cms_GA
Data source: Big Local News · About: big-local-datasette
33 rows where "inspection_date" is on date 2017-08-10
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Suggested facets: facility_name, address, city, zip, scope_severity, complaint, standard, eventid, filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 616 | 616 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2017-08-10 | 252 | E | 0 | 1 | MZNF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the policy titled Serving Meals and staff interviews, the facility failed to ensure a homelike environment during dining. Specifically, the facility failed to remove the meal trays after delivering meals to 35 residents in the Main Dining room, in an effort to de-emphasize an institutional setting. The facility census was 73 residents. Findings include: Observation in the Main Dining room on 8/7/17 beginning at 11:55 a.m. revealed 32 residents seated at tables for lunch. At 12:05 p.m. the facility staff began serving the residents their meals on meal trays. The staff did not remove the meal trays when the meals were delivered to all 32 residents until the residents completed their meal. Further, the staff was not observed asking any of the 32 residents if they wanted the meal tray to remain in place. Observation in the Main Dining room on 8/8/17 at 12:00 p.m. revealed 31 residents seated at tables for lunch. All 31 residents were served their meals on a serving tray. The serving trays were not removed when the meals were delivered to all 31 residents and the staff was not observed asking any of the 31 residents if they wanted the meal tray to remain in place. The meals trays remained in place until they were picked up after the residents completed their meals. Observation in the Main Dining room on 8/10/17 at 12:11 p.m. revealed 35 residents seated at tables for lunch. All 35 residents had been served their meals on meal trays that were not removed. Interview on 8/10/17 at 12:15 p.m. with resident Y in the main dining room revealed he eats most all of his meals in the Main Dining room. The resident stated that the staff brings the meals on a serving tray and the tray is not removed. Resident Y stated the trays are not picked up until they are finished eating. Interview on 8/10/17 at 12:18 p.m. with the Activities Staff DD revealed she assist in the dining room almost every day. She stated that they serve the re… | 2020-09-01 |
| 617 | 617 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2017-08-10 | 441 | E | 0 | 1 | MZNF11 | Based on observation, staff interview and facility policy review. The facility failed to ensure that staff follow proper infection control guidelines when passing ice to residents on one (South) of two hallways. The facility census was 73. Findings include: Review of facility's Infection Control Prevention Manual for Long Term Care for Ice chests and Ice Machines (revised 2009) revealed: Policy: The following policy should be followed to reduce the likelihood of contamination of ice chest (ice-storage compartments) and ice machines. II. Ice scoops used should be smooth and impervious and should be kept on an uncovered stainless steel, impervious plastic or fiberglass tray on tope of the chest or in a mounted holder when not in use. Observation on 08/07/2017 11:45 am. Certified Nursing Assistant (CNA) BB passing ice on the south hall. Observed each time she filled a resident's cup with ice she would place ice scoop back into the ice chest on top of the ice to be given. Also noted CNA BB going from one room to the next with no indication of her rubbing her hands together to indicate that she had washed her hands or used sanitizer. Interview 08/07/2017 12:12 pm. with CNA BB when she returned ice chest to nurses' station revealed, when the ice chest was opened, the ice scoop lying on top of ice that was remaining in ice chest. Further interview with CNA BB stated that I'm supposed to place the ice scoop within the bag in the drawer underneath the ice chest. CNA BB further stated when she passes ice to just a few rooms that she just puts the scoop back into the ice chest between rooms then reported that she should have replaced scoop into bag between each resident. Interview 08/10/2017 4:57 p.m. with the Infection control nurse revealed that the staff are expected to wash their hands after each residents' cup is filled with ice and ice scoop is to be replaced within the plastic bag underneath ice chest between each use not inside ice chest. Interview 08/10/2017 5:09 pm. Director of Nursing (DON) Surveyor ask what her … | 2020-09-01 |
| 1047 | 1047 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 166 | D | 0 | 1 | 4CBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and clinical record review the facility failed to make prompt efforts to resolve a grievance filed by one resident out of three residents reviewed. The facility further failed to document components of the grievance process; the date of the reporting, the summary, the investigation, the findings or conclusion, confirmation, corrective action taken of the grievance and the date the written decision was issued for Resident (R#128). The sample size was 34 residents. Findings include: On 8/7/17 at 3:00 p.m., during an interview with R#128, revealed that he reported about four to five months ago, that he lost $50.00. He indicated he reported it to the Certified Nursing Assistant (CNA) who informed the nurse. He was not able to recall which CNA or nurse he spoke to. He further indicated the nurse and a lady from the front office both came and spoke with him but nothing was ever done about it. When asked who the lady from the front office was, he was not able to remember her name but stated, she was the boss lady. On 8/9/2017 at 3:15 p.m., during an interview with the Social Services Director (SSD), she indicated R#128 had reported to her he had money missing. She however, was not able to recall the date it was reported but revealed it had been sometime in (YEAR). She indicated he had a key to his lock box where he kept his money. He showed her the lock on the lockbox which looked like it had been opened with something other than the key. She indicated maintenance replaced the lock at her request. She further indicated she interviewed on the day the money was reported missing, the housekeeping staff and the direct care staff who was assigned to R#128. She reported the missing money to the Administrator. She revealed nothing further was done in regards to R#128 having missing money. She further revealed the money was not replaced. A review of the Grievance Log from the previous 16 months prior to the survey, with… | 2020-09-01 |
| 1048 | 1048 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 242 | D | 0 | 1 | 4CBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, and staff interview, the facility failed to ensure residents' rights to choose when they desired to get out of or go to bed was honored for two of 34 sampled residents. Residents (R#24 and R#91). Findings Include: 1. R#24 According to R#24's Clinical Resident Profile, R#24 was re-admitted to the facility on [DATE]. Review of the Medical [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimal Data Set (MDS) (a standardize screening and assessment tool used for long term care residents), dated 7/7/2017, revealed under Section C - Cognitive Patterns that R#24 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating R#24 was cognitively intact. Section [NAME] - Behavior - E0800 documented that R#24 rejected care 1-3 days during the seven-day look back period. Section G - Functional Status - G0110 documented that R#24 required extensive assistance of two persons for transfers. During an interview, on 8/8/17 at 11:53 a.m., R#24 stated that staff put him to bed too early at night and get him up too late in the mornings. He discussed that, on his [MEDICAL TREATMENT] days, staff would wake him for breakfast at 7:30 a.m., but do not get him up out of bed until after 12:00 p.m. R#24 further shared, sometimes on the weekends staff don't get him up at all. Review of the R#24's care plan revealed there was no care plan initiated until 8/9/17 (during stage II investigations) which documented that R#24 .exhibited behaviors ie: does not want to get out of bed on [MEDICAL TREATMENT] days, verbally aggressive at times. The goal was that R#24 would cooperate with care through next review date. The interventions included; allow resident to make decisions about his treatments, educate resident and family regarding outcomes of non-compliance with care, give clear explanation of care activities prior to and as they occur, if resistive to care, reassure resident, leave and return to try… | 2020-09-01 |
