cms_GA
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38 rows where "inspection_date" is on date 2017-09-21
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Suggested facets: facility_name, address, city, zip, deficiency_tag, scope_severity, complaint, 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 102 | 102 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2017-09-21 | 431 | D | 1 | 1 | KNJV11 | > Based on the facility's Storage of Medications policy, observations, staff interviews, and review of manufacturer's instructions the facility failed to ensure medications were: 1) dated appropriately when opened in 1 of 2 medication storage rooms, and 2) removed expired medication and biologicals from use in 1 of 2 medication storage rooms. The facility census at the time of the survey was 122 residents. Findings include: 1. Review of the policy titled Storage of Medications last revised on (MONTH) 2007, revealed in number 4, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. a. Failure to Appropriately Date Medications Once Opened. An audit of the Subacute Care (SAC) medication room refrigerator was conducted on 9/20/17 at 11:45 a.m. in the presence of Registered Nurse (RN) Unit Manager (UM). The audit revealed two opened and used multiuse vials of Tuberculin Purified Protein Derivative (PPD) solution (lot number 4). The containers and used vials of PPD solution were not dated when opened. The manufacturer's instructions on the side of the medication container revealed the medication should be discarded 30 days after being opened. During an interview with RN UM on 9/20/17 at 12:16 p.m. RN UM acknowledged the two used vials of PPD solution were not dated when opened. RN UM stated the medication should be dated when opened and the medication was only good for 30 days after being opened. RN UM removed the two opened and undated multiuse vials of PPD solution from use. b. Expired Medication and Biologicals An audit of the Subacute Care medication room cupboards were conducted on 9/20/17 at 11:50 a.m. in the presence of RN UM. The audit revealed: 1. Gericare Vitamin B-6, Dietary Supplement 100 tablets, 100 milligram (mg) unopened with an expiration date of 5/17. 2. Major Geravim liquid (lot number 0710B) 16 ounces unopened with an expiration date of 8/17. 3. Magnesium-oxide 400 mg tablets (lot number 39) … | 2020-09-01 |
| 426 | 426 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2017-09-21 | 272 | D | 0 | 1 | P90P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to accurately assess the presence of a nephrostomy tube for one resident (#183) from a total sample of 32 residents. Findings include: Unit 2: Resident #183 was admitted to the facility on [DATE]. An 8/18/17 nurse's note entry documented that the resident had a right nephrostomy with indwelling Foley catheter. An Admission Mimimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/29/17, was completed by facility staff. However, a review of this Admission MDS assessment, including the accompanying Care Area Assessments (CAA's), revealed that facility staff failed to accurately assess the presence of the resident's urinary appliance. During an interview on 9/20/17 at 2:40 p.m., MDS Coordinator HH confirmed that the presence of the urinary appliance was not accurately coded on the Admission MDS or included in the Urinary CA[NAME] | 2020-09-01 |
| 427 | 427 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2017-09-21 | 279 | D | 0 | 1 | P90P11 | **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 dental status of one resident (#183) from a total sample of 32 residents. Findings include: Unit 2: Resident #183 was admitted to the facility on [DATE]. An Admission Mimimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/29/17, was completed by facility staff. The resident was assessed as having obvious or likely cavity or broken natural teeth on the assessment. The accompanying Dental Care Area Assessment (CAA) documented that the resident had obvious missing and broken teeth, but did not complain of mouth pain. The CAA Summary section was checked to include dental status in care planning. However a review of the care plan revealed that a care plan had not been developed to address the resident's dental status. During an interview on 9/20/17 at 2:40 p.m. with MDS Coordinator HH, they confirmed that a care plan had not been developed to address the resident's dental status. | 2020-09-01 |
| 428 | 428 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2017-09-21 | 282 | D | 0 | 1 | P90P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow the care plan for the wound care dressing change for one (1) resident, Resident (R) #32, out of 32 sample residents. Findings include: Unit 2: Review of the care plan for R#32 revealed care plan for impaired skin integrity was updated on 8/31/17. Under nurses, the intervention is treat as ordered, bandage as appropriate. During an observation of wound care on 9/20/17 at 9:30 a.m., Licensed Practical Nurse (LPN) AA failed to adequately prepare for the dressing change and did not have three (3) of the ordered wound care items available on the field. Wound care orders were as follows for right heel, cleanse with normal saline, apply no sting barrier, apply [MEDICATION NAME] and calcium alginate and wrap with [MEDICATION NAME] three times a week on Monday, Wednesday and Fridays and as needed. LPN AA did not have the [MEDICATION NAME], the calcium alginate and the [MEDICATION NAME] on the field. Observation of wound care on R#32 on 9/20/17 at 11:30 a.m. by LPN AA Wound Care Nurse with assistance of Registered Nurse (RN) BB. LPN AA removed dressing and disposed of properly. Hands were sanitized and nurse donned gloves, area on heel was measured and cleaned and photographed. Hands were sanitized and nurse donned gloves, nurse opened package of skin barrier and applied around wound, reached over and opened drawer on dressing cart. She reached inside and took out a packet of [MEDICATION NAME], opened the package and removed contents. She folded dressing and placed over wound and while holding in place with one hand, nurse opened dressing cart drawer again and took out 4 x 4s and placed over dressing, then opened drawer again and reached in and took out roll of [MEDICATION NAME] and wrapped foot. She then opened the drawer again and took out a pad of dressing strips and placed over [MEDICATION NAME] to hold [MEDICATION NAME] in place. Nurse removed gloves and sanitiz… | 2020-09-01 |
| 429 | 429 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2017-09-21 | 314 | D | 0 | 1 | P90P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow orders for the wound care dressing change and failed to use infection control technique for one resident, Resident (R) #32, out of 32 sample residents. Findings include: Unit 2: Review of medical record for R#32 revealed wound care orders as, remove old bandage from heel, cleanse with normal saline, apply no sting barrier, apply Activoat and calcium alginate and wrap with [MEDICATION NAME] three times a week on Monday, Wednesday and Friday and as needed. During an observation of wound care on 9/20/17 at 9:30 a.m., Liscensed Practical Nurse (LPN) AA failed to adequately prepare for the dressing change and did not have three of the ordered wound care items available on the field. Wound care orders were as follows for right heel, cleanse with normal saline, apply sting barrier, apply [MEDICATION NAME] and calcium alginate and wrap with [MEDICATION NAME] three times a week on Monday, Wednesday and Fridays and as needed. LPN AA did not have the [MEDICATION NAME], the calcium alginate and the [MEDICATION NAME] on the field. Observation of wound care on R#32 on 9/20/17 at 11:30 a.m. by LPN AA Wound Care Nurse with assistance of Registered Nurse (RN) BB. LPN AA removed dressing and disposed of properly. Hands were sanitized and nurse donned gloves, area on heel was measured and cleaned and photographed. Hands were sanitized and nurse donned gloves, nurse opened package of skin barrier and applied around wound, reached over and opened drawer on dressing cart, reached inside and took out a packet of [MEDICATION NAME]. She then opened the package and removed contents, folded the dressing and placed over wound. While holding in place with one hand, nurse opened dressing cart drawer again and took out 4 x 4s and placed over dressing. She then opened dressing cart drawer again and reached in and took out roll of [MEDICATION NAME] and wrapped foot. She again opened the dr… | 2020-09-01 |
| 581 | 581 | MANOR CARE REHABILITATION CENTER - MARIETTA | 115283 | 4360 JOHNSON FERRY PLACE | MARIETTA | GA | 30068 | 2017-09-21 | 279 | D | 0 | 1 | N4J711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure the revision of care plans for non-pharmacological interventions occurred for three of six residents (R#49, R#71, and R#159) reviewed. Findings include: 1. Per the electronic clinical record review, R#159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medical record Care Plan most recently revised on 1/26/16 identified R#159 was at risk for adverse effects related to the use of an anxiolytic ([MEDICATION NAME]). There was no mention to offer non-pharmacological interventions prior to the use of the as needed (PRN) anxiolytic. Another most recently revised Care Plan on 11/27/16 identified R#159 enjoyed activities and noted the resident had cognitive and communication impairments related to dementia. Under the interventions it was documented to offer R#159 1:1 visits, participation in group activities of interest, preferred food items, television in bed, and family visits when available. Again, this section of the plan of care in the medical record failed to identify if these activities were attempts to reduce R#159's anxiety prior to the administration of an anxiolytic medication. 2. Per the electronic clinical record review, R#49 was admitted to the facility on [DATE]. A medical record review of the Care Plan dated as revised on 6/8/17 identified R#49 was at risk for adverse effects related to the use of an antipsychotic ([MEDICATION NAME]). There was no mention to offer non-pharmacological interventions prior to the use of the as needed (PRN) antipsychotic. Another reveiw of the Care Plan dated as revised on 9/6/17, identified R#49 enjoyed activities and noted the resident had cognitive and communication impairments related to dementia. Under the interventions it was documented to offer R#49 .redirection and diversion as needed. Again, this section of the care plan failed to identify if the redirection and diversion, were attempts to redu… | 2020-09-01 |
