cms_GA
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30 rows where "inspection_date" is on date 2015-03-26
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Suggested facets: facility_name, facility_id, address, city, zip, deficiency_tag, scope_severity, eventid, filedate, filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5006 | 5006 | PRUITTHEALTH - LILBURN | 115516 | 788 INDIAN TRAIL ROAD | LILBURN | GA | 30047 | 2015-03-26 | 371 | E | 0 | 1 | UV5I11 | Based on observations, record review, and staff interview the facility failed to label and/or date food stored in one (1) of one (1) walk in freezer. This had the potential to effect one hundred twenty-one (121) residents who take oral alimentation. Findings include: Observation of the walk in freezer on 03/23/2015 at 10:55 a.m. revealed a box of frozen mixed vegetables, a box of frozen peas, a box of lima beans, a box of blacked eyed peas, and a box of broccoli on the shelf. All the boxes were opened, the plastic bag of vegetables inside the boxes were unsecured with frost observed on the food. The plastic bags were not secured, labeled, or dated. Interview with the Dietary Manager (DM) on 03/23/2015 at 11:05 a.m. revealed that her expectation from her staff was that all containers of any food items be labeled and dated when opened and before it was placed back in the walk in freezer. The DM confirmed that the frozen vegetables were not properly secured, labeled or dated and stated that she was unaware why it was not done. During an interview with the DM on 03/24/2015 at 10:33 a.m. the DM revealed that she conducted an in-service with her staff on 03/23/15 to review the proper labeling and dating of opened food items. | 2019-02-01 |
| 5118 | 5118 | PARKSIDE ELLIJAY | 115683 | 1362 SOUTH MAIN STREET | ELLIJAY | GA | 30540 | 2015-03-26 | 278 | D | 0 | 1 | YC5411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of three (3) residents (#32, #120 and #121) from a total sample of thirty-three (33). Finding include: 1. Record review for resident #32 revealed an Admission MDS assessment dated [DATE] which assessed the resident as being independent with a one (1) person assist for toileting. Review of the Quarterly MDS dated [DATE] revealed the resident was assessed as needing extensive assist with one (1) person of one (1) person for toileting Review of the fourteen (14) Day Observation Period 2/23/15-3/1/15 revealed that resident required limited assistance of one (1) person for toileting. Interview with the Director of Nursing (DON) on 3/25/15 at 12:40 p.m., revealed that the quarterly MDS was coded incorrectly and should have been coded as a limited assist, not extensive. 2. Resident #120 was admitted to the facility on [DATE]. Review of the Admission MDS assessment dated [DATE] indicated the resident was frequently incontinent of bladder and required extensive assistance with Activities of Daily Living (ADLS) including bed mobility and transfers. A review of the MDS Quarterly Assessment indicated a decline in bladder incontinence, always incontinent, and a decline in ADLS to totally dependent for bed mobility and transfers. An interview conducted on 3/26/15 at 3:31pm with the Director of Nursing (DON) revealed resident #120 has required total dependence with bed mobility and transfers since her admission due to her size, weight and weak muscles. She was completely unable to put weight on her arms requiring two (2) to three (3) person assist. Further, the resident has always been incontinent of bladder. The DON acknowledged that the Admission Assessment was incorrectly coded for both ADLS and Bladder Incontinence. 3. Record review for resident #121 revealed an admission MDS dated [DATE] which assessed the resident a… | 2019-01-01 |
| 5119 | 5119 | PARKSIDE ELLIJAY | 115683 | 1362 SOUTH MAIN STREET | ELLIJAY | GA | 30540 | 2015-03-26 | 279 | D | 0 | 1 | YC5411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop a care plan for two (2) residents (#32 and #121) with bladder incontinence from a sample of thirty-three (33). 1. Record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that resident #32 was occasionally incontinent of bladder and bowel. Review of resident's care plan, which was last reviewed on 3/13/15, revealed no evidence of a care plan for bladder incontinence. Interview with the Director of Nursing on 3/25/15 at 2:00 p.m., revealed that the resident should have had a care plan developed for bladder incontinence. 2. Record review for resident #121 revealed an Admission MDS dated [DATE] which assessed the resident as being occasionally incontinent of bladder. Review of the resident's care plan revealed no care plan for bladder incontinence. Interview on 03/26/2015 at 11:50 a.m. with Certified Nursing Assistant (CNA) AA revealed resident was incontinent of bladder when she was admitted to the facility. 'AA' further revealed that the resident is on a toileting program and is taken to the bathroom every two (2) hours and as needed. Interview on 03/26/2015 at 12:30 p.m. with the Director of Nursing (DON) revealed that resident was incontinent of bladder on admission. The DON revealed the resident 's bladder status was mentioned vaguely under the skin problem but there should have been a specific problem on the care plan to address her incontinence. | 2019-01-01 |
| 5211 | 5211 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2015-03-26 | 309 | D | 0 | 1 | L7XC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure to administer pain medication in a timely manner for one (1) resident (A), from a sample of twenty-nine (29) residents. Findings include: During interview conducted 3/26/15 with resident (A) from 10:00 a.m. through 10:50 a.m., she revealed that she had requested pain medication before we started our interview and the nurse still has not brought her pain medication. She further indicated that the Licensed Practical Nurse (LPN) II, giving medications today always make her wait for her pain medication. She revealed she has arthritic pain in both knees. A indicated that she takes her pain medication in the morning before therapy with rehabilitation services. She also revealed that she has told this LPN many times that she prefers her pain medication along with her 9:00 a.m. routine morning medications. LPN II was observed standing in the hallway outside resident room, in front of the medication cart, conversing another staff member. The surveyor inquired if II was aware that resident A had requested pain medication. II indicated that A did request her pain medication and she would give it. Record review for resident (A) revealed a current physician's orders [REDACTED]. Further record review revealed the resident has many [DIAGNOSES REDACTED]. During an interview with the LPN II on 3/26/15 at 2:40 p.m., she revealed that she is aware of the resident preference is for all of her 9:00 a.m. morning medication and the [MEDICATION NAME] pain medication to be administered all at once. She normally would give resident (A) her 9:00 a.m. medications and wait for the resident to ask for her as needed (PRN) [MEDICATION NAME] pain medication. She further revealed that she did not provide administration of the [MEDICATION NAME] at the time the resident requested it because she was still conducting medication pass. Interview with the Unit Nurse Manager KK conducted 3/… | 2018-11-01 |