| 1049 | 1049 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 282 | D | 0 | 1 | 4CBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility failed to assure services were provided in accordance with the plan of care for one resident (R#48) of 34 sampled residents. The care plan approach was not followed to apply a splint to the resident's right had as ordered. Findings include: Review of the Face Sheet for R#48 revealed pertinent [DIAGNOSES REDACTED]. Review of the Care Plan with a target date of 9/22/2017 with a date initiated of 12/23/16 revealed a focus of self-care deficit R/T (related to)[MEDICAL CONDITION] right [MEDICAL CONDITION], hand contracture. Goals included; the resident will be clean, dry and well groomed, .Will have ADL (activities of daily living) needs met, and will participate in ADL's within limitations. Approaches included; to apply splint to the right hand as tolerated per order. Review of the current (MONTH) (YEAR) Physician Orders, revealed an order for [REDACTED].>Observations of R#48 on 8/09/2017 at 3:13 p.m., revealed the resident was up in a wheel chair, right hand closed into a fist. When questioned if she could open her hand, R#48 shook head and verbalized no. There was no splint observed in the room. Observation on 8/10/2017 at 9:04 a.m., revealed the resident was up in her wheelchair groomed and dressed for the day. There was no splint on the right hand. Interview with Assistant Director of Nursing (ADON) who is responsible for overseeing the Restorative Nursing Program on 8/10/2017 at 10:07 a.m., when asked about the use of the right-hand splint, the ADON indicated she thinks she remembers seeing a blue splint in R#48's room. Accompanied ADON to the resident's room. No splint was located. On 8/10/2017 at 10:29 a.m., interview with Restorative Certified Nursing Assistant (RCNA) HH revealed R#48 did have a splint, but stated, I think it was D/C'd (discontinued) a while back, not sure when. In the presence of the ADON the surveyor asked if the electronic record could be se… | 2020-09-01 |
| 1050 | 1050 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 285 | D | 0 | 1 | 4CBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) for residents with mental illness was completed as required for one of two residents, Resident (R#97) reviewed. The sample size was 34 residents reviewed. Failure to complete the PASRR could result in the resident not receiving appropriate services needed for their mental illness. Findings include: On 8/9/17 review of the clinical record for R#97 reveals she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the current (MONTH) (YEAR) physician's orders [REDACTED]. Review of R#97's, Care Plan dated 12/14/16 and revised on 5/10/17 related to receiving medication for a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Review of the Georgia Department of Medical Assistance, PASRR Level I Application, Resident Identification Screening Instrument, for R#97 not dated, revealed the Level one documentation questions had been answered but there was no date nor was there a physician's signature; those areas were blank. There was no Level 2 PASRR in the clinical record for R#97. During an interview with the Social Services Director (SSD) on 8/9/17 at 11:00 a.m., she indicated she was not aware R#97 needed a Level 2 PASRR. She also indicated the hospital completed that documentation and she just filed it in the record but did not review for accuracy or to ensure it was complete. She further indicated she was not aware the facility was responsible for completion of the application for Level 2 services if the hospital did not do it. After the SSD reviewed the clinical record for R#97, a follow up interview was completed on 8/9/17 at 4:45 p.m., she revealed the Level 1 PASRR was incomplete and the clinical record for R#97 did not contain a Level 2 PASRR. She further indicated the Level 2 PASRR needed to be completed for R#97. By the facility not completing the application for Level 2 PASRR, the facility f… | 2020-09-01 |
| 1051 | 1051 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 309 | D | 0 | 1 | 4CBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident, and staff interviews, the facility failed to ensure one of 34 sampled residents (R#91) had received as needed (PRN) pain medications and appropriate assessments for pain. Findings Include: According to the Admission Record R#91 was re-admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED].#91 had stage III pressure ulcer, stiffness of the joint, muscle weakness, lack of coordination, abnormal posture, and cerebral infarction (area of necrotic tissue in the brain). Review of the most recent quarterly Minimal Data Set ((MDS) dated [DATE] revealed under Section B0700 Makes Self Understood and B0800 Ability to Understand Others R#91 was understood by others and able to comprehend others. Review of Section C - Cognitive Patterns R#91 scored an 8/15 on the Brief Interview for Mental Status (BIMS) indicating R#91 was cognitively impaired. Section J0100. Pain Management revealed that R#91 did not received PRN medications or decline PRN medications, J0300. Pain Presence resident had not had pain or hurting during the last five days. Section M0300. Current Number of Unhealed Pressure Ulcers at Each Stage documented that R#91 had a stage III pressure ulcer. Review of the Care Plan initiated on 11/16/16 and revised on 8/9/17 (after stage II investigations) R#91 had a focus related to alteration in comfort related to right toe amputation, limited mobility, [MEDICAL CONDITIONS] and pressure wound to left heel. The pertinent interventions were, administer pain medications as ordered, observe for tolerance and effectiveness, assist with repositioning for increased comfort, monitor for signs/symptoms of pain every shift, observe for signs/symptoms of pain/discomfort such as facial grimacing, or change in behaviors. During an interview on 8/7/17 at 3:25 p.m., R#91 revealed both his feet hurt and he stated he has two sores and they, hurt like crazy. He discussed if he is receiving pain medi… | 2020-09-01 |
| 1052 | 1052 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 312 | D | 0 | 1 | 4CBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interview the facility failed to provide assistance with activities of daily living (ADLs) for one resident (R#91) of 34 residents reviewed. who required staff assistance. R#91 was observed needing assistance with changing out of soiled clothing on more than one occasion. Findings include: According to the Admission Record R#91 was re-admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimal Data Set ((MDS) dated [DATE] revealed under Section B0700 Makes Self Understood and B0800 Ability to Understand Others R#91 was understood by others and able to comprehend others. Review of Section C - Cognitive Patterns R#91 scored an 8/15 on the Brief Interview for Mental Status (BIMS) indicating R#91 was cognitively impaired. Section G - Functional Status G0110 documented that R#91 required extensive assistance of one person for dressing, supervision and setup for eating. Review of the Care Plan initiated on 11/16/16 for R#91 had the following focus, The resident has an ADL (activities of daily living) performance deficit r/t (related to) [MEDICAL CONDITION], limited Mobility, Stroke (sic). The goal was the resident's ADL's will be met with dignity and respect and be maintained through next review. The interventions related to dressing were, allow sufficient time for dressing and undressing, assist the resident in selecting simple comfortable clothing to enhance his ability to dress himself and resident requires assistance by staff to dress. During an observation on 8/7/17 at 3:31 p.m., R#91 was observed in bed wearing a green short sleeved shirt. During an observation on 8/8/17 at 10:59 a.m., R#91 was observed in bed wearing the same green short sleeved shirt. There was food debris on the upper left shoulder. During an observation on 8/9/17 at 12:32 p.m., R#91 was observed sitting in his wheelchair in his room. R#91 was wearing th… | 2020-09-01 |