| 582 | 582 | MANOR CARE REHABILITATION CENTER - MARIETTA | 115283 | 4360 JOHNSON FERRY PLACE | MARIETTA | GA | 30068 | 2017-09-21 | 329 | D | 0 | 1 | N4J711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure three residents (R#49, R#71, and R#159) of a total of six sampled residents remained free of potentially unnecessary drugs. Specifically, resident #49 was receiving a PRN (as needed) antipsychotic medication and resident #71 and #159 were receiving PRN antianxiolytic medications without attempts to provide non-pharmacological interventions prior to the use of these drugs. Findings include: 1. Per the electronic clinical record review, R#159 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A medical record physician's orders [REDACTED]. The medical record quarterly Minimum Data Set (MDS) assessment dated [DATE], (section C) Cognition identified R#159 had a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated the resident was severely cognitively impaired. The medical record [MEDICAL CONDITION] Medication Use assessment dated [DATE], documented the following effective non-pharmacological interventions being used for R#159: .Music/art/drama therapy, exercise, recreation and activities, relaxation techniques, counseling, toileting program, pain management, sleep hygiene, redirection, and behavioral therapy. The medical record Medication Administration Record [REDACTED]. There was no documentation, such as Nursing Notes or on the MAR, to show R#159 was offered non-pharmacological interventions prior to the administration of the PRN anti-anxiolytic. The MAR for 9/2017 identified R#159 was administered doses of PRN [MEDICATION NAME] on 9/1/17, 9/13/17 (x2), and 9/16/17. There was no documentation, such as nursing notes or on the MAR, to show R#159 was offered non-pharmacological interventions prior to the administration of the PRN anti-anxiolytic. An interview was conducted with Licensed Practical Nurse (LPN) CC on 9/19/17 at 4:15 p.m., She stated staff would try to do non-pharmacological interventions prior to given [MEDI… | 2020-09-01 |
| 583 | 583 | MANOR CARE REHABILITATION CENTER - MARIETTA | 115283 | 4360 JOHNSON FERRY PLACE | MARIETTA | GA | 30068 | 2017-09-21 | 514 | D | 0 | 1 | N4J711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and review of facility policy titled MEDICATION AND TREATMENT ADMINISTRATION GUIDELINES revised 12/2014, the facility failed to clarify and transcribe orders for a hypertensive medication for one of six sampled residents (R#405). Findings include: Review of R#405's admission medications dated 9/16/17 revealed two orders for [MEDICATION NAME] 2.5 mg (milligrams) Monday through Saturday and 5 mg on Sunday. On 9/17/17 the attending physician wrote an order for [REDACTED]. Nurses were documenting the 2.5 mg of both medications were being given. Interview with Registered Nurse (RN) DD on 9/19/17 at 12:35 p.m., revealed she documented giving both the [MEDICATION NAME] and [MEDICATION NAME] on 9/19/17. She stated it was a duplicate order and it was my bad, I should have discontinued one. She further stated she would follow up with the physician and clarify the orders. Interview with Licensed Practical Nurse (LPN) EE at 1:31 p.m. on 9/19/17, she confirmed someone should have clarified the order with the physician. Interview with the attending physician on 9/19/17 at 1:34 p.m., revealed he wanted the [MEDICATION NAME] to be given daily. He stated he had never seen two different dosages of [MEDICATION NAME] and he did not see any benefit to the resident. Review of the facility policy titled MEDICATION AND TREATMENT ADMINISTRATION GUIDELINES revised 12/2014 revealed Orders are transcribed and noted by the licensed nurse.The licensed nurse noting an order is responsible for accurate transcription and initiation of orders, including removal of discontinued medications from medication carts. Interview with the Assistant Director of Nursing (ADON) on 9/20/17 at 9:10 a.m., revealed she would have expected the nurse taking the order off to verify the medications, ensure it was not a duplicate and clarify if needed. | 2020-09-01 |
| 717 | 717 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2017-09-21 | 280 | D | 0 | 1 | 6G1L11 | Based on record review, family and staff interviews, the facility failed to invite the responsible party to one resident's (R) (R Q) care plan meetings. The sample size was 32 residents. Findings include: During interview with a family member of R Q on 9/18/17 at 3:23 p.m., she stated that she had not been invited to attend the resident's care plan meetings since the resident was first admitted , and that this was something that she would like to attend. Review of the only Interdisciplinary Care Plan Meeting Attendance Sheet found in the active clinical record was dated 4/10/15, and noted R Q and her family member/responsible party attended. During interview with the Minimum Data Set (MDS) Coordinator on 9/20/17 at 3:20 p.m., she stated that the Social Services Director (SSD) was responsible for inviting the resident and the family to the care plan meetings. During interview with the Social Services Assistant on 9/21/17 at 9:54 a.m., she stated that the SSD left employment with the facility about five weeks ago. During further interview, she stated that if a resident was due for an MDS assessment, she would talk to the family to set up the care plan meeting either in person or by phone, as well as invite the resident. She further stated that she had worked at the facility for about five months, and didn't recall R Q's family member being invited to attend a care plan meeting. She verified that R Q had MDS assessments done on 5/27/17, 6/5/17, and 6/24/17, and that care plan meetings would have been held for all of them. During interview with the Social Services Assistant on 9/21/17 at 10:18 a.m., she stated that whenever there was a care plan meeting, the attendance was documented on an Interdisciplinary Care Plan Meeting Attendance Sheet, but that she was not able to find any of these forms for the past year for R Q. During interview with the interim Director of Nursing on 9/21/17 at 11:15 a.m., she stated that they were aware of concerns with residents and families not being invited to attend care plan meetings,… | 2020-09-01 |
| 718 | 718 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2017-09-21 | 282 | D | 0 | 1 | 6G1L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, the facility failed to follow the plan of care related to pain management for one resident (#51). The sample size was 32. Findings include: Review of the clinical records for Resident (R)#51 revealed a current [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set MDS) assessment, a quarterly, dated 8/14/17 revealed the resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. On the quarterly MDS assessment of 8/14/17, R#51 was also assessed as receiving scheduled pain medications, receiving no non-medication interventions for pain, and experiencing severe pain almost constantly that could affect day-to-day activities and/or make it difficult to sleep at night. A review of the R#51's plan of care for chronic pain related to chronic pai[DIAGNOSES REDACTED], last updated 8/24/17 revealed interventions such as: anticipate the resident's need for pain relief and respond immediately to any complaints of pain; evaluate the effectiveness of pain interventions; observe/document for side effects of pain medication; observe/record pain characteristics during rounds and as needed: Quality (e.g. sharp); Severity (1 to 10 scale); observe/record/report to the nurse the resident complaints of pain or requests for pain treatment. A review of the clinical records for R#51 revealed she returned from a leave of absence to visit her family on 9/15/17. A further review of the resident's clinical records revealed that the resident's scheduled pain medication - [MEDICATION NAME] 5-325mg was not dispensed by the remote pharmacy system with the resident's other prescribed medication between 9/15/17 at 9:24 p.m. and 9/17/17 at 3: 53 p.m. due to the unavailability of a current written prescription. During this time, the staff did not: anticipate the resident's need for pain relief by having the resident's scheduled pain medic… | 2020-09-01 |