| 5426 | 5426 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2015-03-26 | 323 | E | 0 | 1 | 7YW311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure that chemicals were inaccessible to residents in two (2) of two (2) common shower rooms, and failed to ensure that equipment that posed a potential burn hazard was inaccessible in one (1) of (1) Beauty Shops. There was a total of twenty-five (25) independently mobile, cognitively impaired residents in the facility. The facility census was fifty-nine (59) residents. Findings include: During observation on 03/23/15 at 3:02 p.m., resident #69 was noted to wander constantly throughout the facility. Upon further observation, she was noted to remove the bedspread off her bed and place it over the commode in her bathroom, then went down the B-hall to another resident's room and obtained a foam wedge and box of tissues from this room and went walking down the hall with them. On 03/24/15 at 10:00 a.m., resident #69 was observed to be walking about the facility without apparent purpose; nursing staff were in attendance but the resident resisted their efforts to redirect her to a common area with other residents and staff. During interview with the Administrator on 03/23/15 at 5:22 p.m., she stated the resident had just been admitted to the facility on [DATE], and verified that the resident wandered constantly and they were trying different interventions to address this. During observations throughout the facility on 03/23/15 at 5:00 p.m., the unlocked General Bath on the A-hall on the side with odd-numbered rooms was noted to contain two 1-quart spray bottles of Comet Disinfecting-Sanitizing Bathroom Cleaner on top of a rolling cart. Upon further observation, one of the bottles was noted to be almost empty, and the other half-full. Review of the labeling on the bottles included causes eye irritation, may be harmful if swallowed. Observation of this rolling cart revealed that it had a compartment with a lock, but the compartment was not locked and contained numerous … | 2018-09-01 |
| 5427 | 5427 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2015-03-26 | 371 | E | 0 | 1 | 7YW311 | The facility failed to maintain steam table temperatures of one hundred and thirty-five degrees Fahrenheit (135 F) to ensure that food items on the steam table were at the proper temperature to prevent potential foodborne illness for (59) fifty-nine residents who received oral alimentation. Findings include: During observation on 3/24/15 at 12:40 p.m. of food items held on the steam table being served to residents at lunch revealed that the following food items were found to be below the minimum safe temperature level of one hundred and thirty-five degrees (135 F). Baked Ham one hundred degrees (100 F). Baked Chicken one hundred and twenty degrees (120 F). Pureed Rice one hundred and twenty degrees (120 F) Pureed Green Beans (125) one hundred and twenty-five degrees (125 F) The above observations were made using (1) one out of (3) three attempted digital thermometers that belonged to the dietary department. Interview on 3/24/15 at 12:40 p.m. with Cook AA revealed that the above food items temperatures were not appropriate and that she had checked the food temperatures prior to serving several residents who were already seated and eating lunch. Interview on 3/24/15 at 1:05 p.m. with the Dietary Manager and the Administrator revealed that they expect Cook AA to maintain food temperatures on the steam table at the appropriate temperatures. Continued interview they acknowledged that after attempting to use (3) three of the facilities digital thermometers the food items were still below the required temperature of one hundred and thirty-five degrees 135 F. | 2018-09-01 |
| 5428 | 5428 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2015-03-26 | 456 | E | 0 | 1 | 7YW311 | Based on observations and staff interviews, the facility failed to ensure that the milk cooler in the kitchen was in safe operating condition. Findings include Observation of the milk cooler on 3/23/15 at 9:15 a.m. revealed that there was a (1) one inch thick build up of ice in the milk cooler and the temperature was thirty degrees Fahrenheit (30 F). Observation on 3/24/15 at 8:05 a.m. revealed that there was still a (1) one inch thick build up of ice in the milk cooler. The temperature was still thirty degrees (30 F). Interview on 3/23/15 at 9:15 a.m. with the Dietary Manager (DM) revealed that the milk cooler had not been functioning properly and keeping the milk cold. The DM further revealed that she had called to have the milk cooler serviced on (MONTH) 9, 2014. Continued interview revealed that after being serviced the milk cooler started having ice build up. The DM revealed that staff are responsible for taking the milk cooler outside every (2) two weeks and defrosting it by hosing it down. The DM further revealed that the milk cooler has not been serviced by Mayfield Foods since (MONTH) 9, 2014 and that she does not keep a log of how often staff defrosts the milk cooler. Interview on 3/24/15 at 10:00 a.m. with the Maintenance Supervisor, revealed that maintenance was not responsible for servicing any equipment in the kitchen. The Maintenance Supervisor revealed that maintenance was only responsible for plumbing issues. | 2018-09-01 |
| 5470 | 5470 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2015-03-26 | 156 | D | 0 | 1 | ZJXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interviews the facility failed to ensure that the facility policy was followed and that staff had a clear understanding of the Advanced Directive status for one (1) resident #52 of twenty four (24) sampled residents. Findings include: Record review the Face Sheet for resident #24 revealed the the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the Advance Directive Checklist dated [DATE] and signed by the resident's representative revealed the resident had executed an advance directive which would be supplied to the facility in addition to a No Cardiopulmonary Resuscitation (DNR) signed on the same day by the resident's representative. Review of the Physician order dated [DATE] revealed an order for [REDACTED].>Record review of the Nurses Notes dated [DATE] at 3:15 a.m. revealed the resident was found not breathing, unresponsive and without a pulse during rounds by Licensed Practical Nurse (LPN) CC. Cardiopulmonary Resuscitation (CPR) was started on the resident and 911 was called. After the Emergency Personal was onsite, it was discovered the resident had a DNR status and CPR was stopped and the resident was pronounced at this time by the on call Registered Nurse (RN). An interview on [DATE] at 3:27 p.m. with LPN CC revealed that she would have to check the chart to determine DNR status but she would error on the side of caution and being CPR. An interview on [DATE] at 3:29 p.m. with LPN BB revealed that she would check the chart under the Advanced Directive tab to determine the Code Status of a resident and that there is a list of DNR status resident on each Medication Administration Record [REDACTED]. An interview and review of the MAR indicated [REDACTED]. LPN CC revealed at this time that he/she did not know who was responsible for updating the list. An interview and review of the facility policy for Do Not Resuscitate Policy: Georgia updated on ,[DA… | 2018-09-01 |