| 1053 | 1053 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 318 | D | 0 | 1 | 4CBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility failed to ensure one resident (R#48) of 34 sampled residents reviewed had a splint placed on the right hand to prevent further contracture and ensure the splint was appropriate for the resident's needs. Findings include: Review of the Face Sheet, R#48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Date Set (MDS) (a standardize screening and assessment tool used for long term care residents) dated 6/15/2017 revealed a Brief Interview for Mental Status (BIMS) of four out of a score of 15 indicating severe cognitive impairment. Section G - Functional Status - Dressing and Personal hygiene Resident required extensive assistance of one person. The Care Plan initiated on 12/23/2016 identified a focus of self-care deficit related [MEDICAL CONDITION] right hand [MEDICAL CONDITION], hand contracture. Goals with a target date of 9/22/2017 indicated the resident will have ADL (activities of daily living) needs met. Splint right hand as tolerated/per order was listed as an intervention. Review of the current (MONTH) Physician Orders, revealed an order for [REDACTED]. Staff interview on 8/8/2017 at 11:23 a.m., with Licensed Practical Nurse (LPN) JJ revealed R#48 does have a contracture of the right arm. When asked if the resident receives range of motion (ROM) or have a splint device in place LPN JJ stated no. Observations of R#48 on 8/9/2017 at 3:13 p.m., and on 8/10/2017 at 9:04 a.m., revealed the resident did not have a splint on the right hand. Interview on 8/10/2017 at 10:07 a.m., with the Assistant Director of Nursing (ADON) who was responsible for overseeing the restorative nursing program revealed R#48 participated in the restorative nursing program. She further revealed R#48 ambulated with a hemi-walker, and was motivated. When asked about the right-hand splint the ADON indicated she would need to check wit… | 2020-09-01 |
| 1054 | 1054 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 323 | D | 0 | 1 | 4CBP11 | Based on observation and staff interview the facility failed to assure electrical safety in one of one room (P4) where an electrical power strip was used to provide electricity to multiple needed medical devices. The sample size was 34 residents. Findings include; On 08/10/2017 at 9:13 a.m., an observation was conducted of patient room P4. An oxygen concentrator was located against the wall to the left of the head of the bed. The concentrator was plugged in to a power strip affixed to wall with a screw. The power strip was plugged in to an electrical wall outlet behind the head of the bed. On 08/10/2017 at 9:15 a.m., an interview with the Maintenance Supervisor (MS) immediately following a shared observation of the power strip in use in room P4. He indicated the power strip was in use to provide adequate numbers of outlets for the medical devices needed by the resident in room P4. He revealed he was aware the use of the power strip was identified as a problem during the Life Safety Code survey earlier in the week. He further indicated the facility planned to install additional electrical outlets in the room as soon as possible to remove the potential safety hazard. On 08/10/2017 11:35 a.m., an interview with the Assistant Director of Nursing (ADON) which revealed the equipment plugged in to the power strip and electrical wall outlet in room P4 included an oxygen concentrator, an electric motorized lift bed and a flotation air mattress. She also verified all these medical devices were in current use. On 08/10/2017 12:03 p.m., an interview with the Administrator revealed the facility did not have a policy on the use of electrical outlet extenders such as power strips. She further revealed the facility tries to abide by all Life Safety Code regulations. She continued to reveal the company whom operates the facility completes regular internal audits of compliance with Life Safety Code regulations. The Administrator indicated the most recent internal audit (within the past two weeks) had made her aware of the use of p… | 2020-09-01 |
| 1055 | 1055 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 334 | D | 0 | 1 | 4CBP11 | Based on staff interview and clinical record review the facility failed to ensure the medical record for four of five residents reviewed contained documentation the resident or their representative had been offered an influenza immunization, with the right to refuse, during the flu season of (MONTH) first through (MONTH) thirty-one annually for residents (R#5, R#128, R#151 and R#161). The facility further failed to ensure the medical record for three of five residents reviewed contained documentation the resident or their representative had been offered a pneumococcal immunization, with the right to refuse for (R#128, R#151 and R#161). The sample size was 34 residents reviewed. Failure to document the consent or decline of the influenza immunization and the pneumococcal immunization meant it was not able to be determined if the immunization was offered which could have prevented severe illness if the resident or their representative had accepted the offer. Findings include: On 8/9/17 at 12:30 p.m., during an interview with Registered Nurse (RN) CC, revealed she was responsible for ensuring the facility offered and obtained consent or decline of the influenza (flu) and pneumococcal immunization for all residents. She indicated during the last flu season the nurses on the floor were responsible for obtaining consent but the facility found the forms were not always being completed. She stated, documentation of administration of immunizations are noted on the . TEST/IMMUNIZATION RECORD. Review of the clinical records on 8/9/17 at 12:30 p.m., with RN CC revealed the consents forms for the flu and pneumococcal immunizations were maintained in a large notebook in the office of RN CC. 1. Review of the facility documentation of flu and pneumococcal immunization with RN CC revealed, the responsible party for R#5 signed the consent for the flu immunization on 10/5/16. Review of the TEST/IMMUNIZATION RECORD for R#5 revealed there was no documentation the flu immunization was administered. 2. Review of the facility documentat… | 2020-09-01 |