| 719 | 719 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2017-09-21 | 309 | D | 0 | 1 | 6G1L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident, staff, and pharmacy interview, the facility failed to follow orders related to pain medication and failed to effectively manage the pain of one resident (#51) by immediately addressing barriers to having the resident's pain medication available to administer when scheduled and offering as needed pain medication. The sample size was 32. Findings include: Review of the clinical records for Resident (R)#51 revealed a current [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set MDS) assessment, a quarterly, dated [DATE] revealed the resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. On the quarterly MDS assessment of [DATE], R#51 was also assessed as receiving scheduled pain medications, receiving no non-medication interventions for pain, and experiencing severe pain almost constantly that could affect day-to-day activities and/or make it difficult to sleep at night. A review of the R#51's plan-of-care for chronic pain related to chronic pai[DIAGNOSES REDACTED], last updated [DATE] revealed interventions such as: administer pain medications prior to treatments and therapy, if indicated; anticipate the resident's need for pain relief and respond immediately to any complaints of pain; evaluate the effectiveness of pain interventions; observe/document for side effects of pain medication; observe/record pain characteristics during rounds and as needed: Quality (e.g. sharp); Severity (1 to 10 scale); observe/record/report to the nurse the resident complaints of pain or requests for pain treatment. A review of the census history for R#51 revealed she was placed on Leave of Absence (LOA) from [DATE] and returned to the facility on [DATE] A review of the nurses' notes of [DATE] documented resident went on LOA on [DATE] at 8:00 p.m. to visit her daughter and that resident had medications to last until 1800 (6:00 p.m.) on [D… | 2020-09-01 |
| 720 | 720 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2017-09-21 | 323 | E | 0 | 1 | 6G1L11 | Based on observation and interview, the facility failed to assure electrical safety in 10 rooms on two of two wings where an electrical power strip was used to provide electricity to multiple medical devices. Extension cords were connected to power strips in two of 10 rooms, supplying electricity to resident's personal equipment. The census was 92 residents. Findings include: 1. Observation on 9/19/17 at 4:32 p.m., on the West Wing, revealed eight resident rooms with power strips affixed to the wall and plugged into an electrical outlet near each hospital bed. Connected to the power strips and supplying electrical current were hospital beds, oxygen concentrators, feeding pumps, and floatation air mattress pumps. 2. Observation on 9/19/17 at 4:32 p.m., on the West Wing, room 1-1, revealed a power strip sitting on the floor at the right side of the bed. The power strip was plugged into electrical outlet on the wall and supplying electricity to multiple electrical items. 3. Observation on 9/19/17 at 4:32 p.m., on the West Wing, revealed rooms 10-1 and 15-2, to have an extension cord in use, plugged into a power strip, draped across the wall and connected to resident's personal televisions. 4. Observation on 9/19/17 at 4:43 p.m., on the East Wing, revealed two resident rooms with power strips affixed to the wall and plugged into an electrical outlet near each hospital bed. Connected to the power strips and supplying electrical current were hospital beds and oxygen concentrators. 5. Observation on 9/19/17 at 4:43 p.m., on the East Wing, room 33-2, revealed an extension cord, plugged into a power strip, draped along baseboard of floor, connected to residents mini-fridge. Interview on 9/20/17 at 5:04 p.m. with Maintenance Supervisor, stated the facility is old and they are making improvements a little at a time. He stated the fire Marshall told him the facility could not use extension cords to plug in electrical equipment, but they could use surge protectors, so the facility will need to purchase extra surge protectors.… | 2020-09-01 |
| 721 | 721 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2017-09-21 | 371 | E | 0 | 1 | 6G1L11 | Based on observation, record review and interview, the facility failed to maintain sanitary conditions in the dietary kitchen with unlabeled/undated powdered product and unidentifiable and unlabeled frozen casserole with use by date of 9/7/17 in the walk-in freezer. Microwave oven had dried food particles on the inside roof and sides of the oven and staff stored personal food items in walk-in cooler. Resident food pantry's on two of two Wings were noted to have multiple opened/unlabeled items along with personal food items stored in refrigerator and non-food items stored on top of refrigerators. The census was 92 residents. Findings include: Observation on 9/18/2017 at 10:40 a.m., in the main kitchen revealed a plastic storage container with white flaky dry product unlabeled and undated. Observation on 9/18/17 at 10:50 a.m., revealed microwave oven in the main kitchen had dry crusty food particles on both sides and on the roof of the oven. Observation on 9/18/2017 at 11:15 a.m., revealed an unidentified and unlabeled frozen casserole in downstairs walk-in kitchen freezer with foil covering peeled off with a use by date on this product was 9/7/17. Observation and interview, with the Food Service Manager (FSM), on 9/18/2017 10:14 a.m., revealed staff members personal pint of coffee creamer in downstairs walk-in cooler unlabeled and undated which was verified at this time by the FSM that the coffee creamer belonged to staff. Observation on 9/19/7 at 10:29 a.m., revealed microwave oven in the main kitchen remained dirty with dry crusty food particles on inside roof and both sides. Observation on 9/20/17 at 9:33 a.m., West Wing resident pantry revealed staff food items (Popeye's chicken) in fridge, multiple unopened/unlabeled bottles of water in bottom storage drawer, top of fridge dusty and brown bag with clothing item on top. Walls in West Wing resident pantry are dirty with dried brown material, around trash can. These observations were verified by DON DD on 9/21/17 at 10:42 a.m. Observation on 9/20/2017 2:31 p.m.,… | 2020-09-01 |
| 722 | 722 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2017-09-21 | 511 | D | 0 | 1 | 6G1L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and radiology employee interview, the facility failed to obtain the results of an ordered chest x-ray (CXR) in a timely manner for one resident (R) (#157), who was complaining of shortness of breath. The sample size was 32 residents. Findings include: Review of R #157's closed clinical record revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital History and Physical dated 7/14/17 revealed the resident developed a pneumothorax that necessitated chest tube placement. Review of her risk for altered respiratory status/difficulty breathing related to a recurrent right pleural effusion, status/post right pneumothorax with chest tube, right [MEDICAL CONDITION], and sleep apnea care plan revealed an intervention to observe for signs and symptoms of respiratory distress and abnormal breathing patterns, and report to the physician as needed. Review of a Medical Attending physician progress notes [REDACTED].#157 had a right pleural effusion, shortness of breath, a loud cardiac murmur, and was on [MEDICAL TREATMENT] due to [MEDICAL CONDITION]. Review of the Plan on this progress note revealed for the resident to have a CXR, and oxygen as needed. Review of physician's orders [REDACTED]. Review of nursing progress notes dated 8/7/17 at 3:43 p.m. revealed the physician visited and R #157 complained of shortness of breath, and a new order was received for a CXR. Review of the portable CXR report results done 8/7/17 noted R #157 had a large right pleural effusion, and possible increased density involving the medial right lung apex as well. Further review of the CXR results revealed a dense consolidation involving right perihilar region and medial right lung apex. Further review of the report revealed the CXR was read by the radiologist at 11:02 p.m. on 8/7/17, with a large notation of ALERT printed across the page. Further review revealed a handwritten notation on the report tha… | 2020-09-01 |
| 2220 | 2220 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2017-09-21 | 253 | D | 1 | 1 | 2UDM11 | > Based on observation and interviews with staff the facility failed to assure that the wheelchairs for ten resident ( (R) R#37, R #22, R#34, R #10, R #26, R#90, R #1, R#91, R#48, and R#57) were without build build-up or torn areas. The facility census was 105 residents. Findings: Observation on 9/18/17 at 1:32 p.m. and 3:37 p.m. Resident #37 observed sitting in wheelchair in dining/activity area of Unit 3 with buildup noted on spokes of wheel chair and cracking of the back of the chair. Observation on 9/19/17 at 10:28 a.m. R #37 sitting in room with buildup on wheels and crack of back of wheelchair. Observation on 9/19/17 at 3:35 p.m. R#91 and R#22 observed on Unit 3 with buildup on their wheelchairs. Observation on 9/20/17 at 9:55 a.m. R#34 and R#57 on locked unit with buildup on spokes of wheelchairs. Observation on 9/20/17 at 10:11a.m. R#48 observed ambulating in wheelchair into dining room. Wheelchair noted to have buildup on the spokes of the wheels. Observation 9/20/17 at 12:11 p.m. R#10 revealed a Geri chair with pieces pulled from the back of the chair. Observation on 9/20/17 at 12:13 p.m. in the activity/dining area of the locked unit revealed that the wheelchairs for R#37 and R#26 had buildup on the spokes of wheels. Observation on 9/20/17 at 12:24 p.m. revealed that the wheelchairs for R#22 and R#34 have buildup on the wheels and that the wheelchair for R#90 has buildup on the wheels and the under carriage of wheelchair. Observations on 9/21/17 at 11 a.m. on Unit 3 revealed that the following wheelchairs for the following residents were observed to have build up R#91, R#1, R#90, R#34, and R#26. Maintenance reported that wheelchairs are cleaned once per quarter and Unit 3 (locked unit) wheelchairs are due to be cleaned this month. Maintenance is reported as being responsible for the cleaning the wheelchairs. Maintenance reported that he can clean the chairs today and that they are dirty again within 2 weeks. Interview on 9/21/17 at 12:14 p.m. with Director of Nursing (DON) who reported that Certified N… | 2020-09-01 |
| 2221 | 2221 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2017-09-21 | 278 | D | 1 | 1 | 2UDM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and clinical record reviews, the facility failed to ensure an accurate assessment for one resident (R#73) for dental status. The sample size was 28. Findings include: Resident #73 (R#73) was admitted with [DIAGNOSES REDACTED]. Review of MDS Assessments revealed for R#73 revealed that on 3/29/17 the Nursing Assessment for R#73, was performed by Licensed Practical Nurse (LPN) EE and indicated no problems with teeth. Review of the 3/29/17 MDS Comprehensive Assessment: indicates selection of item Z for None of the above were present to indicate no problems found in the dental assessment. Review of the 6/29/17 Nursing Assessment for R#73, performed by LPN GG, documented no problems with teeth. MDS assessment dated (MONTH) 29, (YEAR), for R#73, indicates no problems with teeth. Review of Care Plans for R#73 revealed that there were no care plan focus/goals/or interventions for the resident related to dental needs. Interview on 9/20/17 at 10:37 a.m. with the Facility Social Worker (SW) reports that she has been with the facility for 2 years and she is familiar with the resident. She reports the resident is seen by a Dentist who comes monthly and that the resident refuses treatment for [REDACTED]. In addition, the SW revaled that the resident was seen 4/21/17 and 11/8/16 and for each visit the resident has declined treatment. Interview on 9/20/17 at 11:40 a.m. with the MDS Coordinators, MDS CC & MDS DD. MDS CC has been with facility for one year and MDS DD has been with facility for 3 months; they assist the surveyor with reviewing MDS information for assessment and care planning. Quarterly Assessments dated 6/29/17 and Comprehensive assessment dated [DATE] indicate no problems with the resident's teeth; according to the MDS Coordinators, no care plan interventions were developed specific to the resident's teeth because the assessment did not indicate a need. The MDS Coordinators report that they should receive up… | 2020-09-01 |
| 2222 | 2222 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2017-09-21 | 279 | D | 1 | 1 | 2UDM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and clinical record reviews, the facility failed to develop a care plan to address dental status for R#73. The sample size was 28. Findings include: Resident #73 (R#73) was admitted with [DIAGNOSES REDACTED]. Review of the Nursing assessment dated [DATE] for, R#73, performed by Licensed Practical Nurse (LPN) EE indicated no problems with teeth. Review of the 3/29/17 MDS Comprehensive Assessment: indicates selection of item Z for None of the above were present to indicate no problems found in the dental assessment. Review of the 6/29/17 Nursing Assessment for R#73, performed by LPN GG reported no problems with teeth. MDS assessment dated (MONTH) 29, (YEAR), indicates no problems with teeth. Review of care plans for R#73 revealed that there were not any care planned focus/goals/or interventions for resident related to dental needs. Interview on 9/20/17 at 10:37 a.m. with the Social Worker (SW) reports she has been with the facility for 2 years and she is familiar with the resident. She reports the resident is seen by a Dentist who comes monthly and that the resident refuses treatment for [REDACTED]. The SW shows the surveyor the information in the point-click-care documentation system of previous dentist visits: 4/21/17 and 11/8/16 and for each visit the resident has declined treatment. 9/20/17: 11:40 a.m.: interview of MDS Coordinators, CC & DD. CC has been with facility for one year and DD has been with facility for 3 months; they assist the surveyor with reviewing MDS information for assessment and care planning. Quarterly Assessments dated 6/29/17 and Comprehensive assessment dated [DATE] indicate no problems with the resident's teeth; according to the MDS Coordinators, no care plan interventions were developed specific to the resident's teeth because the assessment did not indicate a need. | 2020-09-01 |
| 2223 | 2223 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2017-09-21 | 282 | D | 1 | 1 | 2UDM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to ensure that the care planned interventions were implemented for one resident ((R) #37 ) related to assuring that fall interventions were in place. The sample size was 29. Findings include: Observation on 9/18/17 at 1:32 p.m. and 3:37 p.m. revealed that R#37 observed sitting in wheelchair in dining/activity area of locked unit with no chair alarm, helmet, or lap buddy observed. Observation on 9/19/17 at 8:00 a.m. and 10:18 a.m. revealed that R#37 observed sitting in room in wheelchair with no chair alarm, helmet, or lap buddy observed. Observation on 9/20 /17 at 9:43 a.m. revealed that R#37 was observed ambulating down hallway from room via wheelchair without a helmet. Observation on 9/20/17 at 12:26 p.m. revealed that R#37 observed sitting in wheelchair in room with chair alarm, helmet, or lap buddy observed. Obseration on 9/21/17 at 8:10 a.m. revealed that R#37 observed ambulating in hallway via wheelchair no chair alarm, helmet, or lap buddy observed. Review of R#37's care plan for falls with goal that falls will be minimized with the following interventions documented to be implemented: chair alarm to wheel chair, helmet to be warn during waking hours as resident will allow, chin strap and foam insert to helmet for stabilization, lapbuddy in place. Review of nursing notes from (MONTH) (YEAR) through (MONTH) (YEAR) did not have documentation of resident refusing to wear helmet, chair alarm, or lap buddy. Interview on 9/21/17 at 8:20 a.m. with Licensed Practical Nurse (LPN) II who reported that R#37 has a history of refusing care and often refuses to go to [MEDICAL TREATMENT]. LPN II was not aware of interventions in place for resident related to falls. Review of R#37 care plan reviewed and observation of R#37 revealed no helmet, chair alarm, or lap buddy in place. Interview on 9/21/17 at 8:25 a.m. with LPN Supervisor KK who reported that staff are responsible… | 2020-09-01 |
| 2224 | 2224 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2017-09-21 | 371 | F | 1 | 1 | 2UDM11 | > Based on observation, interview, and review of facility policies and procedures the facility failed to label/date, store foods under proper temperatures to prevent food borne illness, and securely wrap opened food items in one (1) walk in cooler and (1) reach in freezer of two (2) reach in freezers. The facility also failed to ensure the proper cleaning of dinnerware and eating utensils were properly sanitized during the wash and rinse cycle by the Low Temperature Dishwasher. This has the potential to affect all residents in the facility on oral alimentation, the resident census was 105. Findings include: Initial kitchen tour completed on 9/18/17 at 11:20 a.m. with the Dietary Manager (DM) revealed the overhead oven ventilation hoods have dust and splatter that could drop down into pots of food while cooking. The last service date for hood cleaning was (MONTH) (YEAR) the next service date is (MONTH) (YEAR). Interview with the DM at this time confirms the dust and splatter on the overhead oven ventilation hoods, and that staff do not clean or wipe down the overhead oven ventilation hoods in between main hood service. Observation on 9/18/17 at 11:20 a.m. of the walk in cooler revealed a temperature of sixty (60) degrees F. (1) 3/4 bag of chopped celery open not labeled or dated turning brown. (1) Small pan of leftover cooked home potatoes from 9/14/17 with use by date of 9/17/17. (1) 3/4 package of yellow sliced cheese not labeled or dated, slightly warm to touch. (1) opened package of Swiss cheese not labeled or dated, slightly warm to touch. (1) Package of sliced smoked turkey opened, hanging out of bag not labeled, dated, or covered. (2) 4 oz. cups of kozy shack chocolate pudding with use by date 9/13/17. Observation of the reach in freezer #3 with frozen meats revealed: (2) bags of chicken wings 1/2 full with no open date or use by date, and (2) Large bags of chicken breast removed from its original packaging not labeled with an open or use by date. Interview with the (DM) at 11:21 a.m. on 9/18/17 revealed th… | 2020-09-01 |
| 2225 | 2225 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2017-09-21 | 520 | D | 1 | 1 | 2UDM11 | > Based on observation, and staff interviews the facility failed to ensure an effective QA (Quality Assurance) program was in place. The facility failed to ensure that their action plan was effective to ensure that residents wheelchairs remained clean and free of buildup. The facility census was 105 residents. Findings: Observation on 9/18/17 at 1:32 p.m. and 3:37 p.m. Resident #37 observed sitting in wheelchair in dining/activity area of Unit 3 with buildup noted on spokes of wheel chair and cracking of the back of the chair. Observation on 9/19/17 at 10:28 a.m. R #37 sitting in room with buildup on wheels and crack of back of wheelchair. Observation on 9/19/17 at 3:35 p.m. R#91 and R#22 observed on Unit 3 with buildup on their wheelchairs. Observation on 9/20/17 at 9:55 a.m. R#34 and R#57 on locked unit with buildup on spokes of wheelchairs. Observation on 9/20/17 at 10:11a.m. R#48 observed ambulating in wheelchair into dining room. Wheelchair noted to have buildup on the spokes of the wheels. Observation 9/20/17 at 12:11 p.m. R#10 revealed a Geri chair with pieces pulled from the back of the chair. Observation on 9/20/17 at 12:13 p.m. in the activity/dining area of the locked unit revealed that the wheelchairs for R#37 and R#26 had buildup on the spokes of wheels. Observation on 9/20/17 at 12:24 p.m. revealed that the wheelchairs for R#22 and R#34 have buildup on the wheels and that the wheelchair for R#90 has buildup on the wheels and the under carriage of wheelchair. Observations on 9/21/17 at 11 a.m. on Unit 3 revealed that the following wheelchairs for the following residents were observed to have build up R#91, R#1, R#90, R#34, and R#26. Maintenance reported that wheelchairs are cleaned once per quarter and Unit 3 (locked unit) wheelchairs are due to be cleaned this month. Maintenance is reported as being responsible for the cleaning the wheelchairs. Maintenance reported that he can clean the chairs today and that they are dirty again within 2 weeks. Interview on 9/21/17 at 12:14 p.m. with Director of Nur… | 2020-09-01 |
| 2673 | 2673 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 241 | D | 0 | 1 | V4Q111 | Based on observations, staff interview and the facility policy review it was determined the facility failed to assure residents received dignity and respect during personal care for two residents (R#1 and R#112) out of a sample of 31 residents. Findings include: 1. On 9/18/17 at 1:03 p.m., Licensed Practical Nurse (LPN) JJ was observed providing care for R#1 as he laid in bed. The nurse pulled the resident's shirt up, exposing the resident's abdomen and the percutaneous endoscopic gastrostomy tube (PEG tube) (a tube used to provide nutrition and medications) extending from his abdomen. During the care the resident's blinds to his window, which opened to the front drive of the facility building, were open allowing visualization to anyone walking or driving past the window. 2. On 9/20/17 at 10:39 a.m., observations were made of R#112 receiving care from Certified Nurse Aide (CNA) HH. The resident had voiced to the aide she needed to go to the bathroom. CNA HH assisted the resident into the bathroom, and with the door still open, began to pull the resident's pants down to allow her to sit on the toilet. The resident's exposed buttocks were visual to her roommate (R#71), whose bed was directly in front of the bathroom and the surveyor in the room to observe the roommate (R#71). CNA HH did not pull R#71's privacy curtain or close the bathroom door to allow R#112 privacy prior to pulling her pants down. CNA HH closed the door of the bathroom when she left the resident on the toilet. On 9/20/17, around 11:00 a.m., an interview with CNA HH revealed she forgot to close the door. She said she realized she should have closed the door before undressing R#112. Record review of the facility's policy titled, Promoting/Maintaining Resident Dignity, reviewed/revised 4/25/17, revealed .Compliance Guidelines to include .12. Maintain resident privacy . | 2020-09-01 |
| 2674 | 2674 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 253 | E | 0 | 1 | V4Q111 | Based on observation and staff interview the facility failed to maintain the facility environment and common resident areas in a clean, orderly and sanitary manner as evidenced by resident rooms 11, 27, 30, 38, 39, 49, 50, the kitchen area, the outside perimeter of the building and issues with storage in several out buildings. This had the potential to affect all 97 residents in the facility. Findings include: Observation of the kitchen on 9/19/17 at 4:00 p.m., revealed the back door that lead to the outside garbage area was broken. The latch on the door jamb was missing which prohibited the door from closing securely. There was a gap or space around each side of the door that could allow pests to exit and enter the kitchen. Continued observation of the outside area, just beside the kitchen there were two additional doors; one housed soiled linens and the other housed soiled residents' clothing. Both doors were broken and in need of repair. The bottom of the wooden doors was soggy due to water damage and they had peeling and missing paint. Neither door closed or locked securely. This outside area was open and visible to the public. An interview with the Dietary Supervisor on 9/19/17 at 4:15 p.m., confirmed the back door to the kitchen was broken and in need of repair. She indicated because the door did not shut and lock securely, the facility had to use a pad lock to secure the area after the kitchen closed in the evening. Tour of the facility with the House Keeping Supervisor (HSKS) on 9/20/17 from1:00 p.m. through 2:15 p.m., revealed the following issues with maintenance and housekeeping: 1. Observation of resident room 11 revealed the bathroom floor tile to have large dark stained tiles and pieces of the floor tiles were broken. There was a foul odor noted from the sink and had hot water dripping continuously. The bathroom door had a broken top hinge. The ceiling light/vent was damaged and falling out of ceiling. 2. Observation of a large section of the floor tile in the corridor past the front nurse's station… | 2020-09-01 |
| 2675 | 2675 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 279 | D | 0 | 1 | V4Q111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to revise or develop the comprehensive care plan for three residents (R#93, R#17, and R#71) by not utilizing the current assessment to reflect the status of each resident. The sample size was 31 residents. Findings include: 1. On 9/20/17 review of the medical record on the initial physician's orders [REDACTED]. She was admitted with PO for [MEDICATION NAME] (an appetite stimulant) 40 milligrams (mg) by mouth (po) three times a day (TID). Her admission weight was recorded on the Weight Change History form as 88 pounds (lbs.) on admission. On 4/25/17 the PO sheet noted an order for [REDACTED].>On 6/7/17, the Weight Change History form recorded R#93's weight as 82 lbs. On 7/11/17, the Weight Change History form recorded R#93's weight as 83 lbs. On 8/31/17, the Weight Change History form recorded R#93's weight as 81 lbs. R#93's 9/2017 (no specific date listed) Blood Pressure and Weight Chart form weight recorded was 79 lbs. On 9/18/17, 9/19/17, 9/20/17 and 9/21/17, various times throughout the day R#93 was observed pacing about the facility on a frequent basis. She ambulated (walked) continuously in her Merry Walker (a device to aid in ambulation) throughout the building. R#93 was alert with confusion noted to place and time confirmed by attempted interview. PO's dated 9/8/17 noted an order to discontinue Ensure daily and begin Ensure Clear with meals and Ensure pudding with meals. The Ensure Clear (a dietary supplement for nutrition) was provided to R#93 on her meal tray for all meals. There was no documentation noted of the percentage of supplement R#93 received for increased caloric intake. Review of the medical record's comprehensive Care Plan for R#93 dated 8/21/17 revealed an identified problem; .at risk for weight changes and nutritional deficits. Identified interventions did not include the dietary supplement nor the appetite stimulant, R#93 had received daily since a… | 2020-09-01 |
| 2676 | 2676 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 281 | D | 0 | 1 | V4Q111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to ensure physician orders [REDACTED].#71) of two residents reviewed for weight loss. The sample size was 31. Refer to F325. Findings included: 1. Medical record review of R#71's Face Sheet revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the resident's medical record Minimum Data Set (MDS) admission assessment (a comprehensive resident assessment), dated 6/7/17, the resident's weight was 154 pounds (lbs.) on admission. The medical record's dietitian's Nutritional Documentation note, dated 8/31/17, contained her recommendation for one can of Ensure (a nutritional supplement) .bolus one can if she eats less than 50% of a meal. According to R#71's medical record physician's orders [REDACTED]. During a review of R#71's medical record Personal Care Record dated (MONTH) (YEAR), documentation indicated the resident ate poorly, noted as 25% in the document legend, at least nine days. An interview with Licensed Practical Nurse (LPN) AA, on 9/21/2017 at 8:15 a.m., regarding the lack of documentation on R#71's Medication Administration Record [REDACTED]. The LPN AA stated no Ensure had been given on the days the resident had a documented less than 50% meal intake. She further stated sometimes people brought food in for R#71. LPN AA was asked if she knew for sure or had documentation to confirm that the resident received an outside meal and the percentage of that meal intake, on the days identified with less than a 50% intake, for (MONTH) (YEAR). LPN AA stated there was no documentation to indicate the resident ate outside food. | 2020-09-01 |
| 2677 | 2677 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 282 | D | 0 | 1 | V4Q111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of the facility policy Assessment of Psychoactive Medications dated 2005, review of the facility policy Indwelling Urinary Catheter Care undated, observation and staff interview the facility failed to implement the written care plan in the provision of care for an indwelling urinary catheter for one resident (R#11) and monitoring for the effects and side effects of a psychoactive medication for one resident (R#67) of 31 sampled residents. Findings include: 1. Review of the medical record Personal Care Record for R#11 revealed under the section Bowel Movement the resident had a [MEDICAL CONDITION]. Under Incontinence was checked the resident was voiding freely. There was no indication or direction to the Certified Nursing Assistant (CNA) to provide daily indwelling urinary catheter care on the Personal Care Record. Review of the medical record comprehensive Care Plan dated: 6/1/17 for R#11 identified the following problem: .Restated: Foley catheter patent. Refer to concern 17. (No date of this entry.) Problem onset 9/1/17 Indwelling catheter placement. Physical assistance provided with urinary care. Risk for urinary tract infection. Catheter care daily and as needed . Review of the medical record Treatment record for R#11 revealed Foley Cath Care per Protocol. There was no documentation of Foley Cath Care on the record to indicate evidence of care provided per the care plan of R#11. Review of the facility policy Indwelling Urinary Catheter Care undated revealed the following information: .Policy: It is the policy of Pinewood Manor that indwelling urinary catheter care will be provided each shift. Daily cleansing of the catheter and perineum and will be done daily during the scheduled bath and as needed due to soiling.Step 11. Document procedure on CNA flow sheet. A request was made for any additional documentation from the Director of Nursing (DON) on 9/19/17 at 4:15 p.m. related to the care of the indwe… | 2020-09-01 |
| 2678 | 2678 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 315 | D | 0 | 1 | V4Q111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff and resident interview and the facility policy review the facility failed to ensure a resident who did not have a [DIAGNOSES REDACTED]. The facility failed to provide care as ordered by the physician to provide urinary catheter care daily and as needed. The facility failed to implement an order to do bladder training and discontinue the indwelling urinary catheter. This affected one resident (R#11) of 31 sampled residents. Findings include: Review of the medical record Face Sheet for R#11 revealed [DIAGNOSES REDACTED]. Review of the medical record annual Minimum Data Assessment ((MDS) dated [DATE] for R#11 revealed under (Sections C, G, H and I) the Brief Instrument for Mental Status (BIMS) was scored a two out of a possible 15, which indicated R#11's cognitive status was severely impaired. Under [DIAGNOSES REDACTED]. Further review found documentation the resident was incontinent of urine and bowel and dependent for toileting and required extensive assist for personal care. Continued review revealed evidence of a discharge MDS on 6/21/17 and a re-entry MDS on 6/28/17 but no additional detailed MDS information was available. The discharge MDS on 6/21/17 did not include an indwelling urinary catheter documented. During the assessment observation and interview of R#11 on 9/17/17 it was determined the resident could be interviewed. She was reserved, slow to answer and soft spoken. She could not remember dates but was able to respond to questions about her life and her care. Review of the clinical medical record for R#11 revealed a hospital stay with a urinary tract infection and discharge back to the facility on [DATE] with an indwelling urinary catheter in place. Review of the medical record Care Plan dated: 6/1/17 for R#11 identified the following problem: .Risk for incontinent episodes of bladder secondary to medical and functional factors. Briefs/pull-ups worn. Physical support per staff fo… | 2020-09-01 |
| 2679 | 2679 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 323 | D | 0 | 1 | V4Q111 | Based on observations, interviews, and facility policy review it was determined the facility failed to assure one of one staff transported oxygen canisters in a safe manner. Certified Nurse Aide (CNA) AAA was observed carrying an oxygen canister under her armpit. This had the potential to affect all 97 residents who reside in the facility. Findings include: On 9/18/17 around 1:20 p.m., CNA AAA was observed rapidly approaching a closed door on the back hall. Closer observations revealed the aide was transporting an oxygen canister, underneath her right arm pit. At the time, the aide was asked by the surveyor what she was doing. The aide shared she was putting the empty canister in the storage room. During the above interview with the aide, she was asked how she was trained to transport oxygen canisters. She reported she knew she was supposed to use a carrier to transport the oxygen and added if the canister was to drop it could explode. CNA AAA said she did not have a carrier at the time she was removing the canister. A review of the facility's undated Oxygen Safety policy revealed .d. Oxygen cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts approved stands) to secure all cylinders from falling, whether connected, unconnected, full or empty. A resource found at: http://ww.ashe.org/compliance/ec_02_06_01/01_medgas_cylinder_storage.shtml, Medical Gas Cylinder Storage, revealed If a cylinder or cylinder valve is damaged by falling .the cylinder could act like a projectile and fly through the air or spin in circles with great force until pressure is exhausted . On 9/21/17 at 8:53 a.m., during an interview with the Director of Nursing (DON) she revealed her expectation was for staff to utilize the oxygen carrier to safely transport oxygen full or empty canisters. | 2020-09-01 |
| 2680 | 2680 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 325 | D | 0 | 1 | V4Q111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview and facility policy review it was determined the facility failed to implement physician orders [REDACTED].#71) out of two residents reviewed for weight loss. The sample size was 31 residents. Findings include: Medical record review of R#71's Face Sheet revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 9/19/17 at 8:52 a.m., R#71 was observed upright in bed. At the time, the resident acknowledged she had a percutaneous endoscopic gastrostomy (PEG tube) (used to instill nutritional feedings and medications into the stomach). She said she no longer received feedings in the tube, but required daily dressing changes. According to the resident's medical record Minimum Data Set (MDS) admission assessment (a comprehensive resident assessment) dated 6/7/17, the resident's weight was 154 pounds (lbs.) on admission. R#71's medical record Nutritional Documentation dated 7/27/17 revealed the resident received feedings in her feeding tube prior to the discontinuation of the feedings on 8/05/17. R#71's medical record Nurse's Notes dated 8/5/17, indicated the resident was eating food and refusing her tube feedings, and indicated new orders were received allowing the resident to continue to take food in by mouth. The resident's medical record (MONTH) (YEAR) physician's orders [REDACTED]. According to the medical record Nutritional Documentation documented by the Consultant Dietitian (CD), R#71 had a 14-lb. weight loss in 90 days, which was 11.7% loss and an 8-lb. weight loss, which was 5.5% in 30 days. R#71's weight on 8/31/17, documented in the resident's medical record Weight Record was 136 lbs. and on 9/19/17 it was 137 lbs. The CD's medical record Nutritional Documentation note dated 8/31/17, contained her recommendation for one can of Ensure (a nutritional supplement) .bolus one can if she eats less than 50% of a meal. According to R#71's medial record… | 2020-09-01 |
| 2681 | 2681 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 329 | E | 0 | 1 | V4Q111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to document behavior monitoring indication of use, and graduated dose reduction (GDR) for three, Resident (R#20, R#108 and R#67) of five residents reviewed for receiving [MEDICAL CONDITION] medications related to behaviors exhibited in the facility. The sample size was 31 residents. Findings include: 1. On 9/20/17 review of the medical record for R#20 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order on the current monthly Physician's Orders sheet dated 9/1/17 is an order for [REDACTED].>1.[MEDICATION NAME] (a medication given for anxiety) two milligrams (mg) tablet every four hours as needed for agitation which was originally ordered by the physician on 3/9/15, 2. [MEDICATION NAME] two mg QHS (every night at bedtime) routine-hold if sleepy originally ordered 9/16/17, 3. quetiapine [MEDICATION NAME] 200 mg tablet by mouth twice daily in the AM (morning) and HS (bedtime) for [MEDICAL CONDITION] (a psychiatric medical condition) originally ordered 12/15/11. Additional physician's orders also dated 9/1/17 on the same form include: 4.behavior pattern: agitation, chart number of incidents every shift, 5. monitor for side effect: drooling, tongue thrust, shuffled gait, abnormal involuntary movement-chart (Y or N). On 9/20/17 review of the medical record current Medication Administration Record (MAR) for R#20 revealed the order for [MEDICATION NAME] two mg as needed (PRN) for agitation was administered every night from 9/1/17 through 9/15/17. The back of this MAR a place for documentation related to administration of an as needed medication. Documentation is noted daily at bedtime the nurses administered the medication for anxiety and not for agitation as ordered by the physician. There was no documentation in the medical record for R#20 of the symptoms she was experiencing to indicate she was having anxiety. There was also no doc… | 2020-09-01 |
| 2682 | 2682 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 334 | E | 0 | 1 | V4Q111 | Based on clinical record review and staff interview the facility failed to provide education for the potential side effects of the influenza (flu) vaccine for the (YEAR)/2017 flu season and failed to have documentation in each resident's medical record to indicate consent or decline of the flu vaccine for the (YEAR)/2017 flu season for five of the five residents (R#17, R#20, R#45, R#52 and R#67) reviewed for immunization compliance. The sample size was 31 residents. The findings include: 1. On 9/21/17 at 9:15 a.m., interview with the Director of Nursing (DON) revealed she was responsible for monitoring infection control which included information regarding flu immunization/vaccine data. She further revealed education had been provided to the resident's and their families by the former DON, however, she was unable to locate a copy of the education which had been provided to each resident and/or their representative regarding the benefits and potential side effects for the flu vaccine. She confirmed there was no documentation in the medical record for R#17, R#20, R#45, R#52 and R#67 to indicated education on the benefits and potential side effects of the flu vaccine had been provided to them. On 9/21/18, review of the clinical medical record for R#17, R#20, R#45, R#52 and R#67 revealed there was no documentation present to indicate education on the benefits and potential side effects of the flu vaccine for the (YEAR)/2017 flu season had been provided to them. 2. On 9/21/17 at 9:15 a.m. during the interview with the DON, an undated facility document Vaccine Roster Influenza Vaccine (YEAR)-2017 was reviewed. The documentation revealed a roster for residents who received or refused the flu vaccine during the (YEAR)-2017 flu season. The roster had columns for Room, Resident, Date Given, Temp, Site, Signature. The DON stated this was documentation of consent the facility uses. The facility staff had the resident sign this form as consent. They did not have a form which the resident or their representative could sign for… | 2020-09-01 |
| 2683 | 2683 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 371 | F | 0 | 1 | V4Q111 | Based on observation, clinical record review, staff interview and review of facility policies and procedures, the facility failed to ensure food safety as evidenced by: 1) they had not utilized a thermometer following standards of practice, 2) failed to maintain potentially hazardous foods at a safe temperature, 3) failed to follow the manufacturer's recommendations for utilizing the dish machine, and 4) failed to ensure that dented cans of food were removed from the ready to use shelving in the dry storage area. This deficient practice had the potential to affect all the residents who resided in this Long-Term Care (LTC) facility. The sample size was 31 residents. Findings include: 1. Observation of the kitchen on 9/18/17 at 8:30 a.m., revealed the steam table was filled with breakfast foods and staff were serving the residents their meal. The breakfast cook, Dietary Aide (DA) GG, was asked to calibrate the stem dial thermometer and take the temperature of the food on the steam table. DA GG was unable to calibrate the thermometer effectively. She was unsure how much ice and water to place in the cup and she was unsure what temperature the thermometer was required to reach. After surveyor intervention and the thermometers reached 32 degrees Fahrenheit (F), DA GG removed one of the thermometers and placed the probe into the chopped sausage without sanitizing it first. When interviewed about why she did not sanitize the probe before inserting it into the sausage, DA GG stated she thought the ice water would sanitize the thermometer probe. 2. After the Dietary Supervisor (DS) interjected and sanitized the probe effectively, the temperature of the ground sausage and sausage links were taken and recorded. The ground sausage was holding at 80 degrees F and the sausage links were holding at 120 degrees F. Per the 2013 Food Code, potentially hazardous foods (food that requires temperature control) must be held below 41 degrees F or above 135 degrees F to ensure food safety. Both the ground sausage and the sausage links w… | 2020-09-01 |
| 2684 | 2684 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 372 | F | 0 | 1 | V4Q111 | Based on observation, staff interview and review of the facility policies and procedures, the facility failed to maintain the outside garbage area in a clean and sanitary manner. This deficient practice had the potential to affect all the 97 residents who resided in this Long-Term Care (LTC) facility. Findings include: 1. Observation of the outside garbage area on 9/20/17 at 3:30 p.m., revealed the garbage bin and the surrounding area was not maintained in a clean and sanitary manner. There were two garbage bins and four individual lids on each bin. The lids did not close securely. The bins were bent which allowed for a gap between the lid and the bin which inhibited the lids from closing securely. Pests were observed flying in and out of the open gaps. The area exuded a foul odor. Continued observation of the ground surrounding the garbage bins revealed there was a milky, liquid substance which was pooling around the bottom of the bins. The garbage area was also used as a place to store broken equipment. The facility stored broken wheelchairs, bed frames, old air conditioners, and it was over grown with plant debris. In addition, the road leading to the outside garbage bins was in poor condition. There were many pot holes containing standing water and in the water, there were floating dead bugs and live swimming bugs. The water was discolored and full of dead pests. 2. Observation of the outside garbage area on 9/21/17 at 8:15 a.m., revealed staff had over filled the garbage bins and many white plastic garbage bags were hanging over the edge of the garbage bins. The outside garbage area was not secure from the public and was visible from the public road ways. An interview with the Dietary Supervisor (DS) on 9/20/17 at 3:45 p.m., confirmed the outside garbage area was not well maintained and it was the facility's policy to keep the lids closed and ensure that the area was clean and sanitary. Review of the facility's policy and procedure revealed a document titled, Disposal of Garbage and Refuse dated 1/5/14 which… | 2020-09-01 |
| 2685 | 2685 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 431 | E | 0 | 1 | V4Q111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of the facility policy and procedure the facility failed to keep medication and treatment carts locked when not attended by licensed staff and to maintain safe storage of medication in resident rooms for Residents (R#29 and R#112). The facility failed to ensure expired medications were removed from medication stock. The facility failed to date multiple dose vials of medication when first accessed to prevent use beyond the 28-day limit of use per pharmacy recommendation. This had the potential to affect all 97 facility residents. Findings include: 1. On 9/18/17 at 9:30 a.m., while touring the back hall, the treatment cart was observed in the hallway unlocked and unattended by licensed staff. Licensed Practical Nurse (LPN) KK exited a patient room down the hall. As she approached the treatment cart, she was asked if the cart contained medications. She opened the top drawer to reveal multiple tubes of prescription creams. She stated she was unaware of why the cart was unlocked. She also stated the cart should be locked always when no one is obtaining treatment medications from the cart. 2. While conducting a resident interview with R#29, on 9/18/17 at 11:06 a.m., the resident reported she once had a CD (compact disc) missing and there were (confused) residents that came in her room quite often. During the interview, it was noted there was a small paper medicine cup sitting on the resident's overbed table, positioned at the foot of her bed, near the room door. Inside the cup was a small wooden paddle like spoon resting in a white paste like substance. At that time, the resident revealed the substance was butt paste, staff used for her bottom. Also, noted on the overbed table, at the top of a pile of items in a wash basin, was a bottle of pills labelled Congestion DM. R#29 revealed the pills were over-the-counter medications. An interview with the Director of Nursing (DON) on 9/18/17 at 2:10 p.m., c… | 2020-09-01 |
| 2686 | 2686 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 441 | E | 0 | 1 | V4Q111 | Based on observations, staff interview, and facility policy review it was determined the facility failed to ensure consistent infection control practices related to preventing cross contamination during personal care for two residents (R#71 and R#112) and preventing cross contamination during the processing and delivery of linens for all residents. The sample size was 31 residents. Findings include: 1. On 9/20/17 at 8:55 a.m., Housekeeping staff member (HK) GG was observed in the back hall delivering clean linen to a covered storage cart in the hall. She was utilizing a rolling laundry cart which contained bundles of clean linen in the basket and was uncovered. She stated the laundry was outsourced and came tied in bundles with plastic straps. She would put the bundles in her rolling cart and deliver them to the nursing units for the staff to use. She confirmed she did not have a cover for the rolling cart which she used to deliver linen and personal laundry to the nursing units. She cut the straps around the clean linen and placed them in a covered laundry storage cart in the back hall. 2. On 9/20/17 around 10:45 a.m., Certified Nurse Aide (CNA) HH was seen exiting another resident's room, on the front hall, carrying a bag of dirty linen. She was also pushing a mechanical lift. After discarding the linen in a three-compartment dirty hamper in the hallway, the aide proceeded into R#71's room. After entering the room, she assisted R#112 to the bathroom, removed her pants from her bottom, and transferred the resident onto the toilet. She began preparing equipment for R#71's bed bath. During the observation on 9/20/17 at 10:46 a.m., CNA HH was observed providing personal care for R#71. During the care, it was determined R#71 had been incontinent of urine in her adult brief. The brief was soaked with dark yellow urine and the cotton matting had come apart within the brief and was clumped causing the brief to sag. A foul urine smell was detected in the room. CNA HH placed the soiled brief in a plastic bag and placed i… | 2020-09-01 |
| 2687 | 2687 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 456 | F | 0 | 1 | V4Q111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of the facility policies and procedures, the facility failed to ensure their essential equipment, the [NAME]ot Coupe (food blender) was maintained in a safe operating fashion. This deficient practice had the potential to affect 12 of 97 residents who resided in this Long-Term Care (LTC) facility. The sample size was 31 residents. Findings include: Observation of the metal blade inside the [NAME]ot Coupe food blender during the initial kitchen tour on 9/18/17 at 8:30 a.m., revealed the blade was a smooth-edged complete blade; it was not a serrated edge blade. Upon closer inspection of the metal blade, revealed it was chipped and missing many small metal pieces at the edge. During an interview with the Dietary Supervisor (DS) on 9/18/17 at 8:35 a.m., revealed she was unaware of the poor condition of the metal blade. She stated she had not completed a repair order for the blade because she had not identified the concern. The DS further stated the facility utilized the [NAME]ot Coupe food blender to chop and blend the food for those residents who had a physician's orders [REDACTED]. When interviewed about where the missing metal pieces might be, the DS stated that she was unsure. Review of the facility's Census List revealed the facility had 12 residents who had a physician's orders [REDACTED]. Review of the facility policies and procedures revealed a document titled, Safe and Homelike Environment dated 1/5/14 which provided the following information: Policy: .In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensure that the resident can receive care and service safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk .h. Items needing repairs or attention or reported by any sta… | 2020-09-01 |
| 3364 | 3364 | LIFE CARE CENTER | 115654 | 176 LINCOLN AVE | FITZGERALD | GA | 31750 | 2017-09-21 | 371 | F | 0 | 1 | MB2E11 | Based on observation, staff interviews, and review of facility policy, it was determined the facility failed to use sanitizer in the three-compartment sink while washing dishes, failed to label and date food and condiments stored in the walk- in cooler, failed to ensure food temperatures were at safe levels prior to serving prepared food to residents, and failed to adequately monitor dishwasher temperatures and sanitizer levels on the dishwashing machine. These failures put 103 residents who consume oral food out of 105 residents residing in the facility, at risk for developing a food borne illness. The findings include: Review of an undated policy titled, Food Safety Requirements-Use and Storage of Food and Beverage Brought In For Residents, Food Procurement indicated the following: It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all foods including those brought to residents by family and other visitors. It further indicated that food service workers, cooks, dietary aides, dishwashers, food prep aides, or any persons who are in the kitchen working with any type of food, are responsible for adhering to the food safety requirements. The policy also listed factors implicated in foodborne illnesses to include Inadequate cooking and improper holding temperatures promotes the growth of pathogens that may cause foodborne illness, as well as improper sanitation of equipment used in preparation of food. Review of the policy titled, Nutrition Services Manual dated 06/2015, 10.9 indicated for the dish machine, The dish machine is maintained in a clean and sanitary condition. The dish machine is set up for washing dishes/utensils following manufacturer's directions. Temperatures and chemical strength will be checked at each meal and recorded on the Dish Machine/Sanitizer Log. 10.42 indicated for the pot and pan sanitizer concentration log, The cook or dietary aide, after setting up a three compartment sink and before washing pots and pans, utilizes appropriate test strip… | 2020-09-01 |
| 3466 | 3466 | SCOTT HEALTH & REHABILITATION | 115671 | 12 SMITH LANE | ADRIAN | GA | 31002 | 2017-09-21 | 250 | D | 0 | 1 | VM8J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to ensure one Resident (R#7), who was severely cognitively impaired, had a responsible party to assist with making decisions. The sample size was 20 residents. Findings include: Medical record review revealed R#7 had [DIAGNOSES REDACTED]. The current medical record Physician order [REDACTED]. The medication had no attempted gradual dose reductions since the order date. The medical record Minimum Data Set (MDS) quarterly assessment dated [DATE], (Section C) regarding cognitive status, revealed the resident's Brief Interview for Mental Status (BIMS) was a five out of a possible score of 15, which indicated the resident was severely cognitively impaired. The MDS also revealed the resident received antipsychotic medication. The MDS quarterly assessment dated [DATE] revealed the BIMS was seven out of 15, which indicated the resident was severely cognitively impaired. The medical record Care Plan dated 7/5/17 revealed the resident had a cognitive deficit with decision making. R#7 was observed in the hall on 9/20/17 at 2:15 p.m., She asked the surveyor to help her find out about a paper. She stated it had to do with taking care of her. The surveyor informed the resident she would have a staff person assist her with her question. An interview with the Administrator on 9/20/17 at 2:30 p.m., revealed R#7 did not have a responsible party. She stated the resident was not cognitively able to make her own decisions. The Administrator further stated the physician and the ethics committee made the decision the resident was to be a Do Not Resuscitate (DNR). The Administrator indicated she signed the resident's documents when she needed to go to the hospital and there had never been an effort made to get a guardian/responsible party to make decisions for the resident. An interview with the Social Worker (SW) on 9/20/17 at 2:50 p.m., verified R#7 had no responsible party. She stated the res… | 2020-09-01 |
| 3467 | 3467 | SCOTT HEALTH & REHABILITATION | 115671 | 12 SMITH LANE | ADRIAN | GA | 31002 | 2017-09-21 | 329 | D | 0 | 1 | VM8J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interview the facility failed to ensure behavior monitoring was reviewed and utilized regarding an attempt at gradual dose reductions for an antipsychotic medication for Residents (R#7 and R#52). This affected 2 residents of 5 reviewed regarding unnecessary medications. Findings include: 1. R#7 had [DIAGNOSES REDACTED]. The medical record current Physician order [REDACTED]. The medication had no attempted gradual dose reductions since the order date. The medical record Minimum Data Set (MDS) quarterly assessment dated [DATE] (Section C) regarding cognitive status, revealed the resident's Brief Interview for Mental Status (BIMS) score was five out of a possible 15, which indicated the resident was severely cognitively impaired. The MDS also revealed the resident received antipsychotic medication. The MDS quarterly assessment dated [DATE] revealed the BIMS was a score of seven out of 15, which indicated the resident was severely cognitively impaired. The medical record Care Plan dated 7/5/17 revealed [MEDICAL CONDITION] drug use due to [MEDICAL CONDITION]. The Care Plan dated 7/5/17 revealed the resident had a cognitive deficit with decision making. The medical record Behavior Monitoring forms dated 7/1/17 through present revealed the resident had 19 episodes of delusions, impulsive aggression, purposeful vomiting. The monitoring forms revealed 14 of the episodes had a positive response to non-pharmacological interventions. R#7 was observed in the wheelchair in the dining room on 9/18/17 at 12:40 p.m., eating lunch independently and was further observed in the wheelchair in her room on 9/19/17 at 9:20 a.m., She was not observed exhibiting any behaviors according to the Behavior Monitoring forms documentation. An interview with the Regional Registered Nurse (RRN) on 9/20/17 at 3:30 p.m. verified there were no gradual dose reductions attempted for the [MEDICATION NAME] (an antipsychotic) sin… | 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 );