| 5471 | 5471 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2015-03-26 | 279 | D | 0 | 1 | ZJXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility failed to develop a care plan for a Pressure Sore for one (1) resident #74 of twenty four (24) sampled residents. Findings include: Record review revealed the resident was admitted to the facility from the hospital on [DATE] with the following Diagnoses: [REDACTED]. Review of the Admission/Nursing Observation Form dated 11/7/14 revealed under the Hospital Report that the resident had a Pressure Ulcer to the Right heel. The Body Audit Form dated 11/7/14 revealed the resident had no open areas. Review of the Body Audit Form dated 11/10/14 and signed by Licensed Practical Nurse (LPN) DD the Treatment Nurse revealed an open area to the right heel measuring 4.2 centimeters (cm) by 1 by less than 1 in depth. It is noted the resident had a BKA of the left leg. Record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed no pressure areas were assessed although the resident was at risk for developing pressure ulcers. The resident had a Braden Score of 16 dated 11/7/14 for mild risk. Record review of the initial care plan revealed the resident had a care plan for at risk for Impaired skin. The Comprehensive Care Plan dated 11/10/2014 assessed the resident at risk for impaired skin integrity although was not assessed as having a pressure ulcer. Record Review of the Tissue Tolerance Test form dated 11/10/14 and signed by LPN DD noted the resident to have an open area to the right heel and that the resident stated a blister was there previously. An interview on 3/25/15 at 11:06 a.m. with the Director of Nursing (DON) revealed the treatment nurse stated last night that this was a healed blister and not an open area. She could not explain why the record repeatedly stated there was an open area. She felt the resident was not care planned for a pressure area since the treatment nurse did not feel it was an open area. Cross to F314 | 2018-09-01 |
| 5472 | 5472 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2015-03-26 | 282 | D | 0 | 1 | ZJXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow the Plan of Care regarding the administration of medications as ordered for one (1) diabetic resident (#5) from total sample of twenty five (25) residents. Findings include: Record review for resident #5 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's Plan of Care dated 12/17/14 for diabetes mellitus revealed an intervention for medication as ordered by doctor. Review of the physician's orders [REDACTED]. Then on 1/7/15 the Physician discontinued the 50 units of [MEDICATION NAME] and ordered 40 units in a.m. and 20 units at hour of sleep. During review of the Medication Administration Records (MAR) for (MONTH) (YEAR) revealed on 1/13, 1/17, 1/26, 1/27 and 1/30 and in (MONTH) on 2/4, 2/6 and 2/28 revealed Licensed nursing staff initialed and circled the [MEDICATION NAME] as being withheld with out a physician's orders [REDACTED].>During further review of the MAR for (MONTH) 2014 revealed that on 12/25 and 12/30/14, in (MONTH) (YEAR) on 2/13, 2/17, 2/20, 2/21, 2/22, 2/25, 2/26 and 2/27 then on (MONTH) (YEAR) on 3/9 Licensed Nursing staff failed to initial the medication as administered. During an interview on 3/26/15 at 9:00 a.m. with Nurse consultant AA he/she confirmed the Licensed Nursing staff had withheld the [MEDICATION NAME]without a physician's orders [REDACTED]. Refer to F309 | 2018-09-01 |
| 5473 | 5473 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2015-03-26 | 309 | D | 0 | 1 | ZJXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician orders [REDACTED].#5) from a total sample of twenty five (25) residents. Findings include: Record review of the medical record for resident #5 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. Then on 1/7/15 the physician discontinued the 50 units of [MEDICATION NAME] and ordered 40 units in a.m. and 20 units at hour of sleep. In addition, there was a 12/10/14 order for Finger Stick Blood Sugars (FSBS) before meals and at hour of sleep. During review of the Medication Administration Records (MAR)s for (MONTH) (YEAR) revealed on 1/13, 1/17, 1/26, 1/27 and 1/30 and in (MONTH) on 2/4, 2/6 and 2/28 revealed Licensed nursing staff initialed and circled the [MEDICATION NAME] as being withheld with out a physician's orders [REDACTED].>During further review of the (MAR)s revealed in (MONTH) 2014 on 12/25 and 12/30/14, in (MONTH) (YEAR) on 2/13, 2/17, 2/20, 2/21, 2/22, 2/25, 2/26 and 2/27 and then in (MONTH) (YEAR) on 3/9 Licensed Nursing staff failed to initial the medication as administered. In addition, review of the (MONTH) 2014 MAR indicated [REDACTED]. During an interview on 3/26/15 at 9:00 a.m. with Nurse consultant AA he/she confirmed the Licensed Nursing staff had withheld the [MEDICATION NAME]without a physician's orders [REDACTED]. AA also confirmed the staff failed to obtain the resident's FSBSs as ordered. | 2018-09-01 |
| 5474 | 5474 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2015-03-26 | 314 | D | 0 | 1 | ZJXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility to ensure that Pressure Ulcer were accurately documented on admission and to ensure that treatment was put into place upon admission for one resident #74 of twenty four (24)sampled residents. Findings include: Record review revealed the resident was admitted to the facility from the hospital on [DATE] with the following Diagnoses: [REDACTED]. The resident was discharged from the facility on 12/8/2014. Review of the Admission/Nursing Observation Form dated 11/7/14 revealed under the Hospital Report that the resident had a Pressure Ulcer to the Right heel. The Body Audit Form dated 11/7/14 revealed the resident had no open areas. Review of the Body Audit Form dated 11/10/14 and signed by Licensed Practical Nurse (LPN) DD the Treatment Nurse revealed an open area to the right heel measuring 4.2 centimeters (cm) by 1 cm by less than 1 cm in depth. It is noted the resident had a BKA of the left leg. Record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed no pressure areas were assessed although the resident was at risk for developing pressure ulcers. The resident had a Braden Score of 16 dated 11/7/14 for mild risk. Record review of the initial care plan revealed the resident had a care plan for at risk for Impaired skin. The Comprehensive Care Plan dated 11/10/2014 assessed the resident at risk for impaired skin integrity although was not assessed as having a pressure ulcer. Record Review of the Tissue Tolerance Test form dated 11/10/14 and signed by LPN DD noted the resident to have an open area to the right heel and that the resident stated a blister was there previously. An interview on 3/25/15 at 12:00 p.m. with Registered Nurse (R.N.) Consultant AA revealed that the documents do not explain there was no open area. A interview, on the same day, at 2:30 p.m. with the Director of Nursing (DON) and R.N. Consultant AA agreed that it is not clear if the wound was open a… | 2018-09-01 |