| 1056 | 1056 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 353 | D | 0 | 1 | 4CBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff and resident interview, and review of the facility policy, the facility failed to provide sufficient nursing staff to assure the needs of two of 34 residents (R#19 and R#24) were met for residents to achieve the highest practicable level of well-being. Specifically: Residents waited extended time frames for assistance to get out of bed, or were not able to get out of bed due to insufficient staff. Findings Include: Review of the facility policy titled, Safe Lifting and Movement of Residents, revised 10/3/13, revealed in the pertinent part of the policy, .Guidelines: 2. Manual Lifting of residents shall be eliminated when feasible. The use of a mechanical lift with residents requires the assistance of 2 staff members at all times. Review of the Resident Census and Conditions of Residents form revealed the facility census was 92 and of those 92 residents, two residents were independent with transfers, 78 residents required assist of one or two staff and 12 residents were completely dependent on staff. Review of the untitled daily staffing form dated 7/20/17 revealed seven Certified Nursing Assistant (CNA) staff were scheduled for the 7:00-3:00 shift with two working from 7:00-11:00 a.m. leaving five CNAs from 11:00 a.m. to 3:00 p.m. There were two CNA's on the North Unit from 11:00 a.m. to 3:00 p.m. where R#24 and R#91 resided. Further review of the staffing form revealed there were six CNAs for the evening and night shift. The form did not identify if there was a staff call off. During an interview with the North Unit Manager Licensed Practical Nurse (NUMLPN) FF on 8/9/17 at 3:49 p.m., revealed for the most part they are staffed adequately. Today we had six CNAs on the North unit for day shift. She indicated when they only have two CNA's the residents' get care but residents may have to wait a longer period of time. She discussed day shift usually needs more CNAs due to meals, therapy, and ac… | 2020-09-01 |
| 1057 | 1057 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 371 | E | 0 | 1 | 4CBP11 | Based on observation, staff interviews and facility policy review, the facility failed to prepare, distribute, and serve food under sanitary conditions. One Dietary staff aide wore a beard net inappropriately and did not wear a hair net while preparing to serve food to the residents. Three Dietary Aide touched plates, food, cups and containers with contaminated gloves used to serve the food to 92 residents. The practice of improper hygiene, food handling, and glove use, had the potential to affect residents eating in the facility. The sample size was 34 residents reviewed. Findings include: On 8/9/17 at 11:15 a.m., during observation of the noon time meal service the following was observed: 1. The Cook was setting up the steam table wearing a beard net under his chin and exposing the facial hair on his cheeks and above his lip. Also, the cook did not have on a hair net. 2. At 11:43 a.m., the Cook picked up dirty dishes with his bare hands and then placed them in the three sink area. Then, the Cook placed gloves on his hands without washing them and took some dressing out of the warmer and placed it on the steam table. 3. At 11:59 a.m., Dietary Aide BB wore a glove on her right hand and no glove on the left hand. Dietary Aide BB went over to pull over a cart for room trays using both hands. Dietary Aide BB then would use the gloved hand to place rolls on the plate and drinks on the trays. Dietary Aide BB did this with a total of three carts and did not change gloves in between touching the carts and touching the rolls. 4. At 12:25 p.m., Dietary Aide AA was observed to be helping prepare plates on the steam service table. Then, Dietary Aide AA went to the refrigerator to get ice cream touching the handle of the refrigerator and the box in which the ice cream was placed in. Dietary Aide AA came back to the service line touching the utensils without changing gloves. 5. A 12:30 p.m., the Cook was using the same utensils as Dietary Aide A[NAME] The Cook was observed to touch the dressing of one plate with his gloved ha… | 2020-09-01 |
| 1058 | 1058 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 431 | D | 0 | 1 | 4CBP11 | Based on observation and medication review, the facility failed to store drugs in locked compartments with only authorized personnel having access in two of four medication storage carts. The facility further failed to ensure expired medications were stored in separate location from active medications in one medication storage room out of one medication storage room available. The facility placed all residents at risk for adverse reaction/s related to medication safety and storage. The sample size was 34 residents reviewed. The findings include: On 8/8/17 at 9:15 a.m., observation of the medication storage cart on the top of the South Wing was unlocked. Licensed Practical Nurse (LPN) EE was previously observed standing in front of the cart and walked away entering the resident room with her back to the cart leaving the medication storage cart unsecured. She was in the resident's room approximately two minutes and locked the cart when she returned to the cart. On 8/10 /17 at 10:10 a.m., observation of the medication storage cart on the bottom of the North Wing was unlocked. LPN DD who was responsible for the medication cart was not in sight. After waiting two to three minutes, LPN DD returned to the medication storage cart from a resident room. She stated she did not realize she had left it unlocked. On 8/10/17 at 1:45 p.m. during observation of the medication storage room, a small refrigerator for medication storage was observed. The refrigerator contained multiple medications which included several expired medications. Inside the medication refrigerator was a small plastic box, inside this box was one bottle of Novolog insulin (an injectable medication for diabetics to reduce blood sugar levels) which expired 11/2016, one bottle of Novolin R insulin which expired 8/2016 and a Phenergan (anti-nausea medication) suppository 25mg which expired 12/2016. There was also a plastic bag which contained five Preparation H (medication used to reduce hemorrhoids) suppositories which expired 7/2017 and a box of 16 Preparatio… | 2020-09-01 |
| 1059 | 1059 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2017-08-10 | 464 | D | 0 | 1 | 4CBP11 | Based on observation, and staff interview the facility failed to provide a room designated for resident dining with sufficient space to accommodate dining meal services as evidenced by residents were unable to easily and safely exit the dining room without having another resident moved out of the exit path. The sample size was 34 residents reviewed. This deficient practice was observed in one of two dining areas. Findings include: An observation on 8/9/17 at 12:30 p.m., during the lunch meal thirty-six residents (R) were observed in the main dining room. Thirty-four of those residents were in wheel chairs and were not assisted to chairs for dining. The dining room was crowded and only eleven residents would be able to exit the dining area without having to maneuver around other residents. An observation on 8/10/17 at 12:45 p.m., of the lunch meal in the main dining room revealed thirty-nine residents were present. Thirty-seven of them were in wheelchairs. There were ten tables in the dining room. The dining room was crowded and residents in the back of the dining area were not able to exit unless other residents were moved out of the way. The space between the tables was limited with staff sliding sideways to squeeze between residents as they moved from resident to resident to assist the meal. An interview with an anonymous resident was conducted on 08/10/2017 at 1:10 p.m., after she left the dining room following the lunch meal. She indicated the dining room was way too crowded. She stated, it's not always that way but it has been lately. She continued to state, it was so crowded for lunch, she was worried about what would happen if some type of emergency happened and everyone needed to exit the dining room quickly. Further stating, I don't think we could all get out. On 8/10/17 at 1:15 p.m., an interview with the South Unit Manager Licensed Practical Nurse (SUMLPN) RR, revealed the dining room is usually crowded and lately more residents have been coming to the dining area to eat. She indicated she was contempl… | 2020-09-01 |
| 1923 | 1923 | TAYLOR COUNTY HEALTH AND REHABILITATION | 115507 | 165 SOUTH BROAD STREET | BUTLER | GA | 31006 | 2017-08-10 | 279 | D | 0 | 1 | MJ0J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to develop a care plan to address the oral status of one resident (#22) from a total sample of 27 residents. Findings include: A review of the clinical record revealed that Resident (R) #22 received 400 milligrams (mg) of [MEDICATION NAME] on 4/18/17 and 4/23/17 for complaints of tooth pain. A further review of the clinical record revealed that the resident had a visit with a dentist on 5/2/17 and an oral surgeon on 5/22/17. The resident was scheduled for surgery to extract tooth #32 on 8/14/17. On 5/23/17 the physician prescribed 875 mg of [MEDICATION NAME] to be administered for seven days. In addition, the physician prescribed Oragel to be applied to the tooth as need for tooth pain and 5mg/325mg of [MEDICATION NAME]/[MEDICATION NAME] every four hours as needed for tooth pain. A review of the (MONTH) (YEAR) through (MONTH) (YEAR) Administration Records (MAR's) revealed that the resident received the prescibed medication as needed for pain, and it was effective. However, there was no evidence that a care plan problem had been developed to address R#22's oral status and tooth problem. During an interview on 8/10/17 at 12:15 p.m., the Director of Nursing (DON) confirmed that a care plan had not been developed to address the resident's ongoing tooth problem. | 2020-09-01 |
| 1924 | 1924 | TAYLOR COUNTY HEALTH AND REHABILITATION | 115507 | 165 SOUTH BROAD STREET | BUTLER | GA | 31006 | 2017-08-10 | 280 | D | 0 | 1 | MJ0J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interveiw the facility failed to revise the care plan for one resident, #R 40 from a sample of twenty-seven (27). Findings include: Review of R#40's physician order [REDACTED]. Review of physician order [REDACTED]. Observation on 8/8/17 at 2:30 p.m. R#40 is laying in the bed with Foley catheter (F/C) to bed side drainage, in a blue dignity bag. Interview on 8/10/17 at 3:32 p.m. with the Administrator and the Director of Nursing (DON) reported that all staff can update and revise a residents care plan. However, review of R#40's care plan at this time revealed that the care plan had not been updated or revised to reflect the penile tear on 7/11/17. | 2020-09-01 |
| 1925 | 1925 | TAYLOR COUNTY HEALTH AND REHABILITATION | 115507 | 165 SOUTH BROAD STREET | BUTLER | GA | 31006 | 2017-08-10 | 309 | D | 0 | 1 | MJ0J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interveiw the facility failed to remove a 0.1 milligram (mg) [MEDICATION NAME] from one (1) resident, R#19 from a sample of twenty-seven (27). Findings include: Observation on 8/10/17 at 9:22 a.m. during medication pass with Licensed Practical Nurse (LPN) DD the LPN placed a 0.1 mg [MEDICATION NAME] on the right chest wall of R#19, then pulled open R#19's shirt and removed a [MEDICATION NAME] from the residents left chest wall. She shook her head and reported that it should have been removed last night 8/9/17 at 9:00 p.m. The resident was alert sitting in his wheelchair. Review of the Medication Administration Record [REDACTED]. LPN DD confirmed that there was initials on the MAR indicated [REDACTED]. Interview with the Administrator on 8/10/17 at 4:00 pm she reported that LPN DD reported to her about finding the [MEDICATION NAME] on R#19 this morning and that it had been signed out as being removed last night at 9:00 p.m The Administrator revealed that LPN DD called the doctor and received new orders to remove the patch and monitor the resident and then reapply the patch in the morning. | 2020-09-01 |
| 1926 | 1926 | TAYLOR COUNTY HEALTH AND REHABILITATION | 115507 | 165 SOUTH BROAD STREET | BUTLER | GA | 31006 | 2017-08-10 | 314 | D | 0 | 1 | MJ0J11 | Based on staff interview and record review, the facility failed to accurately measure a pressure ulcer on the initial assessment of the ulcer for one resident (#94) from a total sample of 27 residents. Findings include: Resident (R) #94 was identified as having a suspected Deep Tissue Injury (DTI) to the sacrum on 7/28/17. A review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed that the pressure ulcer was described as being maroon/purple and measuring 0.8 centimeters (cm) in length, 0.5 cm in width, and 0.1 cm in depth. During an interview on 8/9/17 at 11:55 a.m. Licensed Practical Nurse (LPN) BB stated that the pressure ulcer, when identified on 7/28/17 was closed, that it was a DTI, not open. She further stated that she thought that all wounds had to have a length, width and depth, but since the pressure ulcer was closed, she defaulted to a 0.1 cm measurement. She confirmed that the measurement of a depth on the DTI was inaccurate. | 2020-09-01 |
| 1927 | 1927 | TAYLOR COUNTY HEALTH AND REHABILITATION | 115507 | 165 SOUTH BROAD STREET | BUTLER | GA | 31006 | 2017-08-10 | 315 | D | 0 | 1 | MJ0J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facilty failed to include the [DIAGNOSES REDACTED].#40 from a sample of twenty-seven (27). Findings include: Record review of the physician orders [REDACTED]. Observation on 8/8/17 at 2:30 p.m. resident is laying in the bed, foley catheter to bedside drainage in blue dignity bag. Interview on 8/10/17 at 12:12 p.m. with Licencse Practical Nurse (LPN) EE revealed that the nurses transcribe all orders and he/she will put any new orders on t he physician order [REDACTED]. Interview on 8/10/17 at 1:58 p.m. with he Adminitrator she reported there should be a [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. | 2020-09-01 |
| 1928 | 1928 | TAYLOR COUNTY HEALTH AND REHABILITATION | 115507 | 165 SOUTH BROAD STREET | BUTLER | GA | 31006 | 2017-08-10 | 441 | E | 0 | 1 | MJ0J11 | Based on observation, staff interview and record review, the facility failed to ensure that the monthly infection control rate was accurate for one month, and failed to ensure that licensed nursing staff washed or sanitized their hands between resident contacts during medication administration. Findings include: 1. A review of the infection control logs revealed an infection rate of 1.4%, documented on the Infection Rate Report for (MONTH) (YEAR). The rate included one Community Acquired Infection (CAI) and no Healthcare Associated Infections (HAI). However, a review of the handwritten Line Listing of Resident Infections forms for (MONTH) (YEAR) revealed three infections were determined to be CAI's and two infections were determined to be HAI's. There was no evidence the infection control rate included the accurate number of infections. During an interview on 8/10/17 at 1:20 p.m., Licensed Practical Nurse (LPN) AA confirmed that the (MONTH) (YEAR) handwritten line listing was correct, that there were three CAI's and 2 HAI's. She stated that the infection information was logged in to the computerized line listing system but that an error had caused them not to be included in the infection rate calculation of 1.4% 2. Observation of medication pass on 8/9/17 at 4:44 p.m. revealed that licensed practical nurse (LPN) CC was observed to not wash or sanitizer her hands prior to or during medication administration of four (4) residents. LPN CC was observed to go in and out of the medication cart, knock on residents doors, touching the medication cart, touch cups and pour water into cups for residents to take medications orally. Interview 8/9/17 at 5:01 p.m. with LPN CC she reported and confirmed that she did not wash or sanitizer her hands between administering the medications to residents R#12, #29, #70, #74 and she also reported that she should have used a Sani wipe to clean the pulse oximetry before and after using it on R#29 to check the pulse prior to administering the medication. Interveiw on 8/13/17 at 4:00 p.m. w… | 2020-09-01 |
| 2370 | 2370 | DADE HEALTH AND REHAB | 115558 | 1234 HIGHWAY 301 SOUTH | TRENTON | GA | 30752 | 2017-08-10 | 309 | D | 0 | 1 | JLS811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to follow the physician's order to obtain and document oxygen (O2) saturation with use of pulse ox meter as needed (PRN) for shortness of breath (SOB) for one (1) resident (R#44) who receives O2 therapy of 22 sampled residents. Findings Include: Record review for R#44 revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of the physician's order for R#44 revealed an order to obtain and document oxygen saturation with use of pulse ox meter PRN for SOB and notify MD if less than ( Record review of the May, June, (MONTH) and (MONTH) (YEAR) medication administration record (MAR) for R#44 revealed no documentation of O2 saturation for the days of which O2 was administered. Observation of R#44 on 8/9/17 at 10:38 a.m. revealed resident in bed wearing a nasal cannula with O2 at 3 liters per minute (lpm) from oxygen concentrator. Observation of R#44 on 8/9/17 at 12:31 p.m. revealed resident sitting in wheelchair outside on the patio wearing nasal cannula with O2 at 3 lpm from [NAME] (type of O2 cannister) cylinder tank. Observation of R#44 on 8/10/17 at 11:00 a.m. revealed resident sitting in wheelchair in lobby visiting with her daughter. The resident was wearing a nasal cannula with O2 at 3 lpm from [NAME] cylinder tank. During an interview with the Administrator on 8/10/17 at 10:00 a.m. she revealed the facility does not have a policy related to oxygen administration or for following physician's orders. During an interview with License Practical Nurse (LPN) DD on 8/10/17 at 11:29 a.m. she stated she places the resident on oxygen when the resident becomes SOB. She also stated today the resident is on oxygen because she became short of breath after taking a shower. The LPN DD stated she documents on the MAR the reason for the PRN oxygen but she does not document the residents' O2 saturation on the MAR. During an interview with… | 2020-09-01 |
| 2586 | 2586 | GREEN ACRES HEALTH AND REHABILITATION | 115578 | 313 ALLEN MEMORIAL DRIVE,SW | MILLEDGEVILLE | GA | 31061 | 2017-08-10 | 241 | D | 0 | 1 | FKXI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review and interview the facility failed to treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Findings include: Observation on (MONTH) 9, (YEAR) at 3:30 p.m. with Licensed Practical (LPN) EE at nursing station standing in front of medication cart resident R # 11 asked LPN EE for his medication LPN EE stood around for several minutes resident started to leave nursing station mumbling. Then, LPN EE took out his medication, put medication on top of the cart said to R#11, here is your medication (nasal spray in box) and stated I do not have time to be bothered by you today. Resident took his medication out of the box used the nasal spray and then returned the medication to the cart. Resident was mumbling something that could not be understood. LPN EE told R#11 that she was not going to be messed with today. R#11 left and went down the hall mumbling. Interview with Resident # 11 on (MONTH) 9, (YEAR) at 3:45 p.m. revealed that he was not afraid of the employee however he felt that LPN EE did not treat him with respect. Review of the medical record revealed that resident was not assessed for, care planned for or have physician order [REDACTED]. Interview with the Director of Nursing on (MONTH) 9, (YEAR) at 4:00 p.m. revealed that her expectation for the residents to be treated with respect and with dignity and this type of communication with residents is not acceptable and will not be tolerated. Further interview revealed that LPN EE was a nursing agency employee. Interview with Nurse Consultant, Director of Nursing, and Administrator on (MONTH) 9, (YEAR) at 4:00 p.m. revealed that R#11 had not been assessed to self-administer medication no order exits for resident to self-administer medication or is his care plan. Nurse Consult… | 2020-09-01 |
| 2587 | 2587 | GREEN ACRES HEALTH AND REHABILITATION | 115578 | 313 ALLEN MEMORIAL DRIVE,SW | MILLEDGEVILLE | GA | 31061 | 2017-08-10 | 282 | D | 0 | 1 | FKXI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow the care plan related to forwarding the Registered Dietician's (RD) recommendations to the physician for one resident (R) #137. The sample size was 30 residents. Findings include: Review of R #137's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of his Admission Minimum Data Set ((MDS) dated [DATE] revealed that Nutritional Status triggered as an area of concern, with the decision to care plan. Review of a risk for alteration in nutrition due to multiple health complications including nutritional compromise, weight loss and dehydration care plan dated 8/1/17 revealed an intervention to consult the Registered Dietician (RD) PRN (as needed), with any recommendations to the MD (Medical Doctor) for review and consideration. Review of his risk for pressure ulcer care plan dated 8/1/17 revealed an intervention to refer to the RD for assessment and dietary needs. Review of the RD Consultant note dated 7/20/17 revealed that R#137 had chronic protein losses through [MEDICAL TREATMENT], and her recommendations included a multivitamin, Prostat AWC (Advanced Wound Care) (a protein supplement), and large entree and meat portions at all meals for 30 days. During an interview with the Resident Care Coordinator (RCC) CC on 8/9/17 at 2:52 p.m., revealed that the RD's recommendations for R #137 were never implemented. During an interview with the Wound Treatment Nurse on 8/10/17 at 2:48 p.m., revealed that there was no evidence that the physician was ever notified of the RD's nutritional recommendations, and that the recommendations had never been implemented. Cross-refer to F 325 | 2020-09-01 |
| 2588 | 2588 | GREEN ACRES HEALTH AND REHABILITATION | 115578 | 313 ALLEN MEMORIAL DRIVE,SW | MILLEDGEVILLE | GA | 31061 | 2017-08-10 | 325 | D | 0 | 1 | FKXI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow the Registered Dietician (RD) recommendations for vitamins, protein supplement, and larger entree portion sizes for one resident (R) #137. In addition, the facility failed to follow the PAR (Patient at Risk) committee recommendation for vitamins for wound healing for R #137. The sample size was 30 residents. Findings include: Review of R #137's clinical record revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Treatment Record-Wound assessment dated [DATE] revealed that R #137 was admitted to the facility with a Stage 2 pressure ulcer to the sacrum, as well as a deep tissue injury to the right heel. Review of the resident's Admission Minimum Data Set ((MDS) dated [DATE] revealed that nutritional status triggered as an area of concern. Review of his risk for alteration in nutrition due to multiple health complications and nutritional compromise, weight loss and dehydration care plan dated 8/1/17 revealed interventions for an RD consult PRN (as needed), with any recommendations to the MD (Medical Doctor) for review and consideration. Review of an [MEDICATION NAME] laboratory result dated 7/16/17 revealed a level of 2.2 (normal level 3.5 to 5.7). Review of an RD Consultant note dated 7/20/17 revealed that R #137 had increased nutrient needs related to chronic protein losses via [MEDICAL TREATMENT]. Further review of the RD's note revealed recommendations for added protein and nutrition, Renal MVI (multivitamins) daily, Prostat AWC (Advanced Wound Care) (a liquid protein supplement) 30 mL (milliliters) twice daily for 30 days, and large entree/meat portions at all meals for 30 days. Review of a PAR note dated 7/21/17 revealed that R #137 was a new admission with a left BKA ([MEDICAL CONDITION]), Stage 2 sacral ulcer, and UDTI (unstageable deep tissue injury) to the right heel. Further review of this PAR note revealed that a multi… | 2020-09-01 |
| 2589 | 2589 | GREEN ACRES HEALTH AND REHABILITATION | 115578 | 313 ALLEN MEMORIAL DRIVE,SW | MILLEDGEVILLE | GA | 31061 | 2017-08-10 | 441 | F | 0 | 1 | FKXI11 | Based on observation, record review, review of Centers for Disease Control and Prevention (CDC) guidelines on processing of laundry, and staff interview, the facility failed to use personal protective equipment (gown) when sorting soiled laundry, and failed to cover clean laundry during transport. The facility census was 89 residents, and the sample size was 30 residents. Findings include: On 8/10/17 at 10:40 a.m., laundry employee DD was observed sorting soiled laundry that was inside a large cart in the laundry room. Further observation revealed that she put on gloves, but no gown or other protective garment, to ensure that the soiled laundry did not touch her clothing. Continued observation revealed that she had to reach over and down into the cart to obtain the soiled items, and she separated the dark laundry from the whites. She was then observed to reach down into the cart to pull the soiled white laundry out, and then put them into the washing machine. Continued observations revealed that after loading the washing machine, laundry employee DD removed her gloves and washed her hands. She was then observed to remove washed and dried laundry from a dryer, and the clean laundry was noted to touch her clothing with each armful she removed. During interview with laundry employee DD at this time, she verified that she did not wear a gown to cover her clothing when sorting the soiled laundry, and only did this if the laundry she was sorting was from a resident on isolation precautions. During further interview, she verified that the cart she used to bring clean laundry back into the resident rooms and clean linen storage areas was not covered during transport. She further stated that clean laundry had been transported this way for years, and she had never been told to cover them. During observation from the exit door on the clean side of the laundry to the door leading back into the facility on the 400-hall revealed that it was an approximate 30-foot distance, and the laundry cart had to be taken outside on a cove… | 2020-09-01 |
| 3281 | 3281 | NORTHSIDE GWINNETT EXTENDED CARE CENTER | 115645 | 650 PROFESSIONAL DRIVE | LAWRENCEVILLE | GA | 30046 | 2017-08-10 | 221 | D | 0 | 1 | 503S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, facility policy review entitled, Use of Restraints dated as revised 11/2015, the facility failed to ensure that one Resident (R) #5) was free from restraints of 25 sampled residents. Findings include: Review of the clinical record for R#5 revealed admission to the facility on [DATE], with a [DIAGNOSES REDACTED]. A physician's order, dated 8/20/15, directed staff to apply alarm safety belt to wheelchair due to fall. The order further indicated the resident could release the alarmed safety belt independently. Review of the quarterly Minimum Data Set (MDS) assessment for R#5, dated 5/1/17, Section C for cognition identified that the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating the resident was severely cognitively impaired and could not complete the interview for this section. For Section G, functional status, it identified the resident needed total assistance for transfers with the assistance of two staff members. Under Section P for restraints, it was identified that there were no restraints used for this resident. On 8/9/17 at 10:40 a.m., R#5 was observed in her bed and requested assistance with transferring to a wheelchair. Two Certified Nursing Assistants (CNA) entered the resident's room and performed a transfer of the resident to the wheelchair using a two person assist with a gait belt. CNA AA applied an alarmed lap belt on the resident after seating the resident in the chair. In addition, the resident was observed mobilizing the wheelchair independently. An interview was conducted with CNA AA and CNA DD on 8/9/17 at 10:44 a.m. CNA AA and CNA DD stated R#5 was not able to release the alarmed lap belt independently. An interview with R#5 was conducted on 8/9/17 at 10:42 a.m. The resident was found to answer questions to assess her interview status and was found to be interviewable. The resident stated she could not remove the alarmed lap belt … | 2020-09-01 |
| 3282 | 3282 | NORTHSIDE GWINNETT EXTENDED CARE CENTER | 115645 | 650 PROFESSIONAL DRIVE | LAWRENCEVILLE | GA | 30046 | 2017-08-10 | 279 | D | 0 | 1 | 503S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and clinical record review, the facility failed to maintain a comprehensive care plan for one Resident (R)#5 of 25 sampled residents. Findings include: Review of the clinical record for R#5 revealed admission to the facility on [DATE], with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order further indicated the resident could release the alarmed safety belt independently. A review of R#5's care plan, dated 5/4/17 was conducted on 8/9/17. Resident #5's care plan did not include documentation for the use of an alarmed lap belt. The quarterly Minimum Data Set (MDS) assessment for R#5, dated 5/1/17, under Section P for restraints, it was identified that there were no restraints used for this resident. On 8/9/17 at 10:40 a.m., R#5 was observed after CNA AA applied an alarmed lap belt on the resident after seating the resident in the chair. On 8/10/17, the DON provided an additional copy of R#5's care plan, dated 5/4/17 with a hand-written addition to the documentation, Use w/c(wheelchair) seat belt alarm as a reminder. | 2020-09-01 |
| 3283 | 3283 | NORTHSIDE GWINNETT EXTENDED CARE CENTER | 115645 | 650 PROFESSIONAL DRIVE | LAWRENCEVILLE | GA | 30046 | 2017-08-10 | 280 | D | 0 | 1 | 503S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and facility policy review, the facility failed to revise the care plan for one Resident (R) #48 of 25 sampled residents. Findings include: Record review revealed R#48 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Per review of the clinical records, the resident had a Plan of Care-Current for depression, which was dated 1/25/17, as initiated. The goals identified were for R#48 not to have symptoms of depression, crying, withdrawal, or a decrease in her appetite. Per Nursing Progress Notes, on 7/4/17, it was documented that the resident's roommate came out of her room and informed nursing that R#48 stated that she was going to kill herself since R#48's daughter refused to bring the resident a hamburger. The mental health provider was notified immediately of this statement and the resident was seen on this same date, by mental health. It was determined that the resident was not suicidal. The resident was seen again on 7/9/17 and again on 7/22/17 by mental health. Per review of the Progress Note .Psychiatric Progress Note . dated 7/9/17, R#48 was diagnosed with [REDACTED]. There were no revisions, to the Plan of Care-Current that identified that the resident had a history of [REDACTED]. An interview was conducted with the Director of Social Work (DSW) on 8/10/17 at 9:06 a.m. Per the DSW, R#48 threatened to commit suicide since her daughter would not bring her a hamburger. The DSW went on to say that the resident was seen immediately and it was determined that the resident was not suicidal. The DSW stated that the resident had a history of [REDACTED]. The DSW reviewed the medical record and was asked if this behavior was care planned and she confirmed that it was not. Interview of the MDS Coordinator on 8/10/17 at 9:22 a.m. revealed she was not the staff member who completed the care plan for R#48. A facility policy entitled Interdisciplinary Plan of Care dated as revised 1… | 2020-09-01 |
| 3284 | 3284 | NORTHSIDE GWINNETT EXTENDED CARE CENTER | 115645 | 650 PROFESSIONAL DRIVE | LAWRENCEVILLE | GA | 30046 | 2017-08-10 | 329 | E | 0 | 1 | 503S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility policy titled Unnecessary Medications review, the facility failed to ensure that one Resident (R#48) was monitored for signs and symptoms for the continued use of an antianxiety ([MEDICATION NAME]) (Cross Reference F280). The facility failed to ensure that one resident (R#73) had a gradual dose reduction (GDR) attempted for the continued use of an antipsychotic ([MEDICATION NAME]) and an antianxiety ([MEDICATION NAME]). Finally, the facility failed to ensure that there was a corresponding [DIAGNOSES REDACTED].#224) for the use of an antidepressant ([MEDICATION NAME]) of 25 sampled residents . Findings include: 1. Record review revealed R#48 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 3/2/16, the physician ordered [MEDICATION NAME] 0.25 milligrams (mg) to be administered per mouth twice daily for anxiety. A document entitled Plan of Care - Snapshot with an effective date of 1/25/17 identified that the resident had anxiety with the goal of .less than 2 episodes of anxiety per week . There was a care plan for R#48's use of [MEDICAL CONDITION] medications and this care plan was dated 1/25/17 and the interventions identified were .Monitor behaviors to assure lowest therapeutic dose given . A review was conducted of the medical records for the months of 6/17 through 8/17. The Medication Administration Record [REDACTED]. The MAR for 7/17 identified R#48 was administered [MEDICATION NAME] twice a day from 7/1/17 through 7/31/17. The quarterly Minimum Data Set (MDS) assessment dated [DATE], Section N for Medications identified R#48 was administered the antianxiety for the 7-day look back period. The MAR for 8/17 identified R#48 was administered [MEDICATION NAME] twice a day from 8/1/17 through 8/8/17. The Nursing Progress Notes were reviewed from the months of 6/17 through 8/17. There were no entries made that the resident was with or without anxiety during this … | 2020-09-01 |
| 3990 | 3990 | ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY | 115727 | 113 SPRING VALLEY ROAD | JEFFERSONVILLE | GA | 31044 | 2017-08-10 | 280 | D | 1 | 0 | 5YLC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facilty failed to develop a plan of care for 1 of 3 sampled residents, which resulted in failure to provide necessary care as identified in the assessment for Resident (R#1). Specifically; the facilty did not care plan diabetes management and did not ensure the care plan for R#1 addressed specific interventions for overt behaviors that were exhibited since admisison. Finding include: Resident (R) #1 was admitted to the facility on [DATE], the Physician admission orders [REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] Section I2900 also coded the [DIAGNOSES REDACTED]. Review of a laboratory result dated 6/13/17 reflected a out of range Glucose level of 518. The facility failed to develop a care care plan to include monitoring signs and symtoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. The MDS dated [DATE] ,Section C1000 coded the resident as severly impaired, in Section E800 he was coded for rejection of care which includes taking medications and Activity of Living assistance. Review of a form titled Interim Plan of Care revealed it did not include specific interventions for behavioral/mental status. It was documented in the clinical record incidents of overt behaviours including refusing to eat, refusing to take medications and grabbing staff during care. During an interview on 8/10/17 at 1:00 p.m., with the Director of Nuring (DON) revealed that she acknowledge the Interim Care plan for R#1 did not include a plan to address diabetes. | 2020-09-01 |
| 3991 | 3991 | ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY | 115727 | 113 SPRING VALLEY ROAD | JEFFERSONVILLE | GA | 31044 | 2017-08-10 | 309 | D | 1 | 0 | 5YLC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed medical record review and staff interviews the facility failed to provide care and services in accordance with the admission assessment for 1 of 3 Residents (R#1) reviewed for care and services . The facilty failed to follow the physican's admission orders [REDACTED]. Finding include; Record review revealed R#1 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Upon admission to the facility his [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] Section I2900 revealed that R#1 was coded for diabetes mellitus. The facility failed to develop a care plan relative to managing diabeties. Review of the hospitial records prior to admission to the facility revealed orders dated 5/27/17 indicating that the resident was receiving insulin per sliding scale before meals and at bed time, in addition to insulin 10 units at bedtime. Upon admission to the facility a form titled, Physician's Interim/Telephone Orders dated 6/1/17 at 2:00 p.m., reflected an order to discontinue Basagllar Kwik Pen Insulin Glargihe Injections. During interview with R#1's physician on 8/10/17 at approximately 2:30 p.m., regarding the discontinued insulin order he stated, I do not remember all the details, but I believe there was no dosage for it, if I remember correctly. I held off on the insulin and did not start a sliding scale, because I was more concerned with the his behaviour since he was on multiple medications for his behavior. When asked about the blood glucose of 516 on 6/13/17, the physician said he would be more concerned with [DIAGNOSES REDACTED]. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR), revealed orders to receive [MEDICATION NAME] 500 mg (milligrams) twice daily. It is documented on the MAR that R#1 refused [MEDICATION NAME] at least six times. The MAR reflects refusals of the [MEDICATION NAME] 500mg's at 9:00 a.m., on 6/3/17,6/14/17 and 6/15/17 and at 9:00… | 2020-09-01 |
| 3992 | 3992 | ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY | 115727 | 113 SPRING VALLEY ROAD | JEFFERSONVILLE | GA | 31044 | 2017-08-10 | 505 | D | 1 | 0 | 5YLC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews and review of the facilities written policy titled Laboratory, Radiology and other Diagnostic Services it was determined that the facility failed to ensure laboratory orders were implemented and results were reported timely in accordance with the facilities written policy for one Resident (R#1) out of 3 residents. Finding include: Upon admission to the facility on [DATE] R#1's [DIAGNOSES REDACTED]. Review of the clinical record it was documented on a form titled Physician's Interim/Telephone orders dated 6/5/17 notes, Admission labs: Hemoglobin A1C (HgbA1C) (blood test to monitor the glucose control of a patient over the last three months) , Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC), Lipids. During an interview with the DON on 8/10/17 at 12:00 p.m., regarding the lab ordered dated 6/5/17 the DON replied, he went to the hospital on the 5th due to a fall. Upon further review of the record a form titled Clinical Laboratory Services, dated 6/5/17 at 10:27 a.m., and the same form dated 6/6/17 at 10:27 a.m., both days were noted No Requisition Received for Comprehensive Metabolic Panel , Lipid Panel, CBC with Diff, PSA screening, and HGB A1C. Futher record review revealed the next Clinical Laboratory Services form in the clinical record was dated 6/13/17 the results reported to the facilty was on 6/13/17 at 1:46 p.m. The report revealed outside range for ; Sodium 159 (136-145), Chloride 114 (98-107), Glucose 518 (70-105). Further record review revealed that at 3:30 p.m. on 6/13/17 LPN BB documented in the 'Skilled Daily Nurses Notes' crtical labs were reported to the doctor. During an interview with Director of Nursing (DON) on 8/10/17 at 12:00 p.m., regarding the time lapse between when the lab report was received for R#1on 6/13/17 and the time LPN BB documented the physician was notified of the out of range results, she replied the labs may have been here at the time on the lab report but… | 2020-09-01 |
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CREATE TABLE [cms_GA] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );