provide protection of residents during investigation of alleged abuse, for one (1) resident (R6) who was verbally, emotionally and physically abused on 6/9/16. The facility failed to report the incident to the State Survey Agency (SSA) in accordance with their policy, failed to implement their policy on abuse including reporting, investigating, and failed to assure protection of R6 and other residents in the facility immediately following the report of alleged abuse and failed to train all staff members in Abuse Policies and Procedures. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ) related to failure to report, failure to protect residents from abusive behavior by a Certified Nursing Assistant (CNA) who verbally, emotionally and physically abused R6; failed to investigate the allegation of the abuse within twenty-four (24) hours of becoming aware of the abuse; failed to adhere to the facility's policy related to abuse and failed to report to the SSA within the 4 hours of becoming aware. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented,… | 2019-11-01 |
| 4367 | 4367 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 253 | E | 1 | 0 | 3P2Y11 | > Based on observations and interviews on the secure unit, the facility failed to maintain a sanitary, orderly and comfortable interior. Specifically, they failed to address the very strong and constant urine odor. There were 35 residents residing on the secure unit. The sample was seventy-seven (77) residents. Findings include: Observtion of the secure unit took place at approximately 10:00 a.m. on 10/31/16. Upon exiting the elevator on to the unit, there was an extremely strong smell of urine. It was pervasive throughout the unit, but especially strong near rooms 308 and 309. Interview with the Unit Manager (UM) of the secure unit on 10/31/16 at approximately 11:00 a.m. revealed she thought the smells were better than when you were here before - in reference to a complaint survey in (MONTH) (YEAR). There were no windows open or patio doors open to help abate the smell. Interview with Restorative Aide (RA) #184 on 11/2/16 at approximately 8:45 a.m. she said she believed the odor was due to one incontinent resident who frequently urinated on the floor of his room and bathroom. She also stated they had incontinent residents in that room before. Interview and observation with the Nursing Home Administrator(NHA) on 11/2/16 at approximately 11:30 a.m. he stated he was aware they had some odor problems. During the observation the NHA acknowledged it was unacceptable. He stated he would have his Maintenance and Housekeeping Directors address the issue immediately. Observations on 11/2/16 at 8:45 a.m. revealed the odor was still very strong. When the elevator door opened to the secure unit, the smell was apparent immediately. It worsened as approaching rooms 308 and 309. Observations on 11/3/16 at 10:00 a.m. revealed the odor was decreased, but still strong. When the elevator door opened to the secure unit, the smell was apparent immediately. It worsened as approaching rooms 308 and 309. Observation on 11/4/16 at 5:00 p.m. revealed that the smell had decreased, but still was unacceptable in its strength. It was still st… | 2019-11-01 |
| 4368 | 4368 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 279 | D | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of Admission Records, Behavior Log and Care Plans (CP), and interviews, the facility failed to initiate and/or revise their comprehensive care plans related to use of a right arm sling that was to be used during transfer activities and meals for resident (R183); and failed to develop and/or revise the care plan to include the resident's behaviors, eating in her room, her inability to get along with others or nonpharmacological interventions for resident (R39). The sample was seventy-seven (77) residents. Findings include: 1 The Admission Record indicated R183 was admitted to the facility in (MONTH) (YEAR) and his [DIAGNOSES REDACTED]. The current CP that was not dated did not indicate R183 required the use of a sling during transfer activities and meals. Interview with Occupational Therapist (OT) 180 on 11/3/16 at 12:16 p.m. and on 11/8/16 at 10:07 a.m., she said R183 had subluxation of the right shoulder and required the use of a sling, which the staff were to use for transfer activities and meals. OT 180 said she was not aware that the CP did not include the use of a sling. Interview with the Director of Nursing (DON) on 11/9/16 at 12:00 p.m., she said although R183 required the use of a sling, there was no CP to address the sling. 2. The Admission Record indicated R39 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. The CP read, in pertinent part, R39 has a behavior problem r/t (related to) yells out a lot, resist care, verbally abusive to others. It was initiated on the CP on 8/3/16 and revised 10/21/16. The interventions were, Administer medications as ordered, allow choices within individual's decision making abilities, anticipate and meet resident needs, notify MD as needed. Observation on 10/31/16 at approximately 10:00 a.m., R39 was observed to be in her room alone. Her breakfast tray was on the overbed table and she had eaten 100%. She stated she was hungry. The Unit Manager (UM) … | 2019-11-01 |
| 4369 | 4369 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 281 | K | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, including review of the Georgia Nurse Practice Act, Chapter 410-10, Lippincott's 8 Rights of Medication Administration, the policy titled Respiration assessment, long-term care Revised: (MONTH) 02, (YEAR), the facility failed to ensure acceptable professional standards were implemented to meet the needs of the residents. Specifically, the facility failed to; a. failed to ensure changes in respiratory status were assessed and monitored as expected for one resident (R21); b. failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two (2) of 2 residents (R28, R29) that had tracheostomies and required multiple medical apparatus; Refer to F328. c. failed to ensure residents with pressure sores (PS) received necessary treatment and services to promote healing for six (6) of thirty (30) sampled residents (R18, R20, R22, R23, R25 and R28). Refer to F314, and; d. ensure eleven (11) of thirteen (13) residents (R32, R5, R7, R9, R10, R14, R18, R19, R231, R25 and R27) who were reviewed for sliding scale insulin, received the appropriate care to stabilize blood sugar (BS). Review of a list provided by the DON on 8/11/16 at 5:20 p.m., revealed that 40 residents had physician orders [REDACTED]. Refer to F309. e. Failed to ensure timely administration of medications to residents. This had the potential to affect the residents on the unit. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility … | 2019-11-01 |
| 4370 | 4370 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 282 | K | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review including Fall Management, Overview, Practice Guidelines and interviews, the facility failed to follow the care plan (CP) which identified individualized interventions developed by the Interdisciplinary Team (IDT) to assist staff to care for the residents, for nine (9) residents (R15, R18, R20, R22, R23, R25, R28, R29, and R183) specifically: a. failed to ensure that the CP included necessary emergency respiratory interventions to address the need of an emergency i.e. inner cannula re-insertion, ambu bags for each resident, and electrical outlets to supply power sources to the needed equipment for two (2) of 2 (R28, R29) residents that had tracheostomies, pressure sores (PS) and required multiple medical apparatus; Refer to F328. b. failed to CP including interventions for prevention, detection, weekly assessments were implement to ensure that residents without PS did not develop PS, failed to ensure residents with PS did not worsen, and failed to ensure residents with PS received necessary treatment and services to promote healing for 6 residents (R18, R20, R22, R23, R25 and R28); Refer to F314. c. failed to ensure that the CP included individualized interventions for R15 who had a history of [REDACTED].e. more frequent monitoring, they failed to determine the actual cause of the falls, failed to use their own Fall Management, Overview, Practice Guidelines therefore R15 fell multiple times while in the facility, contributing to an additional [MEDICAL CONDITION] which led to her ultimate demise, and; Refer to F323. d. failed to apply a right hand splint to prevent contractures for one resident (R 183). Refer to F318. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. On [DATE] at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility ' s … | 2019-11-01 |
| 4371 | 4371 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 309 | E | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews, record review, and facility policy review, review of the American Diabetes Association, Management of diabetes in the long-term care (LTC) setting, the facility failed to ensure eleven (11) residents (R32, R5, R7, R9, R10, R14, R18, R19, R231, R25 and R27) received insulin and/or finger stick blood sugar assessments (FSBS) as ordered by the physician, and failed to ensure that the blood monitoring devices were accurately functioning using the control assessments. The facility had a total of forty (40) residents with physician orders for sliding scale insulin, who were identified by a list provided by the Director of Nursing (DON) on [DATE] at 5:20 p.m. The sample was seventy-seven (77) residents. Findings include: Review of the American Diabetes Association, Diabetes Care (YEAR) Jan; 39 (Supplement 1): S81-S85. > specifically: Treatment in Skilled Nursing Facilities and Nursing specifically Management of diabetes in the long-term care (LTC) setting (i.e., nursing homes and skilled nursing facilities) is unique. It is also recommended that LTC facilities develop their own policies and procedures for prevention and management of diabetes. Major organizations such as the ADA and others concur on the need to individualize treatments for each patient, the need to avoid both [DIAGNOSES REDACTED] and the metabolic complications of diabetes, and the need to provide adequate diabetes training to LTC staff. Older adults with diabetes in LTC are especially vulnerable to [DIAGNOSES REDACTED]. They have a disproportionately high number of clinical complications and comorbidities that can increase [DIAGNOSES REDACTED] risk: impaired renal function, slowed hormonal regulation and counter regulation, and suboptimal hydration, variable appetite and nutritional intake, polypharmacy, and slowed intestinal absorption. Another consideration for the LTC setting is that unlike the hospital setting, the concern is that patients ma… | 2019-11-01 |
| 4372 | 4372 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 314 | K | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure residents without pressure sores (PS) did not develop PS; failed to ensure residents with PS did not worsen, and; failed to ensure residents with PS received necessary treatment and services to promote healing for six (6) residents (R18, R20, R22, R23, R25 and R28). The sample was seventy-seven (77) residents. Review of the CMS Form 671, signed and dated by the Director of Nursing revealed a total of ten (10) residents with PS, five (5) of which were acquired within the facility, 109 residents receiving preventative skin care, 2 residents are bed-fast, 94 residents in the bed/chair most of the time, 79 residents incontinent of urine and 68 incontinent of bowel, with 2 residents on a toileting program. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 3:36 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed the facility's failures in measuring, treating, providing consistent power sources for an air mattress, and preventing worsening of pressure sores created a situation of Immediate Jeopardy for serious harm to the residents. Findings include: 1. Review of the clinical record for R28 revealed he was admitted on [DATE] with a stage 4 PS on the buttocks and a stage 2 pressure ulcer on his posterior thigh the PS was not measured at this time or at any time after admission by the nursing staff. There were numerous omissions for the wound treatments. The Wound Doctor (WD) measured the wounds on [DATE] and again on [DATE], the sacral wound had doubled in size and the stage II was actually a stage III. R28's PS were not measured or adequately assessed upon admission, they were not measured/assessed weekly, the initial inaccurate staging of the posterior thigh wound wa… | 2019-11-01 |
| 4373 | 4373 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 315 | D | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview the facility failed to ensure there was a physician's order for one (1) resident (R4) with an indwelling catheter. Review of the CMS Form -672, signed and dated by the Director of Nursing on 11/1/16, indicated there are a total of nine (9) residents with indwelling urinary catheters. Findings include: Review of the clinical record for R4 revealed a [DIAGNOSES REDACTED]. Review of the care plan (CP) for R4 indicated the date of initiation for the indwelling catheter was 5/4/16. Review of the August, (YEAR) Physician's orders for R4 revealed no evidence of an order for [REDACTED].>Review of the Minimum Data Assessment (a resident assessment tool), dated 8/4/16, indicated R4 had an indwelling catheter. Review of a facility policy, provided by RN157, titled, Indwelling urinary catheter care and management, did not address that a physician's order was required for the use of an indwelling catheter. Observation on 8/8/16 at 8:40 a.m. and 3:00 p.m. and on 8/16/16 at 11:55 a.m., R4 was observed with a catheter leg bag strapped across his left knee. Interview on 8/11/16 at 12:50 p.m., with Licensed Practical Nurse (LPN)32, the LPN indicated R4 was admitted to the facility with the indwelling catheter. | 2019-11-01 |
| 4374 | 4374 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 318 | D | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to communicate the need for use of a sling during transfer activities and meals, failed to ensure use of the right hand splint per the Occupational Therapist's (OT) recommendations, and failed to follow their Splint or Brace Assistance Policy for one (1) resident (R#183). Review of the CMS Form-672 dated and signed by the Director of Nursing on 11/1/16, revealed a total of eighteen (18) resident with contractures. The sample was seventy-seven (77) residents. Findings include: Review of the undated policy entitled Splint or Brace Assistance indicated the minutes and number of times daily that the RA applies the splint or brace should be recorded in the clinical record. The splint or brace is prescribed by a physician. Splint rounds can be conducted weekly or monthly. The Admission Record indicated R#183 was admitted to the facility in (MONTH) (YEAR) and his [DIAGNOSES REDACTED]. The 4/29/16 quarterly Minimum Data Set (MDS) indicated R#183 had a Brief Interview of Mental Status (BIMS) score of 5 out of 15, which indicated R#183 had cognitive impairment. The MDS indicated R#183 required assistance with dressing and two staff for transfer activities. The current plan of care (poc) that was not dated indicated R#183 received restorative care, which included range of motion, a right arm rest on the wheelchair, a right hand splint, and restorative care to be completed per the order. The 1/15/16 Occupational Therapy (OT) Evaluation & Treatment indicated R#183 had impairment of his right shoulder, elbow/ forearm, wrist and hand, and had no current orthotic device. The 2/26/16 Rehab to Restorative Transition Record indicated restorative therapy was to provide sit-to-stand exercises and place the splint on R183's right hand six days a week. The 3/8/16 OT Evaluation & Treatment indicated R#183 was motivated to go home and OT services were initiated until 3/25/16. The 3/17/16 Physician Order inc… | 2019-11-01 |
| 4375 | 4375 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 323 | G | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a safe environment for three (3) residents (R15, R28 and R29). Specifically, the facility: a). failed to provide adequate supervision and assistive devices to prevent accidents for R15 who had a history of [REDACTED]. R15 sufferred actual harm when she fell again contributing to an additional hip fracture which led to her ultimate demise, and; b). failed to ensure the environment remained as free from accident hazards as possible for R28 and R29 who required multiple electrical devices when their medical equipment was plugged in to a power strip, this resulted in actual harm when the facility unplugged the pressure prevention mattress used for R28 who had severe pressure sores. (cross refer to F314) The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Review of the CMS Form 672, signed and dated on [DATE] by the Director of Nursing revealed a total of 10 residents ambulated, 3 ambulated with assistance, 2 are bedfast, and therefore at least a total of 97 residents are at fall risk. Findings include: 1. Review of the Transfer/ Discharge Report revealed R15 was re-admitted to the facility on [DATE] from the hospital after having Open Reduction and Internal Fixation (ORIF) surgery to repair a fractured hip. R15 had [DIAGNOSES REDACTED]. The resident expired on [DATE]. Review of the hospital records [DATE] History and Physical revealed This patient is a very pleasant, [AGE] year-old with a known history of heart failure, chronic pain, neuropathy, spinal stenosis, and generalized debility, who apparently has been having pain in her right lower extremity for the past several days. According to her son, the R15 has not incurred any falls; however, he was informed last Thursday that the R15 had gently slumped to the ground. He states that ever since that time, she has been having severe right lower extremity pain. She has been working with… | 2019-11-01 |
| 4376 | 4376 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 328 | K | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two residents (R28 and R29) residents that had tracheotomies (trachs) and required multiple medical apparatus including ventilator (machine to aid and/or deliver respirations). Review of the CMS Form 672, signed and dated by the Director of Nursing on 11/1/16, revealed no evidence of trachs, and 5 receiving respiratory treatments. The sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/12/16 at 3:36 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ) situation. The facility's failure to ensure all necessary respiratory related medical equipment for two residents (R28 and R29) with tracheotomies were readily available; and that a safe and appropriate power source was available for their medical equipment, placed residents at risk of serious harm or death effective on 6/25/16 Those failures left residents vulnerable to respiratory distress, and/or death. This failure increased the likelihood for serious harm to two (2) of 2 residents (R28 and R29) with tracheotomies, who: Required back-up replacement inner cannulas in the event their cannulas became dislodged and required emergency replacement. The facility did not ensure the necessary equipment for potential respiratory distress (Ambu bags -manual resuscitators- for both residents, and correctly sized replacement inner cannulas for their tracheotomies) was available, and; Required more electrical outlets to ensure effective delivery of care via medical apparatus than was available. The facility used power strips to prov… | 2019-11-01 |
| 4377 | 4377 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 356 | B | 1 | 0 | 3P2Y11 | > Based on observation and staff interview, the facility failed to ensure required nurse staffing information, was updated daily and posted at the beginning of each shift for residents and visitors in the facility. This had the potential to affect residents who were capable of reading the information as well as visitors to the facility. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Findings include: Observtion on 8/8/16 at 8:55 a.m., the nursing staff information was posted in the hallway leading to the East unit by the admission office. There were three nursing staff forms posted with the top form showing a date of 7/30/16, the second form was dated 7/31/16 and the third form was dated 8/1/16. On 8/12/16 at 9:35 a.m., during a group conversation with the Administrator, receptionist and unit manager (UM)162, the receptionist stated that the nurse staffing should be posted daily. She discussed that the scheduler left about a month ago and the managers were all in charge of ensuring it got updated. The Administrator stated, his admission manger had noticed it right away and changed it immediately. The Administrator was informed the postings were from (MONTH) and were over a week old upon entering. The receptionist confirmed this for the Aministrator and he stated, That was my fault, I will own that. | 2019-11-01 |
| 4378 | 4378 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 371 | E | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff and resident interviews, review of the FDA Food Code; the facility's Food Storage: Cold HCSG policy 022; the facility's Food: Preparation HCSG policy 015; and resident clinical records, the facility failed to ensure cold foods were stored and served at appropriate temperatures and failed to ensure food holding temperatures were measured and recorded per the facility policy. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Review of the CMS Form-672, signed and dated on 11/1/16 by the Director of Nursing (DON) revealed a total of six (6) non-oral eating residents, therefore a total of one-hundred-three (103) residents are at risk to food borne pathogens. Findings include: 1. Cold Food temperatures Review of the 2013 Food and Drug Administration Food Code section 3-501.16 Potentially Hazardous Food (Time/ Temperature Control for Safety Food), Hot and Cold Holding revealed: Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, potentially hazardous food/time/ temperature control for safety food shall be maintained: at t 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in (paragraph) 3-401.11(B) or reheated as specified in (paragraph) 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5 C (41 F) or less.P Observation on 11/4/16 at 6:25 a.m. the temperatures of the walk-in refrigerator were observed and revealed two mercury thermometers, one hanging in the front by the door, and one hanging in the rear. The thermometer in the front read 38 degrees Fahrenheit (F) and the one in the rear read 45 degrees F. Observation on 11/4/16 at 6:25 a.m. Dietary Aide (DA) AA was observed putting a rolling tray full of milk into the freezer. Interview on 11/4/16 at 7:25 a.m., DA AA was asked about putting the milk in the freezer. She stated, we al… | 2019-11-01 |
| 4379 | 4379 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 490 | K | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility was not administered in an effective manner, utilizing all its resources, [MEDICAL CONDITION] care, insulin and blood sugar monitoring, pressure sore management, completion of medical record, supervision to prevent accidents, privacy/dignity, indwelling urinary catheter management, contracture management, medication administration timely, development/revision and implementation of care planning, for twenty-four (24) residents (R4, R5, R6, R9, R10, R14, R15, R18, R19, R22, R10, R18, R19, R20, R22, R23, R24, R25, R27, R28, R29, R32, R183 and R231), and dietary management to prevent food borne pathogens. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility ' s policy and procedure related to abuse to R6 beginning on 6/9/16 (F223, F225, F226 at scope and severity (S/S: J) constituted IJ and SQC at 483.13. On 8/12/16 at 3:36 p.m., the NHA and DON were notified that the failure in measuring, treating, providing consistent power sources for air mattress, and preventing worsening of pressure ulcers to six (6) residents constituted IJ when R23 was admitted to the facility with [DIAGNOSES REDACTED]. The facility failed to ensure all necessary respiratory related medical equipment for two resident (R28, R29) with tracheostomies were readily available; and that a safe and appropriate power source was available for their medical equipment, which placed residents at risk for serious harm or death. IJ was identified in effective on 6/29/16, the… | 2019-11-01 |
| 4380 | 4380 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 495 | F | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required 16 hours of training before any direct contact with residents. Specifically, they did not ensure their CNAs were proficient in the [MEDICATION NAME] Maneuver. This failure put all residents at l risk for adverse outcome in a choking event. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Findings include: On [DATE] at approximately 11:30 a.m., the Nursing Home Administrator (NHA) was asked to provide training records for Certified Nursing Assistants (CNAs). There was no evidence they had ensured proficiency in the area of safety and emergency procedures - specifically the [MEDICATION NAME] Maneuver (abdominal thrusts is a three-step emergency response technique that can save a life in seconds, a simple action that will often dislodge food or another object from a person ' s airway when they are choking). Interview on [DATE] at approximately 11:45 a.m., an interview was conducted with the NHA and the facility Human Relations Manager (HRM). The HRM confirmed they did not have evidence their CNAs had successfully completed a competency evaluation program to ensure their proficiency in the [MEDICATION NAME] Maneuver. He stated they were under the impression that anyone who completed CPR training would have that skill. Basic CPR does not always include the [MEDICATION NAME] Maneuver - and in some instances is only taught as an adjunct with AED (automated external defibrillator - portable device that automatically [DIAGNOSES REDACTED]. Both the NHA and the HMR stated they were not aware of the specific requirement to ensure their CNA staff were proficient in the [MEDICATION NAME] Maneuver. They both acknowledged that residents in their facility were at a higher risk of choking due to age, [DIAGNOSES REDACTED]. They were also not aware that an evaluation of compe… | 2019-11-01 |
| 4381 | 4381 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 501 | F | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the Medical Director failed to ensure implementation of policies/procedures, in abuse related to (R6); related to 6 residents (R18, R20, R22, R23, R25, and R28) with pressure sores; 2 residents with [MEDICAL CONDITION] Care (R28, R29); Insulin administration and blood sugar monitoring for 11 residents (R32, R5, R7, R9, R10, R14, R18, R19, R231, R25 and R27), for a total of twenty (20) residents as evidenced by the number of residents affected by Immediate Jeopardy (IJ) and one (1) resident who suffered actual harm related to the failure to supervise to prevent falls. Findings include: According to the Society for Post-Acute and Long-Term Care Medicine (paltc.org/amda-white-papers-and-resolution-position-statements/nursing-home-medical-director-leader-manager) the medical director ' s role is to .be responsible for the overall care and clinical practice carried out at the facility. The function of the medical director includes organizes and coordinates physician services and the services provided by other professionals as they relate to patient care. 1. On 6/9/16, R6 was verbally, physically and emotionally abused by a CN[NAME] It was reported and the facility failed to take immediate action including protecting all residents while an investgation was completed, failed to report to the SSA, physician and family, and failed to follow thier own policy related to abuse. Cross refer to F223, F224 and F226 for details 2. Treatment/Services to Prevent and/or Heal Pressure Ulcers: The facility failed to ensure residents without pressure ulcers did not develop pressure ulcers, and failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for R18, R20, R22, R23, R25, and R28) including providing consistent power sources for an air mattress for R28 of 2 residents with numerous medical devices/equipment, to prevent the worsening of 2 pressure ulcers (S… | 2019-11-01 |
| 4382 | 4382 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 514 | E | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure electronic Medication Administration Records (MAR), the Kiosk Care Tracker/Plan of Care (CP) utilized for documenting Activities of Daily Living (ADL), and failed to document the administration of enteral feedings for five (5) residents (R9, R11, R20, R23 and R27). The information contained in these documents is essential for determining the resident's progress including response to treatment, change in condition, and changes in treatment. The sample was seventy-seven (77) residents. Findings include: [NAME] The legend for administration of medication and treatments for R11, R20, R23 and R27 was not followed. Chart Codes noted on the bottom of the electronic MAR identified the legend as follows: v=Administered, I=Ineffective, E=Effective, U=Unknown, H=On Hold By Physician; 1=Away from facility with meds, 2=Away from facility without meds 3=Hold due to Condition, 4=Hold Order/ See Progress Notes, 5=hospitalized , 6=Nauseated/Vomiting, 7=Not Given re: Vitals outside admin parameter, 8=Other/See Progress Notes, and 9=Partial Administration, 10=Refused Med(s), 11=Sleeping 12=Spit out Meds 13=Start IV/Feed, 14=Stop IV/Feed. 1. Review of record of R11 revealed she was admitted on [DATE]. The [DATE] Minimum Data Set (MDS), identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS included that R11 required 1-person assistance/support with Activities of Daily Living, to include bed mobility, transfers, dressing, toilet use and personal hygiene, and total dependence for bathing. Her monthly physical exams from (MONTH) (YEAR) through (MONTH) (YEAR) described R11 as cooperative, well groomed, not in acute distress; oriented to time, place, purpose and person. Her [DIAGNOSES REDACTED]. Interview on [DATE] at 3:10 p.m., with R11 while she was sitting in bed, she received mail to include Medisea a dietary … | 2019-11-01 |
| 4383 | 4383 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 517 | F | 1 | 0 | 3P2Y11 | > Based on observation, staff interviews and record review, the facility failed to ensure they had a Disaster Manual readily available on all units; that the staff knew where to obtain that information; and that their Emergency Contact list of phone numbers was accurate and up-to-date. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Findings include: Interview on 8/13/16 at approximately 11:45 a.m., with the Nursing Home Administrator (NHA) was conducted. He was asked if they had Emergency Disaster Manuals available to all staff. He stated that they did have a red Emergency Manual on each unit. The NHA was asked to do a walking tour of the facility with the surveyor to ensure the Emergency Manuals were in fact in place. He agreed. Our first stop was the West Wing. There was not an Emergency manual at the Nurses Station - where he stated it should be. The NHA asked several nursing staff in the area if they knew where the Emergency Manual was. They had varying answers (should be here at Nurses Station and I don't know). The NHA and some of the staff started looking around the Nurse's Station, the Medication Storage room, closets etc. The Disaster Manual could not be located. We proceeded to tour the remaining units. The next unit (East Wing) did have the Disaster Manual in place. However, the Emergency Phone list was out-of-date and had management staff listed that no longer worked at the facility. The list in the manual was from 2014. The last unit (Terrace) also had the Disaster Manual in place but had an out-of-date Emergency Phone list as well. The list in the manual was from (YEAR). The failure of ensuring the staff had both a Disaster Manual in place, and the contact information for management was current, put residents at risk of timely intervention/direction by management in the event of an emergency. | 2019-11-01 |
| 4384 | 4384 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 520 | K | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the findings of deficient practices identified during the Complaint Survey, from 8/8/16 through 11/9/16, demonstrated that the facility failed to ensure the Quality Assurance Committee developed and implemented appropriate plans of action to correct identified quality deficiencies to attain the residents' highest practicable physical, mental, and psychosocial well-being. The facility also failed to identify additional quality deficiencies which had the potential to affect all residents. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility ' s policy and procedure related to abuse to R6 beginning on 6/9/16 (F223, F225, F226 at scope and severity (S/S: J) constituted IJ and SQC at 483.13. On 8/12/16 at 3:36 p.m., the NHA and DON were notified that the failure in measuring, treating, providing consistent power sources for air mattress, and preventing worsening of pressure ulcers to six (6) residents constituted IJ when R23 was admitted to the facility with [DIAGNOSES REDACTED]. The facility failed to ensure all necessary respiratory related medical equipment for two resident (R28, R29) with tracheostomies were readily available; and that a safe and appropriate power source was available for their medical equipment, which placed residents at risk for serious harm or death. IJ was identified in effective on 6/29/16, the day R28 was admitted to the facility, placed in the room without the needed power sources at F238 S/S:K. An acceptable Allegation of Compliance (AoC) was received on 8/19/1… | 2019-11-01 |
| 4385 | 4385 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2016-02-18 | 252 | E | 0 | 1 | XWP411 | Based on observation, interview and record review the facility failed to provide a homelike environment during dining on four (4) of four (4) days of survey including Unit A1, Unit B1, Unit 2C, Unit D2, and day areas. Findings include: Observation of meal service revealed the following: On 2/15/2016: Observation on 02/15/2016 at 12:30 p.m. in the Dining Area on Unit 2C revealed that residents were served meals on trays. The television remained on during the meal and there was no homelike decor. Additionally it was observed that medical equipment was stored in the dining area. Observation conducted on 2/15/16 at 12:55 p.m. revealed that a resident located on Unit A1 in room 111C received lunch on a tray in a Styrofoam plate Observation and interview conducted on 2/15/16 at 12:55 p.m. with R 128 on the Unit A1 revealed staff delivered a tray with the meal in a Styrofoam plate and a piece of fruit on the tray. No beverage was served. The tray was placed on the over bed table and the staff person left the room. On 2/16/2016: Observation of meal service on 02/16/2016 at 7:21 a.m. on Unit 2C revealed that meals were served on trays in the Dining Area, the television remained on and medical equipment remained in the dining area. Observation on Unit A1 on 02/16/2016 at 7:42 a.m. revealed residents received breakfast served on trays at the table in the dining area on the unit and the plate was not removed from the tray. Observation conducted on 2/16/16 at 8 a.m. revealed residents being served on trays. Trays served on the hall were placed on the over bed tables and plates were left on the trays throughout the meal. Observation conducted on 2/16/16 at 8:00 a.m. revealed residents served meals in the day area on trays and the dishes were left on the trays during the meal. Further observations revealed when trays were passed on the halls to residents eating in their rooms the trays were placed on over bed tables and the plates left on the trays throughout the meal. On 2/17/2016: Observation on 02/17/2016 at 1:04 p.m.in the … | 2019-11-01 |
| 4386 | 4386 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2016-02-18 | 371 | F | 0 | 1 | XWP411 | Based on observation and interview, the facility failed to ensure foods and ice were stored in a safe and sanitary manner in the pantry refrigerators on five (5) of five (5) Units. Findings include: 1. Observations on 2/17/16 between 12:35 p.m. and 1:51 p.m. revealed the following: Unit A1 Hall Pantry: Observation revealed one (1) container from Popeye ' s dated 2/4/16, one (1) container of cream cheese that was unlabeled, one (1) cup of cereal that was not dated or labeled, three (3) unlabeled bottles of water located in the refrigerator. Observation of the freezer part of the refrigerator revealed one (1) package of chopped spinach not labeled or dated, Imperial butter was not labeled or dated with had an expiration date of 1/23/16. Unit A2 Hall Pantry: Observation revealed no thermometer in the freezer portion of the refrigerator to monitor the temperature. A pink substance build up on dispensing door of ice machine. Rust marks on the top and side of the refrigerator. Unit B1 Hall Pantry: Observation revealed six (6) sandwiches that were not labeled or dated, orange juice not labeled with an expiration date of 1/27/16, and a gallon water jug with expiration date of 5/1/14 in the refrigerator. In the freezer was a container of ice cream cups that were not labeled or dated. The ice machine had black and brown build up on the dispensing door. The microwave and snack cart each had food build up and stains. Unit B2 Hall Pantry: Observation revealed an Activia Yogurt with an expiration date of 12/08/15 in the refrigerator. Unit C2 Hall Pantry: Observation revealed one (1) covered bowl of soup not labeled or dated and two (2) pitchers of red juice not labeled or dated in the refrigerator. A pink and black substance on the dispensing door to the ice machine. The microwave had food buildup inside. Interview with Maintenance Manager (MM) on 02/17/2016 at 4:41 p.m. related to ice machines in pantries that the quarterly cleaning of ice machines was to be done today. MM reported that the ice machines are cleaned quarterly … | 2019-11-01 |
| 4387 | 4387 | WESTBURY MEDICAL CARE AND REHAB | 115563 | 922 MCDONOUGH ROAD | JACKSON | GA | 30233 | 2015-09-17 | 161 | B | 0 | 1 | M5A011 | Based on record review and staff interview, the facility failed to ensure that the surety bond covered the ending balances in the resident trust account for four (4) of twelve (12) months reviewed. The facility handled a total of one-hundred and thirty-three (133) resident accounts. Findings include: Review of the surety bond revealed that it was in the amount of $100,000.00, and the effective date of the bond was 01/01/15 through 01/01/16. Review of resident trust account bank statements revealed that two accounts were used; one account received deposits and the other was used to write checks for liability and other expenses. The ending balances in both accounts were added together each month from (MONTH) of 2014 to (MONTH) of (YEAR), and in the following months the ending balance exceeded the surety bond limit: October 2014: $108, 922.04 December 2014: $113, 253.06 April (YEAR): $106,493.41 July (YEAR): $105,990.97 During interview with administrative employee MM, who handled the resident trust account, on 09/16/15 at 4:40 p.m., she stated that Social Security occasionally direct-deposited checks into the resident trust account twice in one month, and the facility only wrote resident liability checks once a month, and in those instances the ending balances in the trust account would exceed the surety bond limit. Upon further interview on 09/17/15 at 12:05 p.m., employee MM stated that because the trust fund balances exceeded the surety bond limit only a few times a year and for only a few days before liability checks were written and cleared, she did not feel that they needed to increase the bond limit. Review of trust account check images revealed checks did not clear to drop the balances below the surety bond limit until 01/15/15 for the excessive (MONTH) ending balance, and on 11/06/15 for the excessive (MONTH) ending balance. | 2019-11-01 |
| 4388 | 4388 | WESTBURY MEDICAL CARE AND REHAB | 115563 | 922 MCDONOUGH ROAD | JACKSON | GA | 30233 | 2015-09-17 | 371 | E | 0 | 1 | M5A011 | Based on observation and staff interview the facility failed to have male dietary staff with facial hair wear appropriate hair restraints to prevent contamination; failed to properly secure opened food items in the walk-in freezer; failed to properly label and date food items in walk in refrigerator, walk in freezer, and in one (1) of two (2) resident nourishment rooms; and failed to properly maintain the cleanliness of 1 of 2 resident nourishment room refrigerators. This deficient practice had the potential to affect one hundred eight (180) residents receiving an oral diet. Findings include: Observation on 09/14/15 at 9:20 a. m. of the walk-in refrigerator revealed that there were three (3), 1 gallon containers of Italian Salad Dressing opened with no date. Continued observation of the walk-in refrigerator revealed that there was 1, 1 gallon container of Thousand Island Dressing opened with no date, 1, 1 gallon of Sweet Pickle Relish opened with no date, and 1, 1 gallon container of mayonnaise that was open with no date. Further observation of the kitchen revealed that in the walk-in freezer there was an open clear plastic bag containing twelve (12) breaded chicken tenderloins as well as an open clear plastic bag of fish patties. Both bags were not securely wrapped and did not have a date of when opened. Interview on 09/14/15 at 10:00 a. m. with the Dietary Supervisor revealed that she confirmed that the staff did not date the opened gallon containers of Italian Dressing, Thousand Island Dressing, Sweet Pickle Relish, and Mayonnaise. She revealed that dietary staff discard these items every seven (7) days and did not feel that they needed to be dated. The Dietary Supervisor was unable to tell me how long the gallon containers had been in the walk-in refrigerator undated and which day the staff would be expected to discard the food product. Continued interview with the Dietary Supervisor revealed she was not able to find the open date of chicken tenderloins and frozen fish patties in the walk-in freezer. She conf… | 2019-11-01 |
Advanced export
JSON shape: default, array, newline-delimited
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 );