| 5475 | 5475 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2015-03-26 | 371 | F | 0 | 1 | ZJXE11 | Based on observation, and staff interview, the facility failed to ensure that one (1) of one (1) ice machine was maintained in a sanitary manner. The census was sixty-one (61) with fifty-five (55) residents using ice from this machine on a daily basis. Findings include: Observations of the ice machine on 03/23/2015. revealed that the facility had one (1) ice machine located in a separate room just outside the kitchen. It had a black discoloration on the white plastic chute inside the ice machine, and it had a black discoloration on the inside lip of the machine. Observation and interview with the Dietary Supervisor, on 03/23/2015 at 12:05 p.m. confirmed that the ice machine had a black discoloration on the white plastic chute and a black discoloration on the inside lip of the ice machine. During an interview with the Dietary Supervisor it was revealed that the ice machine was on a monthly cleanining schedule and as per the Dietary Supervisor they were running a little behind schedule. Review of the kitchen cleaning schedule revealed the the last cleaning date for the ice machine by dietary staff was on the afternoon of 03/23/2015. Follow up interview with Dietary Manager reveals that ice machine was emptied and cleaned after initial observation on 03/23/15. Review of Ice Machine Policy reveals that ice machine is to be cleaned and sanitized monthly by dietary staff. ______________________________________________________________________ 03/23/15 10:45(NAME)over stove is clean. Cleaned every 6 months by Complete Care Exhaust Services Incorporated, last cleaned on 12/14/14. 03/23/15 12:05 pm Black build-up in ice machine around chute and on inside inner lip of machine. Dietary Manager, Brenda(NAME)confirmed that black build-up present. When asked if it is a permanent stain or if it is a cleaning issue, Dietary Manager took a damp paper towel and began to wipe it off. Dietary Manager states that normal procedure is to clean ice machine monthly, but that they have gotten a little behind on schedule. 03/25/2015 9:29:35… | 2018-09-01 |
| 5476 | 5476 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2015-03-26 | 428 | D | 0 | 1 | ZJXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review the consultant pharmacist failed to identify and report medication irregularities, related to Insulin administration and Finger Stick Blood Sugars (FSBS), for one (1) resident (# 5) of twenty five (25) sampled residents. Findings Include: 1. Review of the clinical record for Resident #5 revealed a [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. An order dated 1/7/15 revealed to discontinue the 50 units of Levemir Insulin and start 40 units of Levemir Insulin in the a.m. and 20 units of insulin in the p.m Review of the Medication Administration Records (MAR)s revealed in (MONTH) 2014 there was eighteen (18) times that the FSBSs were not obtained and documented as ordered, in (MONTH) (YEAR) there were 5 times licensed nursing staff withheld the Levemir Insulin without a physician's orders [REDACTED]. Review of the monthly Consultant Pharmacist review revealed a pharmacy reviews dated 12/29/14, 1/26/15, 2/19/15 and 3/10/15 without evidence that the irregularities were identified during these visits by the Consultant Pharmacist and brought to the attention of the Director of Nursing (DON) or the Physician. | 2018-09-01 |
| 5477 | 5477 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2015-03-26 | 514 | D | 0 | 1 | ZJXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interviews the facility failed to ensure that non-pressure wounds were assessed and documented for one (1) resident #44 of of twenty four (24) sampled residents. Findings include: Record Review of the Minimum Data Set (MDS) revealed the resident was admitted to the facility on [DATE] with the following diagnoses, included but not limited to: High Blood Pressure, Diabetes, [MEDICAL CONDITION], Parkinson Disease, [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. Review of the laboratory results revealed a Culture and Sensitivity of the Left Buttock with a heavy growth of Staphylococcus Intermedius, Escherichia Coli and Proteus Mirabilis. Review of the Body Audit Form date 2/8/15 reveals a red open area to the left buttocks although there is no further description of the wound. Record review of the Nurse's Notes dated 2/5/15 at 5:15 p.m. reveals a note Swab for culture done on Left buttock. Record review of the physician telephone orders dated 2/6/15 reveals an order for [REDACTED]. A second physician's order dated 2/9/15 revealed the resident was transferred to Appling Healthcare Services Senior Care Unit due to behaviors. 3/25/15 at 9:00 a.m. the Director of Nursing (DON) was asked for a listing of resident's with wounds in the building for the months of January, (MONTH) and March. An interview with the DON and the Registered Nurse (RN) Consultant AA on the same day at 12:45 p.m. confirms that the resident is not on the wound list for January, (MONTH) and March. An interview on 3/25/15 at 1:16 p.m. with Licensed Practical Nurse (LPN) EE revealed that he/she had filled out the Body Audit Form dated 2/8/15 and that the resident had a sebaceous cyst on his/her buttocks rather than a pressure ulcer. LPN EE agrees the documentation is not clear and does not describe the wound but it should. Record review of the facility Policy and Procedure that was in place during the resident's stay revealed Documentation of… | 2018-09-01 |
| 5506 | 5506 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2015-03-26 | 509 | D | 0 | 1 | P9SF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy for capillary blood sampling (finger stick blood sugar), medical record review, and staff interview, the facility failed to obtain a physician order for [REDACTED]. Findings Include: The medical record for resident #37 revealed that the resident was admitted to the facility (MONTH) 2014. Upon admission, the facility started obtaining finger stick blood sugar sample four (4) times a day. A review of the physician's orders revealed that there were no physician orders to collect these finger stick blood samples. Further review of the medical record, revealed that on 11/5/14 and 3/4/15, the pharmacist consultant requested the finger sticks to be evaluated by the Medical Doctor (MD) for discontinuation or change in the frequency of collection. This did not occur until the surveyor made the facility aware of this issue. An interview on 3/25/15 at 2:17 p.m. with Licensed Practical Nurse (LPN) AA revealed that he/she was not aware of the resident not having orders for finger stick four (4) times a day and verified that there was not an order for [REDACTED].>An interview on 3/25/15 at 2:53 p.m. with the Director of Nursing (DON) verified that resident #37 did not have an order for [REDACTED].> | 2018-08-01 |
| 5507 | 5507 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2015-03-26 | 514 | D | 0 | 1 | P9SF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of the facility Medication Administration-General Guidelines the facility failed to maintain accurate clinical record regarding the administration of insulin , antidepressant and antipsychotic medication for one (1), #138, of twenty eight (28) sampled residents. Findings include: Review of resident #138's clinical record revealed a 2/1/2015 physician's orders [REDACTED].> [MEDICATION NAME] 100 units/milliliter vial 8 units subcutaneous three (3) times a day with meals, [MEDICATION NAME] 100 units/milliliter vial 20 units subcutaneous at hour of sleep and [MEDICATION NAME] 30 milligrams by mouth daily for Depression. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed no documentation that nursing staff administered the [MEDICATION NAME] at 5:00 p.m. on 2/6/15 , 2/14/15 and 2/15/15, the [MEDICATION NAME] on 2/2/15 and the [MEDICATION NAME] on 2/9/15 . An interview with Licensed Practical Nurse (LPN) DD on 3/25/15 at 3:16 p.m. revealed that while he/she had administered the [MEDICATION NAME] as ordered he/she had failed to initial the medication as being administered on 2/14/15 and 2/15/15 at 5;00 p.m. Review of resident #138's clinical record revealed a 3/1/ physician's orders [REDACTED]. Continued review of the MAR for (MONTH) (YEAR) revealed no documentation on 3/9/15 that nursing staff had administered the [MEDICATION NAME] 0.25 milligrams every morning as ordered on that day. Review of the facility Medication Administration-General Guidelines revealed under Procedural Guidelines, #10. The resident's Medication Administration Record (MAR) is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are verified with a full signature on nurse's signature sheet or the individual MAR. An interview with the Director of Nurses (DON) on 3/25/15 at 2:5… | 2018-08-01 |
| 5510 | 5510 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2015-03-26 | 282 | D | 0 | 1 | Q5YD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that care and services were provided according to the care plan for one (1) resident (#152) related to inappropriate behaviors, and one (1) resident (#65) related to sliding scale Insulin coverage from a sample of twenty (20) residents. Findings include: 1. Review of the Quarterly Minimum Data Set assessment dated [DATE] indicated that resident #152 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually for one to three (1 to 3) days during the seven (7) day look back period. Review of the Comprehensive Care Plan dated 1/9/15 revealed that the resident exhibits inappropriate behaviors such as; screams out loudly, sobs at random when around others and physically aggressive behavior. The goal was that the resident would not injure self or others as a result of her behavior during the review period. The interventions included to assure safety of resident and others, to notify/consult physician of any new behaviors or exacerbation of behaviors, pharmacy consult, and administer medication as ordered. Review of the clinical record for resident #152 revealed a Note to the attending Physician from the Consultant Pharmacist dated 2/11/15 that the resident had been acting strangely since starting her [MEDICATION NAME] per nurse and to please consider trying a different Antipsychotic medication that she would possibly adjust to better. The Physician replied on 2/12/15 that an evaluation was underway. Review of the physician's orders [REDACTED]. This order was noted on 2/6/15 by Registered Nurse (RN) AA. Interview conducted with RN AA on 3/25/15 at 2:35 p.m. revealed that she attempted to have resident #152 placed in a psychiatric facility for behaviors or, to see if a Psychiatrist would visit. RN AA further revealed that she could not get an available Psychiatrist to see the resident or, an ava… | 2018-08-01 |
| 5511 | 5511 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2015-03-26 | 309 | D | 0 | 1 | Q5YD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow Physician's orders for two (2) residents (#152, #65) related to inappropriate behaviors and sliding scale Insulin coverage. The sample size was twenty (20) residents. Finding include: 1. Review of the Quarterly Minimum Data Set assessment dated [DATE] indicated that resident #152 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually for one to three (1 to 3) days during the seven (7) day look back period. Review of the Comprehensive Care Plan dated 1/9/15 revealed that the resident exhibits inappropriate behaviors such as; screams out loudly, sobs at random when around others and physically aggressive behavior. The goal was that the resident would not injure self or others as a result of her behavior during the review period. The interventions included to assure safety of resident and others, to notify/consult physician of any new behaviors or exacerbation of behaviors, pharmacy consult, and administer medication as ordered. Review of the clinical record for resident #152 revealed a Note to the attending Physician from the Consultant Pharmacist dated 2/11/15 that the resident had been acting strangely since starting her [MEDICATION NAME] per nurse and to please consider trying a different Antipsychotic medication that she would possibly adjust to better. The Physician replied on 2/12/15 that an evaluation was underway. Review of the Physician's Order dated 2/6/15 revealed to get a Psychiatric Consult for behaviors. This order was noted on 2/6/15 by Registered Nurse (RN) AA. Interview conducted with RN AA on 3/25/15 at 2:35 p.m. revealed that she attempted to have resident #152 placed in a psychiatric facility for behaviors or, to see if a Psychiatrist would visit. RN AA further revealed that she could not get an available Psychiatrist to see the resident or, an available bed at the … | 2018-08-01 |
| 5999 | 5999 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2015-03-26 | 157 | D | 0 | 1 | VVSI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interview, and physician interview, the facility failed to immediately consult with the physician regarding a significant change in condition for one (1) resident (#87), whose blood pressure medications were held due to low blood pressure readings, from a total survey sample of thirty-four (34) residents. Findings include: Record review of Resident #87 revealed an Admission Minimum Data Set (MDS) assessment of 03/05/2015 which documented an admission date of [DATE]. Section I - Active [DIAGNOSES REDACTED].#87 had [DIAGNOSES REDACTED]. Review of the admission February 2015 physician's orders [REDACTED].#87 revealed physician's orders [REDACTED]. Review of Resident #87's March 2015 Medication Administration Record [REDACTED].m This MAR, however, documented that by 5:00 p.m. on 03/24/2015, Resident #87 had a low systolic blood pressure reading of 83, and a diastolic blood pressure reading of 75. Resident #87's MAR indicated [REDACTED]. Further record review for Resident #87 revealed that, despite the resident's 03/24/2015, 5:00 p.m. low blood pressure reading of 83/75 and the medication nurse holding the resident's [MEDICATION NAME], and Carvedilol anti-hypertensive medications as referenced above, there was no evidence to indicate that the attending physician was consulted regarding either the resident's low blood pressure reading or the doses of medication being held. During an interview with the Director of Nurses (DON) conducted on 03/26/2015 at 10:10 a.m., the DON stated the policy on holding medications was to circle medication doses. The DON acknowledged the low blood pressure reading of 83/75 for Resident #87 on 03/24/2015 at 5:00 p.m., and that the nurse circled the doses of [MEDICATION NAME], and Carvedilol on the MAR. The DON also stated that she would have expected the medication nurse to notify the physician of Resident #87's low blood pressure reading and the holding of the anti-hypertensive m… | 2018-05-01 |
| 6000 | 6000 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2015-03-26 | 279 | D | 0 | 1 | VVSI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility's policy for the Prevention and treatment of [REDACTED].#37), who was assessed as being at risk for the development of pressure sores, from a survey sample of thirty-four (34) residents. Findings include: Resident #37's Annual Minimum Data Set assessment of 12/19/2014 documented diagnoses, in Section I-Active Diagnoses, including, but not limited to, Diabetes Mellitus, [MEDICAL CONDITIONS], and [MEDICAL CONDITION]/[MEDICAL CONDITION]. Section M-Skin Conditions identified Resident #37's risk for pressure sore development. Review of the care plan of 03/11/2015 for Resident #37 documented a Focus area, initially dated 07/30/2013, which identified the resident to be at risk for pressure ulcer development, and also referenced Interventions related to this risk. However, further review of these care plan Interventions intended to address Resident #37's risk for pressure ulcer development revealed no planned measures or pressure reducing devices to prevent pressure ulcer development. One Intervention related to Resident #37's risk for pressure ulcers instructed staff to follow facility policies for the prevention/treatment of [REDACTED]. During a post-survey Quality Assurance telephone interview with Nurse GG conducted on 04/30/2015 at 11:25 a.m., Nurse GG acknowledged Resident #37's need for pressure relief for the lower extremities. Cross refer to F314 for more information regarding Resident #37. | 2018-05-01 |
| 6001 | 6001 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2015-03-26 | 282 | D | 0 | 1 | VVSI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that care was provided in accordance with the plan of care for one (1) resident (#87), regarding the administration of antihypertensive medication, and for one (1) resident (#65), regarding monitoring for side effects related to antipsychotic drug therapy, from a survey sample of thirty-four (34) residents. Findings include: 1. Resident #87's Admission Minimum Data Set (MDS) assessment of 03/05/2015 documented, in Section I - Active Diagnoses, the resident to have [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #87 revealed a Focus area dated 03/09/2015 which identified the resident's [DIAGNOSES REDACTED]. Interventions on Resident #87's Care Plan, as related to hypertension, included to give the antihypertenisive medications as ordered. Resident #87's March 2015 physician's orders [REDACTED]. Resident #87's March 2015 Medication Record (MR) documented the SPB readings exceeded 180 on 03/04/2015, 03/08/2015, 03/09/2015, 03/10/2015, 03/15/2015, 03/17/2015, 03/19/2015, 03/22/2015, and 03/23/2015 (9 occasions) in a range from 181 to 200. However, further record review revealed no evidence to indicate that Resident #87's supplemental [MEDICATION NAME] 10 mg dose was given for the elevated SBP readings as ordered for those nine (9) occasions during which the SBP exceeded 180. Resident #87's medication package containing [MEDICATION NAME] 10 mg doses contained 19 remaining doses of the original 25 doses dispensed on 02/25/2015, thus revealing that six (6) [MEDICATION NAME] 10 mg tablets were gone; however, as indicated above, no [MEDICATION NAME] 10 mg doses were documented as administered to Resident #87 on the nine (9) days between 03/04/2015 and 03/23/2015. This was despite Resident #87's physician's orders [REDACTED]. During an interview with the Director of Nursing (DON) on 03/25/2015 at 2:08 p.m., the DON acknowledged the lack of evidence to indicate that Res… | 2018-05-01 |
| 6002 | 6002 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2015-03-26 | 314 | D | 0 | 1 | VVSI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide pressure relief for one (1) resident (#37), who had been assessed to be at risk for pressure-sore development, from a survey sample of thirty-four (34) residents. Findings include: Review of the clinical record of Resident #37 revealed an Annual Minimum Data Set (MDS) assessment having an Assessment Reference Date of 12/19/2014 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Section G - Functional Status indicated that Resident #37 was totally dependent on staff for bed mobility, and Section M - Skin Conditions, indicated that while the resident had no pressure sores at that time, she was at risk for the development of pressure sores. Additional record review for Resident #37 revealed a Braden Scale assessment completed on 03/04/2015 which documented the resident to have a Braden Scale score of 13 and therefore to be at moderate risk for skin breakdown. However, even though Resident #37's 12/19/2014 MDS assessment and 03/04/2015 Braden Scale assessment, both referenced above, assessed the resident to be at risk for pressure-sore development, further review of the clinical record of Resident #37 revealed no evidence of the planned use of interventions to provide pressure relief and to serve as preventive measures for pressure ulcer development. During an observation of Resident #37 conducted on 03/25/2015 at 9:40 a.m., no pressure relieving devices were observed in place as the resident was in bed and receiving wound care. The resident was lying on her left side with her right foot resting on a pillow while receiving wound care, but with her left foot lying directly on the bed with no pressure relieving device in place. During a subsequent observation conducted on 03/25/2015 at 1:15 p.m., Resident #37 was observed in the hallway sitting in a wheelchair with no heel protectors or other pressure relieving device… | 2018-05-01 |
| 6003 | 6003 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2015-03-26 | 329 | D | 0 | 1 | VVSI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure adequate monitoring for adverse consequences, to include side effects, for one (1) resident (#65) who received an antipsychotic medication, of thirty-four (34) sampled residents. Findings include: Record review for Resident #65 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 11/11/2014 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Section E - Behaviors of this MDS documented that Resident #65 had behaviors which included Hallucinations and Delusions, and Section N - Medications documented that the resident received antipsychotic medications. The current March 2015 physician's orders [REDACTED].#65 specified that the resident was to receive the antipsychotic medication [MEDICATION NAME] 200 milligrams (mgs) orally twice daily for [MEDICAL CONDITION]. Review of the Psychopharmacologic Drug Monthly Flow Records for Resident #65 revealed that the facility was providing ongoing monitoring of the Specific Behaviors related to the resident's [MEDICATION NAME] antipsychotic drug therapy. However, further review of Resident #65's clinical record, to include review of the Psychopharmacologic Drug Monthly Flow Records, revealed no evidence of monitoring for medication side effects regarding the [MEDICATION NAME] drug therapy for the months of December 2014, January 2015, and March 2015. During an interview with Licensed Practical Nurse (LPN) BB conducted on 03/25/2015 at 8.30 a.m., LPN BB stated that medication side effects should be monitored. LPN BB further acknowledged that the section of the Psychopharmacologic Drug Monthly Flow Records designated for Side Effects monitoring for Resident #65 showed no evidence that monitoring for side effects had been performed. During an interview with the Director of Nursing (DON) conducted on 03/25/2015 at 8.50 a.m., the DON stated she expected nu… | 2018-05-01 |
| 6004 | 6004 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2015-03-26 | 333 | D | 0 | 1 | VVSI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure that one (1) resident (#87), from a survey sample of thirty-four (34) residents, was free of a significant medication error, related to the failure of the facility to administer Resident #87's anti-hypertensive drug [MEDICATION NAME] as ordered for elevated systolic blood pressure readings. Findings include: Record review for Resident #87 revealed an Admission Minimum Data Set assessment having an Assessment Reference Date of 03/05/2015 which documented in Section I - Active [DIAGNOSES REDACTED]. The March 2015 physician's orders [REDACTED].#87 specified that the resident receive [MEDICATION NAME] 25 milligrams (mgs) three times daily and that the resident's blood pressure be taken three times daily. An additional order specified that Resident #87 receive a supplemental dose of [MEDICATION NAME] 10 mgs (in addition to the [MEDICATION NAME] 25 mg dose) as needed for a systolic blood pressure (SBP) of greater than 180. However, further review of the medical record of Resident #87, to include review of the resident's March 2015 Medication Record (MR), revealed that on the following nine (9) dates and times, the resident's SBP exceeded 180 in the following amounts without the ordered supplemental dose of [MEDICATION NAME] 10 mg being administered as ordered: - On 03/04/2015 at 9:00 a.m. for a SPB reading of 187; - On 03/08/2015 at 1:00 p.m. for a SPB reading of 187; - On 03/09/2015 at 1:00 p.m. for a SBP reading of 185; - On 03/10/2015 at 5:00 p.m. for a SBP reading of 181; - On 03/15/2015 at 5:00 p.m. for a SBP reading of 185; - On 03/17/2015 at 9:00 a.m. for a SBP reading of 192; - On 03/19/2015 at 1:00 p.m. for a SBP reading of 194; - On 03/22/2015 at 9:00 a.m. for a SBP reading of 200; - On 03/23/2015 at 9:00 a.m. for a SBP reading of 194. During an interview with Licensed Practical Nurse (LPN) AA conducted on 03/25/2015 at 1:30 p.m., LPN AA stated that she pro… | 2018-05-01 |
| 6005 | 6005 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2015-03-26 | 371 | F | 0 | 1 | VVSI11 | Based on observation and staff interview, the facility failed to ensure that food was stored, distributed, and served under sanitary conditions during observation of the kitchen. The facility's Form CMS-672, Resident Census and Conditions of Residents, documented that only one (1) resident received nutrition by tube feeding, indicating that the facility's remaining sixty-six (66) residents received food prepared in the kitchen thereby had the potential to be affected by this deficient practice. Findings include: During observations of the kitchen conducted on 03/24/2015 at 10:00 a.m., the thermometer in the walk-in cooler was not functional. Twelve (12) cups of yogurt in the walk-in cooler had an expiration date of 12/14/2014, and an unopened case of yogurt had an expiration date of 02/12/2015. Additionally, five (5) dented cans were observed stored on a rack and available for use. During interview with the Dietary Manager conducted at the time of these observations, he/she stated he/she did not know how long the thermometer had been broken and that it was his/her expectation that staff would report equipment that was broken. She/he stated the facility had a resident on yogurt as part of her dietary supplement but she had been discharged and the remaining yogurt had not been removed from the cooler. He/she stated that he/she was not aware of an issue using dented cans, that they were delivered by their food supplier and she thought they were safe. During observation of the lunch meal conducted on 03/23/2015 at 12:30 p.m., non-dietary staff were walking into the kitchen area in front of steam table and picking up trays. Uncovered food items were on a tray against the wall and not behind the sneeze guard. After serving the tray the staff would return to the kitchen. Some staff were observed using hand sanitizer and some staff did not use hand sanitizer, but no staff washed their hands with soap and water. During observation of the supper meal conducted on 03/23/2015 at 5:30 p.m., non-dietary staff entered the kitch… | 2018-05-01 |
| 6006 | 6006 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2015-03-26 | 441 | D | 0 | 1 | VVSI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 (#37) from a survey sample of thirty-four (34) residents. Findings include: Resident #37's 12/19/14 Annual Minimum Data Set assessment documented, in Section I-Active Diagnoses, the resident had [DIAGNOSES REDACTED]. A Weekly Skin Condition Report for Resident #37 dated 01/28/2015 documented that a vascular wound had been observed on the resident's right lateral foot. A current, 03/20/2015, Telephone Orders form for Resident #37 specified to clean the resident's right lateral foot wound with normal saline and pat dry, apply collagen dressing and cover with calcium alginate dressing, then a dry dressing, and protect with bordered dressing daily and as needed. During an observation of wound care for Resident #37 conducted on 03/25/2015 at 9:40 a.m., the Wound Care Nurse did not put a protective barrier under the resident's foot before starting wound care. He/she did not wash the hands with soap and water between changing the soiled dressing and beginning the clean dressing, but rather washed hands with soap and water only after the wound was cleaned and before the dressing was applied. The Wound Care Nurse also did not clean wound in a circular motion, starting at the center of the wound and working to outer edges, but rather only dabbed the wound with normal saline-soaked gauze. During an interview with Director of Nursing (DON) conducted on 03/25/2015 at 11:10 a.m., the DON stated facility protocol specified that nurses wash their hands after three uses of hand sanitizer. When changing a dressing, hands were to be washed before starting the procedure, after completion of soiled-dressing removal, at the beginning of clean dressing application, and after dressing change was completed. | 2018-05-01 |
| 6007 | 6007 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2015-03-26 | 514 | D | 0 | 1 | VVSI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain an accurately documented medical record for one (1) resident (#87), from a survey sample of thirty-four (34) residents, related to the documentation of medication administration. Findings include: Resident #87's 03/05/2015 Admission Minimum Data Set assessment documented [DIAGNOSES REDACTED]. Resident #87's March 2015 physician's orders [REDACTED]. Resident #87's March 2015 Medication Record (MR) documented that on 03/04/2015, 03/08/2015, 03/09/2015, 03/10/2015, 03/15/2015, 03/17/2015, 03/19/2015, 03/22/2015, and 03/23/2015, the resident's SBP readings had exceeded 180; however, the clinical record did not document the administration of doses of [MEDICATION NAME] of 10 mgs, ordered to be administered for SBPs readings of greater than 180. Despite Resident #87's medical record failing to document the administration of doses of [MEDICATION NAME] 10 mgs for the nine (9) occasions as referenced above, the medication package containing Resident #87's [MEDICATION NAME] 10 mg (dated as dispensed on 02/25/2015) revealed six (6) missing doses of the drug. During an interview with Licensed Practical Nurse (LPN) AA on 03/25/2015 at 1:45 p.m., LPN AA acknowledged there was no documentation to indicate that Resident #87 had received the [MEDICATION NAME] 10 mg doses. Cross refer to F333 for more information regarding Resident #87. | 2018-05-01 |
| 6123 | 6123 | WINDERMERE HEALTH AND REHABILITATION CENTER | 115291 | 3618 J DEWEY GRAY CIRCLE | AUGUSTA | GA | 30909 | 2015-03-26 | 356 | C | 0 | 1 | PUUK11 | Based on observations and staff interviews, the facility failed to display the nurse staffing data as required in a prominent place readily accessible to residents and visitors. The facility census was one hundred and seven (107) residents. Findings Include: Observation on 03/23/15 at 10:45 a.m., during the initial tour of the facility revealed no posting of nurse staffing hours. During the observation, an interview with the Assistant Director of Nursing(ADON) at that time revealed that she was not aware of the posting. The ADON stated that she needed to check with the staffing coordinator. Interview on 03/23/15 at 11:30 a.m. with the ADON revealed that per the staffing coordinator, the posting had been taken down due to construction. Observation on 03/24/15 at 9:00 a.m. revealed that the staffing hours were posted in a file box on the back of the staffing coordinator's door. Review of the nurse staffing document revealed that it was incomplete and not easily accessible to residents or visitors. The document was noted to cover staffing for the whole week, and had no facility name or, resident census information. Interview with the Director of Nursing (DON) on 03/26/15 at 1:20 p.m. confirmed that the staff posting for hours and census that was supposed to be displayed daily and was incorrect and not posted as required. | 2018-03-01 |
| 6124 | 6124 | WINDERMERE HEALTH AND REHABILITATION CENTER | 115291 | 3618 J DEWEY GRAY CIRCLE | AUGUSTA | GA | 30909 | 2015-03-26 | 456 | E | 0 | 1 | PUUK11 | Based on observation and staff interviews the facility failed to properly maintain one (1) of two (2) ice machines in the nourishment rooms in a clean and sanitary manner. The facility census was one hundred and seven (107) with nine (9) of those residents who received an alternative means of nutrition. Findings include: Observation on 03/24/15 at 12:35 p.m. of the East Hall resident nourishment room revealed that the white ice slide inside the ice machine had a substance on the bottom edge that was green, brown, and pink in color. This discoloration extended the entire length of the bottom of the ice slide. Observation on 03/25/15 at 9:10 a.m. and 3:05 p.m. of the East Hall ice machine revealed that the green, brown, and pink substance was still observed at the bottom edge of the ice slide inside the ice machine. Observation on 03/26/15 at 9:45 a.m., 12:15 p.m., and 2:00 p.m. revealed that the green, brown and pink discoloration was still observed on the white ice slide inside the ice machine. When wiped with a paper towel the substance was easily removed and was noted to have a slimy texture. Interview on 03/26/15 at 2:15 p.m. with Director of Maintenance revealed that he was responsible for cleaning the ice machines in the resident nourishment rooms. He further revealed that he cleans the ice machines monthly. The Maintenance Director confirmed that there was a pink, green, and brown buildup on the ice slide and acknowledged that it was mold. Continued interview revealed that the ice machine on the East Hall was older than the ice machine on the West Hall and this ice machine tends to develop the mold buildup on the ice slide inside the ice machine 2 weeks after it is cleaned. The Director of Maintenance acknowledged that the mold buildup was a problem. He further revealed that he had considered cleaning the ice machine more often, however due to general maintenance of other facility equipment if would be difficult to schedule more routine cleanings. | 2018-03-01 |
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CREATE TABLE [cms_GA] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );