cms_GA
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard ▼ | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10616 | 10616 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 315 | D | S0VI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that one resident (#1) had a medical [DIAGNOSES REDACTED]. Findings include: Resident #1 had an indwelling urinary catheter since at least 12/14/09. However, review of the resident's medical record revealed [REDACTED]. During an interview on 8/25/10 at 2:00 p.m., the Director of Nursing (DON) stated that the resident had the catheter because the resident's family had requested it. | 2014-02-01 | ||
| 10617 | 10617 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 387 | D | S0VI11 | Based on record review, staff interview, and review of the facility's Quality Assurance committee meeting minutes, it was determined that one resident (#1) was not seen by a physician at least once every 60 days in a sample of 15 residents. Findings include: Resident #1 had a 1/14/10 physician's progress note signed by his/her attending physician. However, there was not another physicians's progress note or evidence of a physician's visit to the resident until a 7/19/10 progress note signed by the Medical Director. During an interview on 8/25/10 at 11 a.m., the Director of Nursing (DON) stated that the facility had identified that the resident's attending physician had not visited him/her since January, 2010. She said that the problem had been discussed in the April Quality Assurance meeting and a corrective action plan was developed. She said that as of July, the attending physician had still not visited the resident so, the Medical Director visited him/her. However, despite the facility having identified the lack of physician's visits to resident #1 in April, a physician did not visit the resident until 7/19/10. | 2014-02-01 | ||
| 10618 | 10618 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 164 | D | S0VI11 | Based on observation, it was determined that the facility failed to provide personal privacy during incontinence care for one resident (#3) from a total sample of 15 residents. Findings include: During an observation of incontinence care being provided on 8/25/10 at 4:20 p.m., certified nursing assistant (CNA) "BB" failed to close the privacy curtain between the A and B beds in the room. Resident #3 was exposed from the waist down and his/her roommate was present in the room. | 2014-02-01 | ||
| 10619 | 10619 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 225 | D | S0VI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to investigate the cause of a fracture for one resident (#3) from a total sample of 15 residents. Findings include: Resident #3 sustained a moderately displaced and mildly angulated spiral fracture to his/her left distal tibia and fibula that was identified by an x-ray report on 2/8/10. Licensed nursing staff documented in the 2/5/10 at 4:17 a.m. nursing notes that a certified nursing assistant (CNA) had observed that the resident's left ankle had [MEDICAL CONDITION] (swelling) and was painful with movement. However, review of the resident's record revealed no known etiology (cause) for the fracture. The licensed nurse coded the resident as requiring extensive assistance of one staff member (3/2) for bed mobility and dressing on the 12/8/09 quarterly Minimum Data Set (MDS) assessment. During an interview on 8/25/10 at 9:50 a.m., the Director of Nursing confirmed that the facility did not conduct a thorough investigation to determine the cause of the resident's fracture. | 2014-02-01 | ||
| 10620 | 10620 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 323 | D | S0VI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to evaluate the effectiveness of or develop new interventions to prevent injury from the bed siderails for one resident (#3) from a total sample of 15 residents. Findings include: Resident #3 had [DIAGNOSES REDACTED]. He/She sustained a moderately displaced and mildly angulated spiral fracture to his/her left distal tibia and fibula that was identified by an x-ray report on 2/8/10. Licensed nursing staff documented in the 2/5/10 at 4:17 a.m. nursing notes that a certified nursing assistant (CNA) observed that the resident's left ankle had edema (swelling) and was painful with movement. However, review of the resident's record revealed no known etiology (cause) for the fracture. During an interview on 8/25/10 at 9:50 a.m., the Director of Nursing (DON) stated that the facility did not complete an investigation into the cause of the resident's fracture. He/she stated that the resident had probably hit his/her leg on the side rail of the bed and it had fractured because of having osteopenia. However, the 2/8/10 x-ray report noted "diffuse osteopenia" only in the resident's left ankle. The resident was observed in bed on 8/24/10 at 11:50 a.m., 12:40 p.m., 2:40 p.m., on 8/25/10 at 11:00 a.m., 12:00 p.m. and on 8/26/10 at 7:55 a.m. with 3/4 siderails up. There was not any padding on them. During an interview on 8/26/10 at 11:30 a.m., the DON stated that padded siderails had been tried after the resident's fracture but, the resident had removed them. He/she stated that there was no documentation related to the resident having had padding on his/her siderails or about the resident's behavior of removing them. She said that there were not any other interventions that had been put in place. During an interview on 8/26/10 at 9:45 a.m., CNA "CC" stated that he/she had not seen padding on the resident's siderails after the resident's 2/2010 fracture. There … | 2014-02-01 | ||
| 10621 | 10621 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2010-10-27 | 157 | D | CU8M11 | Based on record review and staff interview, the facility failed to promptly consult with the physician, and immediately notify the family, regarding a significant change in the physical status of one (1) resident (#1) of thirteen (13) sampled residents Findings include: Record review for Resident #1 revealed Nurse's Note of 09/17/2010 at 11:22 a.m. which documented that the resident was alert and responsive, with no distress observed. Then, a Nurse's Note of 09/17/2010 at 5:30 p.m. documented that staff had noted softness and puffiness of the resident's left hand. There was no evidence to indicate that the physician was consulted or that the family of the resident was notified of this change in status at that time. A Nurse's Note of 09/25/2010 at 9:30 a.m. documented that the resident left arm had been elevated with a pillow roll and the left leg was elevated due to swelling. There was no evidence to indicate that the physician was consulted or that the family of the resident was notified of this change in status at that time. A Nurse's note of 10/19/2010 at 6:30 p.m. documented that the resident's family was concerned about the resident having left arm swelling. This Note documented that the physician was notified at that time, and that orders were received for a chest x-ray and Doppler studies of the left arm. During an interview conducted on 10/26/2010 at 2:15 p.m., the Director of Nursing stated that she called the doctor as soon as the family told her the resident's arm was swollen. | 2014-02-01 | ||
| 10622 | 10622 | PALMYRA NURSING HOME | 115628 | 1904 PALMYRA ROAD | ALBANY | GA | 31702 | 2010-10-15 | 314 | D | E1CR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and staff interview, it was determined that the facility failed to provide the treatment as ordered for healing for one resident, Resident #2, out of a sample of four residents with pressure sores, from a total sample of five residents. Findings include: Based on review of the documentation on the facility's Wound Record for Resident #2, revealed an unknown stage pressure sore to the right heel, which was facility acquired and first identified on 7/16/10. A review documentation on the Treatment Record revealed there was a treatment order, to cleanse the right heel with normal saline, apply [MEDICATION NAME] and dry dressing, and to change every three days. This order was discontinued on 10/11/10 when a new physician's orders [REDACTED]. However, during an observation of the resident's right heel and dressing on 10/15/10 at 3:10 p.m. with licensed staff member "AA" revealed that the dressing over the right heel pressure sore was the [MEDICATION NAME] dressing. The [MEDICATION NAME] was then reapplied at that time. Another observation of the resident's right heel with licensed staff member "AA" at 4:40 p.m. on 10/15/10 revealed that the [MEDICATION NAME] dressing was in place over the pressure sore on the right heel. This was confirmed by licensed staff "AA" at 3:10 p.m. and 4:40 p.m. during interview. A review of the documentation on the October 2010 treatment record on 10/15/10 at 3:45 p.m. revealed that the old treatment order to cleanse the right heel with normal saline, apply [MEDICATION NAME] and dry dressings, and to change every three days, was still being documented as done from 10/11/10 through 10/15/10. There no documentation that the new treatment order of 10/11/10 had been transcribed nor implemented by staff to cleanse the right heel with normal saline, apply Santyl and dry dressings, and to change every other day. This was acknowledged by licensed staff "AA" at 5:20 p.m. during an interview. | 2014-02-01 | ||
| 10623 | 10623 | PALMYRA NURSING HOME | 115628 | 1904 PALMYRA ROAD | ALBANY | GA | 31702 | 2010-10-15 | 315 | D | E1CR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, it was determined that the facility had failed to ensure the appropriate care to prevent urinary tract infections for one resident, Resident #2, from a sample of five residents. Findings include: Resident #2 was observed on 10/15/10 at 3:10 p.m. in bed with smeared, dried bowel movement (BM) on the right buttock and in the perineal area. At that time, the resident was not having a bowel movement. Both licensed staff member "AA" and certified nursing assistant "'BB", who were in the room during the observation, acknowledged that this was old bowel movement and that the resident had not been cleaned thoroughly after her last bowel movement. A review of a culture and sensitivity reports from Doctors Laboratory, Inc. revealed documentation showing that the resident had a urinary tract infection on 4/23/10 with a positive [MEDICATION NAME] and over 100,000 colonies/milliliter of Eschericia Coli (E. Coli) and another urinary tract infection with a positive [MEDICATION NAME] and over 100,000 colonies/milliliter of E. Coli on 8/10/10. | 2014-02-01 | ||
| 10624 | 10624 | GOLD CITY CONVALESCENT CENTER | 115689 | 222 MOORE DRIVE | DAHLONEGA | GA | 30533 | 2010-10-27 | 203 | D | 0EJX11 | Based on record review and staff interview, it was determined that the facility failed to notify three (3) of four (4) sampled residents (#2, #3, and #4), and family members of these residents, in writing of the residents' transfer to the hospital and of additional information as required. Findings include: Record review revealed Nurse's Notes dated 10/17/2010 at 7:00 pm. for Resident #2, 10/21/2010 at 5:30 p.m. for Resident #3, and 10/11/2010 at 10:50 a.m. for Resident #4 which documented that each resident had been transferred to the hospital. However, for each of these residents, there was no evidence to indicate that either before hospital transfer, at the time of hospital transfer, or since hospital transfer, each resident and the resident's family had received a written notice of the transfer indicating the reason for the transfer, the date of the transfer, the location to which the resident was being transferred, a statement that the resident had the right to appeal the action to the State, and the State Ombudsman's name, address and telephone number. During an interview conducted on 10/27/2010 at 12:46 p.m., the facility's Director of Nursing acknowledged that there was no evidence of a written notice of transfer containing the required information specified above having been issued/provided to Resident #2, #3, and #4, and to resident family members, regarding the residents' hospital transfers. | 2014-02-01 | ||
| 10625 | 10625 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2010-07-15 | 371 | F | DUNS11 | Based on observation and staff interview the facility failed to ensure that foods being served to residents in the facility's main dining room were held at a temperature necessary to prevent the likelihood of foodborne illnesses. This affected all residents in the facility (census = 15). Findings include: Observation on 7/13/10 at 12:15 p.m., with dietary employee "EE", in the serving kitchen of the dining room revealed a stainless steel pan full of tossed green salad was sitting unrefrigerated on a cart in the serving area. Continued observation revealed that the pan of salad was sitting in another pan containing ice. A temperature check of the tossed salad, using a digital thermometer, revealed that the temperature was 62 degrees Fahrenheit, well above the safe holding temperature of 41 degrees Fahrenheit. Further observation revealed a small stainless steel pan of chopped ham, being used to make chef salads, sitting on the cart. The pan of chopped ham was being held at room temperature without any means of keeping the ham cold. The temperature of the chopped ham was measured with a digital thermometer at 61 degrees Fahrenheit. | 2014-02-01 | ||
| 10626 | 10626 | MUSCOGEE MANOR & REHAB CENTER | 115146 | 7150 MANOR RD | COLUMBUS | GA | 31907 | 2010-09-01 | 157 | D | 4BQ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the physician was consulted in a timely manner for two (2) residents (#s 1 and 2 ), who had experienced significant changes in condition related to urinary tract symptoms, from a survey sample of eight (8) residents. Findings include: 1. Record review for Resident #1 revealed a Nurses Progress Note of 07/30/2010 at 9:45 p.m. which documented that the resident was noted to have cloudy and foul smelling urine. However, further record review revealed no evidence to indicate that the physician was consulted regarding this resident's significant change in physical condition until a Nurse's Progress Note of 08/03/2010 at 1:30 p.m. documented that a new order had been received. An order signed by the nurse practitioner, and dated 08/03/2010 at 8:50 a.m., specified that urine be collected for a urinalysis with culture and sensitivity. This represented an approximate three (3) day delay in physician consultation. A urinalysis laboratory report for Resident #1 dated as collected on 08/04/2010 documented urine with a positive [MEDICATION NAME], three (3) plus abnormal white blood cells, and one (1) plus abnormal protein. A physician's telephone order of 08/06/2010 specified that the resident receive the [MEDICATION NAME] milligrams twice daily for three weeks for a urinary tract infection. 2. Record review for Resident #2 revealed a Nurse's Progress Note of 08/16/2010 at 6:30 a.m. which documented that during a urinary catheter change, thick and milky white secretions were noted in the resident's peri-area. A foul odor was also noted. This Note did not document physician consultation regarding the resident's significant change in status at that time, but rather documented that the resident had been added to physician rounds for evaluation and treatment. A Nurse's Progress Note of 08/24/2010 at 7:30 p.m. documented that upon assessment of the resident's … | 2014-01-01 | ||
| 10627 | 10627 | MUSCOGEE MANOR & REHAB CENTER | 115146 | 7150 MANOR RD | COLUMBUS | GA | 31907 | 2010-09-01 | 514 | D | 4BQ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the clinical record was complete for one (1) resident (#2) from a survey sample of eight (8) residents. Findings include: Record review revealed that Resident #2 had a 07/13/2010 physician's orders [REDACTED]. However, there was no documentation of any signs or symptoms of [MEDICAL CONDITION] in the Nurses Progress Notes, or elsewhere in the clinical record. Resident #2 also had a 07/27/2010 physician's orders [REDACTED]. However, there was no documentation of any signs or symptoms or the reason for this new treatment regimen in the Nurses Progress Notes or anywhere else in the clinical record. This was acknowledged by licensed staff member "AA" on 08/25/2010 at 4:30 p.m. | 2014-01-01 | ||
| 10628 | 10628 | GOLDEN LIVINGCENTER - DUNWOODY | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2010-09-01 | 225 | D | 7R0511 | Based on record review and staff interview, it was determined that the facility failed to immediately report an injury of unknown origin to the state regulatory agency for one (1) resident #1 in a survey sample of four (4) residents. Finding include: The Interdisciplinary Progress Note dated 8/8/2010 documentation revealed that at 7:40 a.m. resident #1 was noted by the oncoming nurse to have a swollen right eye and the physician was notified. The Physician's Progress Note dated 8/8/2010 revealed that the resident had a bruise to the right eye that was identified as an ocular contusion. Review of the letter sent to the state regulatory agency dated 8/17/2010, revealed that the bruise of unknown origin to the eye of the resident was reported on 8/10/2010, two days after the bruise was noted by the physician on 8/8/2010 rather than immediately as required During an interview with the Director of Nursing on 9/1/2010 at 10:45 a.m., it was confirmed that the injury of unknown origin was not reported to the state until 8/10/2010. A phone interview with the Director of Nursing on 9/9/2010 at 2:20 p.m. revealed that the Physician's Progress note identified the bruise to the right eye as an ocular contusion that indicated an injury of unknown origin. It was further confirmed that the injury should have been reported that day to the state regulatory agency and an investigation immediately started. | 2014-01-01 | ||
| 10629 | 10629 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 203 | D | L1C411 | Based on record review and staff interview, the facility failed to issue a written notice of discharge/transfer at least 30 days before the discharge or transfer for one (1) resident from seventeen (17) sampled residents. Findings includes: Record review for resident #16 revealed a nurse's note dated 4/30/09 that indicated the resident was discharge to another nursing home. Further review revealed a social service note dated 4/20/09 that the social service staff spoke with the resident's son regarding that the resident had been observed smoking in the room and that cigarettes were found in the room. No other written notification related to the resident's discharge was found in the resident's medical record. Interview with Social Worker "AA" on 5/13/09 at 10:10 am revealed that she did not issue a written notice related to discharge of this resident to another nursing home. | 2014-01-01 | ||
| 10630 | 10630 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 322 | D | L1C411 | Based on observations, staff interviews, and review of facility policy, the facility failed to provide appropriate positioning, during incontinence care, for two residents (2) residents (#4, #9) receiving gastrostomy tube feeding from a sample of seventeen (17) residents. Findings include: 1. Observation on 5/13/09 at 8:15 am of CNA "BB" providing incontinence care to resident # 9 revealed that tube feeding was being administered via a pump at 55 cc per hour. During the care the head of the resident's bed was flat and the tube feeding continued to infuse. Interview on 5/13/09 at 8:35 am with CNA "BB" revealed that the she was suppose to keep the head of the bed up during incontinent care or get the nurse to turn the tube feeding off. "BB" acknowledge that the feeding continued to infuse while the resident was flat in bed. 2. Observation on 5/11/09 at 1:30pm. of CNA "BB" providing incontinence care to resident #4, revealed that tube feeding was infusing via pump and she lowered the head of the bed to lower tha thirty (30) degrees. The CNA did not pause or stop the feeding while providing care. Interview on 5/11/09 at 1:35pm with CNA "BB" revealed that she was never instructed to stop or pause the feeding pump when providing care. She further revealed that she never notified the nurse prior to care or lowering the head of the bed. Interview with Director of Nursing (DON) "CC" on 5/11/09 at 3:10pm revealed that she was not aware of a policy to stop or pause the feeding pump when head of the bed is lowered. Review of the facility policy for Tube Feeding indicated that a resident's head will be elevated at least 30-45 degrees at all times with continuous feedings unless temporarily stopped when the head is lowered to render care. | 2014-01-01 | ||
| 10631 | 10631 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 502 | D | L1C411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the February 2009 Pharmacist consultant report and staff interview the facility failed to ensure that a Comprehensive Metabolic Panel was obtained in a timely manner for one (1) resident (#1) from a sample of seventeen (17) residents. Findings include: Review of the medical record for resident #1 revealed a physician's orders [REDACTED]. Further review revealed no laboratory results in the record. Review of the Monthly Pharmacist Reviews dated February 2009 indicated a CMP was due in February and then every 6 months. Interview with Unit Manager "EE" on 5/12/09 at 1:00pm revealed that when laboratory test are ordered there is one drawn at the time of order as a baseline and then as frequent as ordered by the physician. "EE" further revealed the first/base line or any CMP had not been done after the 2/23/09 physician's orders [REDACTED]. | 2014-01-01 | ||
| 10632 | 10632 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2010-09-02 | 157 | D | 42L211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to immediately inform the family member of one (1) resident (#1), in a survey sample of twenty four (24) residents, of the development of a pressure sore. Findings include: A review of Resident #1's Nurse's Notes dated 4/26/2010 revealed documentation that the family member was notified of the resident's excoriated gluteal cleft and buttocks and of a treatment order for [MEDICATION NAME] cream. On 6/20/2010, documentation in the Treatment Record revealed that the left upper buttock had developed a sheet sheared area that was turning necrotic with eschar and slough measuring 4.0 by 1.0 centimeters. It was also documented that the area was treated with Santyl. However, there was no documentation to indicate that the responsible party of the resident was notified of the wound and treatment. During interview with Nurse "AA" conducted on 08/24/2010 at 2:45 p.m., this nurse acknowledged that there was no documentation to indicate that the responsible party was notified of the progression of the wound. | 2014-01-01 | ||
| 10633 | 10633 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2010-09-02 | 162 | E | 42L211 | Based on record review and staff interview, the facility failed to appropriately manage resident accounts for fifteen (15) residents (#s 5, 6, 7, 9, 11, 12, 14, 15, 16, 17, 19, 20, 22, 23 and 24) in a survey sample of twenty-four (24) residents, related to charging and deducting a fee for laundry service from the resident trust fund account, but for which payment had already been made under Medicaid. Finding include: Review of the facility's resident trust fund Patient Activity Report revealed the following: 1. For Resident #5, the facility deducted a charge of $31 from the resident trust fund on 05/31/2010 for laundry service. 2. For Residents #9, #17, and #19, the facility deducted a charge of $31 from the resident trust fund on 03/31/2010 and 07/31/2010 for laundry service. Review of the August 2010 Account Statements for these residents revealed that the facility did credit $31 for that month to these residents' accounts on 08/26/2010, after the initiation of this complaint survey during which the issue was identified. 3. For Residents #6, #7, #11, #12, #22, and #23, the facility deducted a charge of $31 from the resident trust fund on 03/31/2010 for laundry service. 4. For Residents #14, #15, #16, #20, and #24, the facility deducted a charge of $31 from the resident trust fund on 03/31/2010 and 07/31/2010 for laundry service. During an interview with Staff Member "BB" conducted on 08/24/2010 at 3:30 p.m., this staff member stated that she/he was aware that some residents had been charged the laundry fee incorrectly. Staff Member "BB" also acknowledged that there was no system in place to ensure that residents who were charged the laundry fee were identified and that the money was reimbursed back into the account. | 2014-01-01 | ||
| 10634 | 10634 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 160 | E | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to convey within thirty (30) days the balance of resident trust funds, and a final accounting of those funds, to the individual administering the resident's estate. This affected four (4) randomly reviewed trust fund accounts belonging to deceased residents. Findings include: A review of resident trust fund accounts managed by the facility revealed that the following trust fund account disbursements made to the estates of deceased residents exceeded 30 days: ? Resident expired on [DATE], disbursement made on [DATE] ? Resident expired on [DATE], disbursement made on [DATE] ? Resident expired on [DATE], disbursement made on [DATE] ? Resident expired on [DATE], disbursement made on [DATE] This information was confirmed by Office Manager "DD" in an interview on [DATE] at 10:15 a.m. | 2014-01-01 | ||
| 10635 | 10635 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 164 | E | 82I011 | Based on observation and staff interview, the facility failed to provide privacy during medication pass for three (3) observed residents on two (2) of three (3) halls with three (3) of three (3) nurses. Findings include: During medication pass with LPN "BB" from 12:44 p.m.- 12:55 p.m., she was observed to close the mini blinds in a resident's room but left the door open to the hallway. While administering an insulin injection into the resident's abdominal area, one (1) person was observed walking by the open door. Also, the privacy curtain between the beds was not pulled and the resident's roommate was in their bed. During observation of med pass with LPN "AA" at 11:35 a.m. on 3/09/11, she did not close the resident's door, pull the privacy curtain or close the mini blinds during a blood sugar (BS) check and the administration of an injection in the resident's abdomen area. The resident's roommate was in the room. On 3/09/11 at 11:55 a.m., LPN "CC" was observed obtain a blood sample to monitoring a resident's blood sugar. LPN "CC did not close the resident's door during the blood glucose check. Three persons were observed to walk by the resident's door. Interview with the Director of Nursing (DON) on 3/08/11 at 1:30 p.m. confirmed that privacy should include closing the resident's bedroom door, window blinds, and privacy curtains. When giving an injection a resident should be provided privacy. | 2014-01-01 | ||
| 10636 | 10636 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 279 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop a comprehensive plan of care that included measurable objectives and timetables to meet a resident's medical needs related to weight loss and antianxiety medications for one (1) resident, (#24) on a sample of nineteen (19) residents. Findings include: 1. Review of the physician orders [REDACTED]. She was ordered Carnation Instant Breakfast 120 milliliters three (3) times a day on 2/22/11. Observation of the lunch meal on 3/08/11 at 12:20 p.m. revealed that resident #24 was served chopped meat, white rice, sweet potatoes, brussel sprouts, a roll, fruit, tea, water and coffee. Interview with Licensed Practical Nurse (LPN) Clinical Manager at that time revealed that the rice was considered to be a fortified food item. Record review revealed an admission weight, dated 9/22/10, of 178.8 pounds and a height of 61 inches. Following monthly weights were: 10/2010=177 pounds; 12/2010=165 pounds; 1/08/11=155 pounds. Review of the medical record for resident #24 revealed that no care plan had been developed for this resident. The Minimum Data Set (MDS) assessment from her admission on 9/22/10 were on the medical record and the RAP summaries. However, there was no individualized plan of care related to nutrition or weight loss for the resident. On 3/08/11 at 4:00 p.m., interview with the MDS Coordinator revealed that resident #24 did not have a care plan that addressed her nutritional status. 2. Review of the Physician order [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The most recent quarterly MDS 3.0 assessment documented that the resident was receiving an antianxiety medication daily. On 3/8/2011 at 4:15 p.m. review of resident #24's medical record revealed that there was no developed plan of care related to antianxiety medications. Interview with the MDS Coordinator on 3/08/2011 at 4:00 p.m. revealed… | 2014-01-01 | ||
| 10637 | 10637 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 280 | D | 82I011 | Based on record review and staff interview the facility failed to revise a Plan of Care to reflect the change in condition of one (1) resident (#11) and the dental needs for one (1) resident ("A") from a sample of nineteen (19) residents. Findings include: 1. A review of the clinical record of resident #11 revealed that she had experienced significant weight loss as follows: 03/01/2011; Weight: 117 (12.7% loss in 3 months) 01/13/2011; Weight: 127 (5.2% loss in 1 month) 12/20/2010; Weight: 134 (baseline weight) Further record review revealed the resident's care plan regarding the potential alteration in nutrition status had not been reviewed or revised since 12/24/10. An interview with the facility's Care Plan Coordinator on 3/08/11 at 3:00 p.m. revealed the care plan had not been revised to reflect this weight loss. Although the care plan did not reflect the resident's weight loss, review of Dietary Notes revealed the weight loss was identified and interventions in place to address the weight loss. 2. A family interview for resident "A" on 3/07/11 at 7:30 p.m., revealed the resident had lost weight since admission and the resident's dentures no longer fit properly. Review of the resident's care plan revealed a care plan that addressed nutrition but that had not been updated to reflect the ill fitting dentures. Interview with the Minimum Data Set (MDS) Coordinator on 3/08/11 revealed she had not been made aware of a denture problem for resident "A", therefore, the care plan had not been revised. Interview with the Social Worker on 3/08/11 at 10:13 a.m. revealed she was aware of the resident's ill fitting dentures but had not been able to arrange for a dental visit. She agreed the care plan has not been updated to reflect the ill fitting dentures. | 2014-01-01 | ||
| 10638 | 10638 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 281 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to meet professional standards of quality of care related to obtaining a blood sugar and administering insulin before meals for one (1) resident (#36) from a sample of nineteen (19) residents. Findings include: During the medication pass observation on 3/07/11 at 12:44 p.m. and 12:55 p.m. Licensed Practical Nurse (LPN), "BB" was observed to check the resident's blood glucose (BG) level and then to administer a routine dose of insulin ([MEDICATION NAME] 10 units). Interview with the Licensed Practical Nurse (LPN),"BB", at 12:55 p.m. on 3/07/11 revealed she was aware that the resident had already eaten lunch prior to the BG being checked and the insulin being administered. Review of the March 2011 Physician order [REDACTED]. A later review of the March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" had signed that the blood glucose check was completed at 11:30 a.m. and that that insulin was administered at this time (11:30 a.m). Reference: The Georgia Nurse Practice Act 943-26-1;Article 2; subsection 2.3.2- Standards Related to Licensed Practical Nurse Professional Accountability revealed that the practice practical nursing as a Licensed Practical Nurse (LPN) by performing for compensation acts authorized by the board related to the maintenance of health and prevention of illness through acts, which shall include: administering treatments and medication as ordered by a physician. 2.3.1 B. Demonstrates honesty and integrity in nursing practice. Cross Refer to F-309 | 2014-01-01 | ||
| 10639 | 10639 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 287 | F | 82I011 | Based upon observation, record review and staff interviews the facility failed to ensure that Minimum Data Set (MDS) 3.0 transmitted and accepted since 10/01/11. Findings include: Upon entrance to facility it was determined the facility had a census of ninety two (92) but after reconciliation it was discovered that the resident census pool contained twenty three (23) residents. A telephone interview with the Georgia State MDS Coordinator on 3/08/11 at 9:34 a.m. revealed that since 10/01/10, only eleven (11) MDS 3.0 had been submitted and accepted from the facility. An interview with the Administrator on 3/07/11 at 12:00 p.m. revealed she was aware there had been issues with rejection of 3.0 MDS at submission. Interview on 3/08/11 at 8:45 a.m. with the Administrator and MDS coordinator revealed they were unaware that only eleven (11) MDS 3.0 had been accurately transmitted and accepted since 10/01/11. | 2014-01-01 | ||
| 10640 | 10640 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 309 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to ensure that physician orders [REDACTED]. Findings include: Record review for resident #36 revealed that she was admitted with a [DIAGNOSES REDACTED]. Review of the March Physician order [REDACTED]. The resident was to receive [MEDICATION NAME] (type of insulin) ten (10) units before meals. During the medication pass observation on the C-hall with Licensed Practical Nurse (LPN), "BB", on 3/07/11 from 12:44 a.m.-12:55 p.m., LPN "BB" was observed to complete a blood glucose (BG) level then to administer [MEDICATION NAME] (insulin) ten (10) units. Interview with the LPN "BB" on 3/07/11 at 12:55 p.m. revealed that the resident had eaten lunch prior to resident's BG being checked and/or insulin being administered. Interview with the Director of Nursing (DON) on 3/09/11 at 2:45 p.m. revealed expectations were that the physicians order would be followed. Review of the March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" signed that the accucheck was completed at 11:30 a.m. and also, that insulin was administered at the same time, documenting the insulin was administered prior to the lunch meal and not after the meal. | 2014-01-01 | ||
| 10641 | 10641 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 441 | K | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of manufacturer's recommendations and staff interview, the facility failed to ensure an Infection Control Program designed to ensure a safe environment to prevent the development and transmission of disease and infection by failing to ensure the cleaning and sanitizing of glucometers between each resident use. This affected two (2) sampled residents, (#17 and #36) and nineteen (19) residents who received blood glucose monitoring on a daily basis via a multiple resident use glucometers. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for these twenty-one (21) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to the resident health and safety existed from March 8, 2011 related to glucometers not being cleaned and disinfected when used for multiple residents until March 10, 2010, when a plan of correction was implemented by the facility to remove the jeopardy situation. Additional concerns, not related to jeopardy, were identified regarding hand washing during the medication pass observation. Findings include: 1. During medication pass on the A-Hall with LPN, "CC", on 3/08/11 from 11:51 a.m. she donned her gloves, took the glucometer out of the medication cart drawer, used the meter to check resident #17's blood glucose level. The nurse returned the glucometer to the medication cart drawer, but did not clean or disinfect the meter after use. In addition, LPN continue to draw up insulin and administer the injection without changing the gloves or washing her hands. Interview with LPN, "CC", on 3/08/11 at 12:08 p.m. revealed she did not clean the glucometer before she went into the resident #17 room, stating that she thinks she might have cleaned it after the last resident, but was unsure. 2. During medication pass task on the B-Hall on 3/08/11 at 12:40 a.m. with LPN "AA" revealed prior to checking a rand… | 2014-01-01 | ||
| 10642 | 10642 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 463 | E | 82I011 | Based on record review, observation and staff interview, the facility failed to ensure that two (2) call lights in resident's bathrooms (#24 and a randomly observed resident) on the C-hall was maintained in functioning order. Findings include: During facility environmental rounds on 3/08/11 at 11:08 a.m., in bathroom C-14, there was no pullcord and/or toggle on the call light system. However, there was a 4 inch x 4 inch orange sign that reminded the resident to call for assistance, "we don't want you to fall". Staff interview with the Maintenance Supervisor on 3/09/11 at 9:10 a.m., revealed the toggle for the bathroom call system had been fixed the day before. He indicated that if a resident was using that particular restroom and needed help, than the resident would have to verbally call for help. A log was kept at the nursing station for staff to enter maintenance requests which he checks at the beginning of the shift and throughout the day. In addition, he does room rounds daily and facility wide rounds monthly. Review of the nursing station repair request log for February and March 2011 revealed no reference of call light problem in bathroom C-14. During the initial observation of resident #24's room on 3/07/2011 at 12:14 p.m. there was no toggle or call light cord in the resident's bathroom. There were signs posted in the bathroom that stated please call for assistance, "we don't want you to fall". On 3/08/2011 at 11:15 a.m. Licensed Practical Nurse (LPN"BB") was observed to wash her hands in this bathroom. When questioned by the surveyor the nurse stated that there was no way to use the call light in this bathroom. | 2014-01-01 | ||
| 10643 | 10643 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 490 | K | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interviews, the facility failed to be administered in a manner that ensured staff members were trained appropriately regarding the need to clean and disinfect glucometers between each resident. This affected 21 residents currently in the facility who received daily monitoring of blood glucose levels where mult-use glucometers are used. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those 21 residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed from March 8, 2011 until March 10, 2011 when a plan of correction was implemented by the facility to remove the jeopardy situation. Findings include: Interview on 3/8/11 at 1:00 p.m. with the Administrator, Director of Nursing (DON) and the Clinical Education Director revealed that the DON was unaware of the revision to F441 dated July 17, 2009 and was that the DON and the Clinical Education Director were not familiar with the facility Policy for cleaning and disinfecting of the blood glucose monitors. Review of the facility policy Cleaning/Disinfecting Glucometers with creation date of 4/30/10 and fax date of 3/08/11, from the corporate office, revealed that alcohol should never be used, as it can damage the LED (light emitting diode) readout and the machine, if no visible soil is present, should be disinfected after each use following the manufacture direction or wipe with a cloth damped with EPA (environmental protection agency) registered detergent/germicide that has a TB ([MEDICAL CONDITION]), HBV ([MEDICAL CONDITION]),[MEDICAL CONDITION](human immunodeficiency virus) label or dilute beach solution of 1:10 concentration, and allow to self dry. At this time the DON revealed that he had an in-serviced and instructed all professional staff to clean the blood glucose monitors with an alcohol wipe before and after use… | 2014-01-01 | ||
| 10644 | 10644 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 325 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure nutritional parameters were maintained for two (2) residents ("B" and #11) from a sample of nineteen (19) residents. Findings include: 1. Review of the physician orders [REDACTED]. She was ordered Carnation Instant Breakfast 120 milliliters three (3) times a day on 2/22/11. Observation of the lunch meal on 3/08/11 at 12:20 p.m. revealed that resident #24 was served chopped meat, white rice, sweet potatoes, brussel sprouts, a roll, fruit, tea, water and coffee. Interview with Licensed Practical Nurse (LPN) Clinical Manager at that time revealed that the rice was considered to be a fortified food item. The resident was observed to quickly eat the meat, rice and tea but no other food items. No substitutes or second servings were offered. Interview with the resident at that time revealed she did not have much of an appetite and had lost weight since admission to the facility. She decribed herself as a picky eater at times but does like the vanilla drink she receives with her medications. Record review revealed an admission weight, dated 9/22/10, of 178.8 pounds and a height of 61 inches. Following monthly weights were: 10/2010=177 pounds; 12/2010=165 pounds; 1/08/11=155 pounds. Review of the medical record for resident #24 revealed that no care plan had been developed for this resident. There was no individualized plan of care related to nutrition or weight loss for the resident. Interview with the LPN Manager revealed she considered the weight loss for this resident as beneficial. 2. A review of the clinical record of resident #11 revealed that she had experienced significant weight loss as follows: 03/01/2011; Weight: 117 (12.7% loss in 3 months) 01/13/2011; Weight: 127 (5.2% loss in 1 month) 12/20/2010; Weight: 134 (baseline weight) Further record review revealed the resident's care plan regarding the potential alteration in nutrition status had not been revi… | 2014-01-01 | ||
| 10645 | 10645 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 225 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview the facility failed to ensure that an injury of unknown origin was investigated and immediately reported to the State Survey and Certification Agency for one (1) resident ("A") on a sample of thirty (30) residents. The findings include: Review of a Nurse's Note dated 5/22/0 at 5:30 p.m. revealed that resident "A" complained of chest pain since 5/21/09 and had received an antacid and pain medication without relief. The physician was notified and orders were obtained to send the resident to the hospital emergency room for evaluation. Review of a Nurse's Note dated 5/23/09 at 2:15 a.m. revealed the resident returned from the hospital with a [DIAGNOSES REDACTED]. The 24 Hour Report/Change of Condition Report dated 5/22/09 included a notation that the resident had returned to the facility at 2:00 a.m. with a fractured right rib. Interview with the Licensed Practical Nurse Unit Manager (LPN) "EE" on 6/15/09 at 2:05 p.m. revealed she was unaware that the resident had a fractured rib and would obtain the report from the hospital. Review of the Radiologist Report with an order date of 5/22/09 documented there was a subacute [MEDICAL CONDITION] posterior 12th rib. Review of the Minimal Data Set assessment revealed resident "A" had short term memory loss, however interview with the resident on 6/15/09 at 11:30 a.m. revealed the resident was able to state place of residence, day of the week, month and year of admission, and family information. During interview with the resident on 6/15/09 at 3:10 p.m. he/she remember having severe pain in the chest area and he/she was told of the rib fracture a few days ago but could not remember which day. Interview with the Director of Nurses (DON) on 6/16/09 at 7:22 a.m. revealed she was unaware that the resident had a fractured rib and therefore it had not been been investigated or reported to the State Agency. Further interview with the DON on 6/16/09 at 9:30 a.m.… | 2014-01-01 | ||
| 10646 | 10646 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 431 | B | 5ICH11 | Based on staff interview, it was determined that the facility failed to establish a system of records of receipt and disposition of all controlled drugs. The findings include: During an interview with the Director of Nurses, on 6/17/09 at 7:45 a.m., she stated that the facility did not have any system of reconciliation of controlled drugs and the facility relied on proof of use sheets utilized during shift to shift controlled drug counts done by staff nurses. | 2014-01-01 | ||
| 10647 | 10647 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 309 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician's orders for blood glucose monitoring for one (1) resident (#7) and follow up appointments after an injury for one (1) resident (#13) and on a sample of thirty (30) residents. The findings include: 1. Record review revealed resident #7 to have a [DIAGNOSES REDACTED]. In addition to the routine insulin, the resident was to receive additional insulin as needed based on blood glucose monitoring at 6:30 a.m. and 4:30 p.m. Physician orders included to notify the physician for blood glucose values greater than 400. Review of the facility policy [MEDICAL CONDITION] (elevated blood glucose), the clinical record should have included the resident's symptoms, blood sugar results, the resident's oral intake, notification of the physician and family, and the resident's response to treatment. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with Licensed Practical Nurse "EE" on 6/16/09 at 12:30 p.m. confirmed that the physician was not made aware of this elevated blood sugar. Interview on 6/16/09 at 4:00 p.m. with the Director of Nursing revealed the nurse should have documented the blood sugar, the resident's symptoms and that the physician was notified. 2. Review of a Nurse's Note dated 5/22/0 at 5:30 p.m. revealed resident #13 returned to the facility from the emergency room with a [DIAGNOSES REDACTED]. There was no documentation that the resident had a follow up physician visit after this injury. Interview with the Assistant Director of Nurses on 6/17/09 at 8:20 a.m. confirmed that a follow up physician visit had not been conducted. | 2014-01-01 | ||
| 10648 | 10648 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 371 | F | 5ICH11 | Based on observation, record review and staff interview the facility failed to store and prepare food under sanitary conditions for all residents consuming food (total = 187). The findings include: Observation of the kitchen on 6/15/09 at 10:00 a.m. revealed: The microwave was soiled inside with food particles on all sides, particularly the top and bottom. A pan of pureed bread was sitting on top of the stove ledge. The Food Service Director (FSD) confirmed it was for the lunch meal and should be refrigerated or held at 135 degrees Fahrenheit (F). In the dishmachine area the tile floor was wet and soapy. The FSD stated staff washed the floor a few times each day and used a hose with a sprayer attachment. Observation revealed the water from the floor was being sprayed onto clean dished that were stacked on carts. The can opener in the food preparation area had a thick, dark gummy substance built up on the blade. The microwave in the dining room was dirty on all six (6) sides. Observation on 6/16/09 at 7:05 a.m. revealed: Three (3) items in the cooler did not register a temperature of 41 degrees F or less. The facility thermometer was calibrated twice to ensure accuracy. Pork chops were 47 degrees, black eyed peas were 49 and buttermilk was 48 degrees F. These items were in the cooler over eighteen (18) hours. The tile floor throughout the kitchen needed repair including grout cleaning and replacement. Interview with the Administrator and Maintenance Director on 6/17/09 at 9:00 a.m. revealed they were aware of the tile problems but did not have a specific plan for repairs at this time. Review of the Daily Cleaning Assignments for kitchen staff provided by the facility and signed by staff for 5/11/09 to 6/07/09 revealed cleaning the microwave was not listed under any assignments. | 2014-01-01 | ||
| 10649 | 10649 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 364 | E | 5ICH11 | Based on observation, resident and staff interview the facility failed to serve food using methods that conserve the nutritional value for all residents consuming food (total = 187). The findings include: Observation of the kitchen on 6/15/09 at 10:00 a.m. revealed ground pork chops, gravy, potatoes and rutabagas were being held hot on trayline. Interview with the Food Service Director (FSD) at that time revealed staff were served at 11:00 a.m. and residents were served at noon. Observation on 6/16/09 at 7:30 a.m. revealed a large pan of green beans boiling on the stove. The FSD stated the beans were for lunch at noon. At 9:55 a.m. the trayline held chicken stew, mashed potatoes, gravy and beef steak also for lunch. Interview with resident "H" on 6/16/09 at 3:00 p.m. revealed the green beans were always over cooked. | 2014-01-01 | ||
| 10650 | 10650 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 253 | B | 5ICH11 | Based on observation and staff interview the facility failed to provide housekeeping services to maintain a sanitary and comfortable interior related to dirty floors and furniture in need of repair on two (2) of three (3) Wings (East and West) and one (1) of two (2) solariums. The findings include: During intial tour of the East Wing on 6/15/09 at 11:30 a.m. the floors of the hallways were observed to be dirty with a black substance waxed into the tile floor. General observation tour on 6/16/2009 at 9:30 a.m. revealed that the three (3) hallways that make-up the East Wing of the building were in need of stripping and rewaxing. Additional observations at that time: Room 204- The door frame to the bathroom was scuffed and missing paint. The inside of the bathroom door was scuffed and the paint was peeling in a one (1) foot by eight (8) inch section. Room 236- The bedside table for the resident in the second bed was marred and scraped and had missing veneer across the entire front and at the bottom corners. Room 247- The floor was marred with the wax scraped as if someone had pulled something heavy across the floor. Interview with the Administrator on 6/16/2009 at 3:15 p.m. revealed that she was aware the hallways were in need of stripping and waxing. Observation on the West wing on 6/16/09 at 7:25 a.m. revealed the following: Room 302 - Bed A nightstand was missing the trim strip around the top of the stand. Room 326 - The foot board was missing the side strips, exposing bare wood or fiber board. Room 335 - Bed A footboard was scuffed on the edges and was missing the finish. Room 337 - A water stain was on the wall to the right of the air conditioner and was visible from the hallway. One of two (1 of 2) solariums had peeling wallpaper at the air conditioner and window sill. The pink sofa's vinyl was darkened in spots making the sofa appear dirty. One of two (1 of 2) green benches in the hallway had vinyl that had was discolored. Interview on 6/16/09 at 2:00 p.m. with the Maintenance and Housekeeping Supervisors con… | 2014-01-01 | ||
| 10651 | 10651 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 363 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide fruit juice as planned on the menu for breakfast for one (1) resident, resident "D" on a sample of thirty (30) residents. The findings include: Review of the physician orders [REDACTED]. Review of the prepared and planned menu for 6/16/2009 revealed that the resident should have received four (4) ounces of a juice with breakfast. Observation of the resident on 6/16/2009 at 7:50 a.m. revealed that the resident received the pureed food as ordered but not the juice as indicated on the meal plan. The resident told the surveyor that they liked juice. Observation of the resident on 6/17/2009 at 7:40 a.m. revealed that the resident did not receive any juice for breakfast. Interview with Certified Nursing Assistant (CNA) "BB" at that time revealed she did not know why the resident had not received juice. It was observed that other residents in the dining room did receive juice with their breakfast. Review of the resident's diet card did not list juice as a dislike. | 2014-01-01 | ||
| 10652 | 10652 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 372 | C | 5ICH11 | Based on observation and staff interview, the facility failed to ensure refuse containers were in good condition for the garbage compactor. The findings include: Observation on 6/15/09 at 11:45 a.m. revealed the garbage compactor to be dripping a dark liquid from the roller end. The liquid was sufficient in quantity to cause a oily, milky runoff three (3) feet wide by sixteen (16) feet long. Interview on 6/15/09 at 3:35 p.m. with the Maintenance Director confirmed that the compactor was leaking and needed repair. | 2014-01-01 | ||
| 10653 | 10653 | CARTERSVILLE HEIGHTS | 115571 | 78 OPAL STREET | CARTERSVILLE | GA | 30120 | 2010-09-27 | 314 | D | DI8T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined that the facility failed to provide pressure sore treatments as ordered by the physician for two (2) residents (#2 and #6) in a survey sample of eight (8) residents. Findings include: 1. Record review for Resident #2 revealed an 08/13/2010 Minimum Data Set assessment which indicated that the resident had one Stage IV pressure sore, with an open lesion on the foot. The resident's Pressure Ulcer Documentation Form indicated that the resident had a left heel pressure sore. Additionally, the resident's September 2010 treatment record documented that the resident had [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. with Kling every day. However, review of the September 2010 treatment record referenced above revealed no documented evidence to indicate that the dressing change was done on Sunday, 09/26/2010, as ordered. During a treatment observation for Resident #2 conducted on 09/27/2010 at 11:45 a.m., when Treatment Nurse "BB" began the treatment procedure and removed the existing dressing on the resident's left heel pressure sore, this nurse stated that the dressing removed from the left heel wound was dated 9/25/2010, and that the dressing had not been done on 09/26/2010, as ordered. 2. Record review for Resident #6 revealed a 09/02/2010 Minimum Data Set assessment which indicated that the resident had [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. However, review of the September 2010 treatment record revealed no documented evidence to indicate that the dressing was changed on 09/26/2010, as ordered. Additionally, during a treatment observation for Resident #6 conducted on 09/27/2010 at 3:15 p.m., the existing dressing on the upper back of Resident #6 was dated 09/25/2010. During an interview with Treatment Nurse "BB" conducted on 09/27/2010 at 3:15 p.m., this nurse acknowledged that the dressing was not changed on 09/26/2010 as ordered. | 2014-01-01 | ||
| 10654 | 10654 | CARTERSVILLE HEIGHTS | 115571 | 78 OPAL STREET | CARTERSVILLE | GA | 30120 | 2010-09-27 | 309 | D | DI8T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide wound care as ordered by the physician for two (2) residents (#5 and #7) in a survey sample of eight (8) residents. Findings include: 1. Record review for Resident #5 revealed a 07/15/2010 Minimum Data Set assessment which indicated that the resident had no pressure ulcers or stasis ulcers at that time, but did have a [DIAGNOSES REDACTED]. Further record review for Resident #5 revealed a current physician's orders [REDACTED]. However, review of the September 2010 treatment record referenced above revealed no documented evidence to indicate that the treatment was done on Sunday, 09/26/2010. During an interview with Treatment Nurse "BB" conducted on 09/27/2010 at 2:00 p.m., this nurse acknowledged that the treatment was not done on 09/26/2010 as ordered. 2. Record review for Resident #7 revealed a 09/23/2010 Minimum Data Set assessment which indicated that the resident had [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. However, review of the September 2010 treatment record revealed no documented evidence to indicate that the treatment was done on Sunday, 09/26/2010. During an interview with Treatment Nurse "BB" conducted on 09/27/2010 at 2:15 p.m., this nurse acknowledged that the treatment was not done as ordered on [DATE]. | 2014-01-01 | ||
| 10655 | 10655 | FOUNTAINVIEW CTR FOR ALZHEIMER | 115697 | 2631 NORTH DRUID HILLS ROAD N E | ATLANTA | GA | 30329 | 2010-09-21 | 323 | G | GYV611 | Based on resident medical record review, staff interview, facility Investigative Report review, and hospital Discharge Summary review, the facility failed to ensure a safe transfer, per facility policy and the plan of care, for one (1) resident (#1) from five (5) sampled residents. This resulted in actual harm to the resident, with the resident sustaining bleeding lacerations to the left eyebrow area and left side of the forehead, a hematoma on top of the head, and a skin tear on the right hand, with bruising. Findings include: Medical record review for Resident "A" revealed a Care Plan entry dated 05/28/2010 which indicated that resident required the assistance of two (2) persons with total lift transfers. A Nurse's Note of 09/01/2010 timed at 4:00 p.m. documented the nurse had been called to the room of Resident "A" at around 2:35 p.m. by Certified Nursing Assistant (CNA) "CC" and observed the resident with bleeding lacerations to the left eyebrow area and left side of the forehead, a hematoma on top of the head, and an approximate 2 centimeter (cm.) by 2 cm. skin tear on the right hand, with bruising. This Note documented that the physician was notified, Emergency Medical Services was called, and the resident was transported the to the hospital around 3:00 p.m. A review of hospital Discharge Summary record dated 09/13/2010 for Resident "A" revealed documentation that the resident did not receive fractures and had no orbital damage, but had received sutures to the left forehead. The facility conducted an investigation into this resident's injury and obtained a statement from CNA "CC", who was the CNA who had been caring for the resident during the shift at the time of the discovery of the resident's injury on 09/01/2010. CNA "CC" gave a written statement in which she documented that she and another staff member had put Resident "A" in the bed, changed the resident's diaper, then left the room to assist another resident. The CNA documented that the family of Resident "B", the roommate of Resident "A", then came … | 2014-01-01 | ||
| 15 | 15 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 656 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that medication for pain was administered for one of 12 residents(A) and failed to provide wound care for one of 12 residents (B) as care planned. Findings include: 1. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waits until her pain medication runs out to order more. Record review revealed that RA had a care plan since 2/819 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration. The care plan included an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed that there was a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. Record revealed that on 5/24/19 a physician's orders [REDACTED]. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. Therefore, the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. Cross refer to F697 2. Record review revealed that RB had a care plan problem, dated 4/2/19, for receiving treatment with an antibiotic for bilateral [MEDICAL CONDITION]. The care plan problem was updated on 4/29/19 to include the use of an intravenous antibiotic and an intervention for nursing staff to provide wound care as ordered. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left la… | 2020-09-01 |
| 16 | 16 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 684 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that wound treatments were provided as ordered by the physician for one of 12 residents (R B). Findings include: Record review revealed that Resident (R) B had [DIAGNOSES REDACTED]. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., with Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes dared 5/10/19 confirmed that RB reported the use of silver dressings to her lower extremity wounds. During an interview on 6/7/19 at 12:55 a.m., with the Director of Nursing (DON) revealed that she expected licensed nursing staff to obtain a physician's orders [REDACTED]. | 2020-09-01 |
| 17 | 17 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 697 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility policy titled, Obtaining and Receiving Medications from Pharmacy the facility failed to ensure the medication for pain was obtained timely for one of 12 residents (R A). Findings include: The facility had an Obtaining and Receiving Medications from Pharmacy policy. The policy documented that medications that must be reordered by the nurse included controlled substance medications. The policy further documented that Schedule II medications such as [MEDICATION NAME] and [MEDICATION NAME] products required a signed prescription by the physician and should be reordered at least seven days in advance. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waited until her pain medication ran out to order more. Record review revealed that RA had a care plan since 2/8/19 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration with an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed a Physician's order since 2/15/19 for [MEDICATION NAME] 10-325 milligrams (mg) to be administered every six hours for pain. There was also a physician's order since 2/13/19 for [MEDICATION NAME] 10-325 mg to be administered every six hours as needed for pain. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. On 4/23/19 a Physician's order was obtained to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when it was available. 2) Administer [MEDICATION NAME] 10-325 mg every six hours, scheduled and discontinue when the [MEDICATION NAME] became available. 3) Keep the order for [MEDICATION NAME] 10-325 mg every six hours as needed for pain. A review of the (MONTH) 2019 M… | 2020-09-01 |
| 149 | 149 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-02-05 | 725 | F | 1 | 0 | 6UET11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, review of the monthly schedule (needs list), daily assignments, grievances, staff and resident interviews the facility failed to provide adequate staffing to provide care for two out of two residents interviewed R A and R B. The facility census was 76. Findings include: Interview on 2/4/19 at 10:50 a.m. with resident (R) 'A' who stated that the longest she has had to wait for someone to change her brief has been 30 - 45 minutes. Further stated that she hasn't noticed it being on any particular shift or at a certain time of day. RR: Review of Quarterly MDS dated [DATE] revealed resident with BIMS of 13. Interview on 2/4/19 at 10:55 a.m. with the East Hall Unit Supervisor HH who stated that if they have a nurse to call in that they have an on-call schedule for the nurses. Further stated that she is on call this week and that she split a shift last night with another nurse to cover the shift. Further stated if a Certified Nursing Assistant (CNA) calls in they will ask someone from the previous shift to stay over or ask if someone from the on-coming shift can come in early. Stated that they have used CNA's from the hospital when the hospital census is low. HH further stated that they do use agency CNA's and currently have a contract nurse working nights for them. Interview on 2/4/29 at 12:30 with CNA BB stated that they work short staffed at times, but they ask her to work overtime a good bit, because they can't find anyone else to work. She further stated that they post a schedule with vacant positions on it, and staff are encouraged to sign up to work extra shifts, and she tries to work two to three extra shifts a week, because she needs the money. Interview on 2/4/19 at 2:00 p.m. with CNA EE stated that she works agency, but works three to four 12 hour shifts per week at this facility. Interview: 12/4/19 at 2:14 p.m. R 'B' stated that she has had to wait as long as 30 minutes for staff to answer call light to get help … | 2020-09-01 |
| 150 | 150 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-02-05 | 727 | F | 1 | 0 | 6UET11 | > Based on observation, record review, review of facility daily nurse staff posting and staff interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight (8) consecutive hours a day, for seven (7) days a week for three (3) days (1/2/19, 1/26/19 and 2/4/19) of a 30 day review. The census was 76. Findings include: Observation during initial tour on 2/4/19 at 10:22 a.m. revealed no Registered Nurse (RN) on duty, other than the Director of Nursing. Review of past 30 days of Daily Nurse Staffing posts, revealed there was no RN on duty for the minimum eight (8) consecutive hours per day on 1/2/19, 1/26/19 and 2/4/19. Review of the Daily Nurse Staffing posted for 1/2/19, revealed no RN worked in the building for eight (8) consecutive hours for that date. Review of the Daily Nurse Staffing posted for 1/26/19, revealed no RN worked in the building for eight (8) consecutive hours for that date. Patient per day (PPD) for 1/26/19 was below the State requirement. Review of the Daily Nurse Staffing posted for 2/4/19, revealed no RN worked in the building for eight (8) consecutive hours for that date. Interview on 2/5/19 at 1:30 p.m. with Director of Nursing (DON) stated that she looks at the Daily Nurse Staffing posting and hasn't noticed any days that an RN was not on duty, for eight consecutive hours. She stated that she does not make any revisions to the Daily Nurse Staffing posting once the unit clerk has it posted. She verified that on 1/2/19 and 1/26/19 there was not a RN coverage for eight (8) consecutive hours and on 2/4/19, there was not a RN for eight (8) consecutive hours. She further stated that the RN Supervisor was called in to cover the floor for staff call-outs on 2/19. | 2020-09-01 |
| 151 | 151 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2018-04-18 | 609 | D | 1 | 0 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, staff interviews and family interview the facility failed to report and investigate an injury of unknown origin related to a burned area on the upper left chest of Resident #1 (R#1). The sample was four (4) residents. The facility census was seventy-seven (77). Findings include: Record review for R#1 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. During an observation conducted on 4/18/18 at 10:25 a.m. of R#1 an area of burned, discolored skin was noted on her left upper chest. She was sitting in the dining room for activities and her shirt was positioned slightly away from her left upper chest. The area was one inch long and three quarters inch wide with 2 small pink superficial open areas. The area was clean, dry, without drainage or redness. R#1 did not show any signs of discomfort. R#1 was confused and did not express herself clearly and could not explain anything about this burned area. Review of Nurse's Notes dated 4/14/18, time 20:35, revealed as follows: Resident noted to have an old burn mark in the shape of a curling iron on her left collar bone area. At least 3 days old it is beginning to peel off in areas. Resident is unable to say how it happened and expresses no c/o pain or (sic) from it. Resident's responsible party present and aware. Nurses notes revealed the Physician was notified of findings on 4/15/18 at 7:31. An Incident Report dated 4/15/28, time 8:14 revealed the same Nursing documentation as the above Nurse's Note. During an interview conducted on 4/18/18 at 1:30 p.m. Certified Nursing Assistant (CNA) CC revealed she had showered R#1 on 4/12/18 and she had no burn, blister or mark on her left upper chest. On 4/16/18 when she gave R#1 a shower she had recorded on the shower skin inspection sheet that R#1 had a blister on her upper left chest. Review of Body Audit Form, completed by the night shift working the night of 4/13/18 and … | 2020-09-01 |
| 152 | 152 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2018-04-18 | 610 | D | 1 | 0 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, staff interviews and family interview the facility failed to investigate an injury of unknown origin related to a burned area on the upper left chest of Resident #1 (R#1). The sample was four (4) residents. The facility census was seventy-seven (77). Findings include: Review of Abuse Prohibition Policy and Procedure effective date 12/20/17- Investigation of injuries of unknown source. Interviews will also be conducted when a resident has an injury from an unknown source. Signed statements will be gathered from : Staff who cared for resident just prior to and just after injury; Other reliable residents in the vicinity nearby area; Family or visitors who may have noticed anything. Once an injury of unknown source has been identified, staff will observe resident and watch behavior to see if the source of injury can be identified based on the resident's behavior (i.e. how they move their arms, walk, push a wheelchair, behave, etc.) The chart will be reviewed for any pertinent information that could help the investigation. If the abuse resulted in an injury, the facility will report to appropriate agencies no later than 2 hours after the allegation is made. Record review for R#1 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. During an observation conducted on 4/18/18 at 10:25 a.m. of R#1 an area of burned, discolored skin was noted on her left upper chest. She was sitting in the dining room for activities and her shirt was positioned slightly away from her left upper chest. The area was one inch long and three quarters inch wide with 2 small pink superficial open areas. The area was clean, dry, without drainage or redness. R#1 did not show any signs of discomfort. R#1 was confused and did not express herself clearly and could not explain anything about this burned area. Review of Nurse's Notes dated 4/14/18, time 20:35, revealed as follows: Resident noted t… | 2020-09-01 |
| 176 | 176 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2018-04-17 | 550 | D | 1 | 0 | TFUK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, family interview and staff interview, the facility failed to ensure that dignity was maintained for one (1) resident (R) (R#A) from a sample of six (6) residents. The facility census was one hundred thirty-two. Cross refer to F 565 Findings include: An interview conducted on 4/11/18 at 2:01 p.m. with a family member of R#A revealed she had requested several times for her aunt to be dressed properly when in or out of the bed, during the day and night. The family member revealed she has found her aunt in bed, both at night and during the day for naps, with no pants or pajama bottoms on and has requested the Administrator, the Director of Nurses (DON), Social Service Director, Nurses and CNA's do something about this. Continued interview on 4/17/18 at 3:20 p.m. revealed she and the other family members do not want R#4 in bed or out without pants or pajamas bottoms on. Their aunt, when she was younger and alert, was modest and concerned about her appearance and would not go anywhere without the proper clothing and now that she is [AGE] years old gets cold easily. She would be embarrassed if she had to go to the hospital and knew she was only wearing a shirt and a brief, and she would be cold as well. The family would be very upset by this. Observations for R#A on 4/11/18 at 1:30 p.m. revealed she was in a wheelchair in the dining room wearing a T shirt, a pink over shirt, and matching pink pants. She was wearing non- skid footwear and had no signs of incontinence. On 4/11/18 at 4:45 p.m. an interview with Licensed Practical Nurse EE revealed the day shift Certified Nursing Assistants (CNA's) had put R#A to bed for an afternoon nap at 2:00 p.m. On 4/11/18 at 4:45 p.m. R#A was observed in bed wearing the same T shirt and pink over shirt she was wearing for earlier observations. The matching pink pants were folded twice and were on a chair in the corner of the room out of reach of the bed. The wheel chair was … | 2020-09-01 |
| 177 | 177 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2018-04-17 | 565 | D | 1 | 0 | TFUK11 | > Based on observation, record review and staff and family interview, the facility failed to resolve grievances filed for one resident (R), (R#4) from a sample of six residents. The facility census was one hundred thirty-two. Cross refer to F 355 Findings include: A family interview for R#A on 4/11/18 at 2:01 p.m. revealed she has discussed with the facility the family's wishes for R#A to wear proper clothing at all times. The family member revealed she had found R#A with out pants on when in bed, clothed only in a brief and shirt, or brief and pajama top at night, more than once. The family member revealed she has explained to the facility that the resident should wear pants when in bed during the day for naps and wear pajama bottoms at night when in bed. She revealed she brings home the resident's laundry and knows she has not been properly dressed when she finds 2 pajama tops and one or no pajama bottoms. She was unable to give dates and times when she has found the resident in bed with no pants on but it has happened more than once and she has found this recently. The family member confirmed she had expressed the family's wishes to the Administrator by email, at care plan meetings, in grievances and individually to Certified Nursing Assistants and Nurses over the last year, with improvement sometimes for a brief period, possibly a week then she will find her aunt without pants or pajama bottoms on in bed again. She revealed she has also repeatedly asked for lotion or oil to be applied to her aunt's skin every day and when laundering the clothing she is aware that this is not being done because the clothing sometimes has an excessive amount of dry skin on the inside. She revealed she intermittently also finds the residents pants and pajama bottoms soaked with an excessive amount of urine, like she had not received incontinence care at regular intervals and has included this in discussions, emails, and grievances without results. Record review of Care Plan Conference Summary, dated 6/20/17 revealed the family m… | 2020-09-01 |
| 178 | 178 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2018-04-17 | 584 | E | 1 | 0 | TFUK11 | > Based on observations, family interview and staff interview the facility failed to provide a clean, comfortable, homelike environment in two of three resident shower rooms. There were one hundred two (102) residents (R) potentially affected by the lack of shower room sanitation in the third and fourth floor showers. The facility census was one hundred thirty-two (132). Findings include: An observation of the third floor shower room was conducted on 4/11/18 at 5:45 pm. There were pieces of a brown substance on the floor, the room smelled of BM and there were 4 wet gloves and 3 wet towels on the floor. An interview on 4/11/18 at 3:20 p.m. was conducted with a family member of R#[NAME] The family member revealed she finds the showers dirty with trash on floor, wet towels and brown smears of bowel movement (BM) on the floor and smelling like BM whenever she has ever looked at them. An interview with the Unit Manager of the third floor on 4/11/18 at 5:50 p.m. revealed the housekeeper is expected to clean shower before they go home, and the Certified Nursing Assistants (CNA's) are expected to pick up the trash, wet linens and clean up any smears or stains of body substances before showering the next resident. An interview was conducted with R#D on 4/17/18 at 10:10 a.m. R#D revealed she has not made a formal complaint but she and others on her floor do not get to the shower room much because for the last 2 months the residents have been told intermittently that the shower drain was plugged and given bed baths instead. R#D revealed when she has had a shower the room was not clean and sanitary, with trash and dirty linen on floor first thing in the AM, so she knows it was probably from the day before and sometimes there are stains and smears on the floor. R#D revealed when she has been in the shower recently the drain was not plugged. An observation of the fourth floor shower room on 4/17/18 at 10:15 a.m. revealed pink and brown stains and standing water on a white plastic sheet suspended under the shower bed, and a red… | 2020-09-01 |
| 179 | 179 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2018-04-17 | 606 | E | 1 | 0 | TFUK11 | > Based on record review, review of facility policy and Administrator interview the facility failed to ensure Georgia Crime Information Center background checks were completed on seven (7) of eighteen (18) employees hired during the month of October, (YEAR). The facility census was one hundred thirty-two (132) residents. Findings include: During a record review of employee files for the dietary department a failure to provide a Georgia Crime Information Center (GCIC) background check was identified related to the Dietary Manager, hired on 10/19/17. The Dietary Manager had federal and county background screening. A review of facility policy titled Georgia Credentialing Checklist dated 12/27/17 revealed a Georgia Statewide Consent was required to be scanned and uploaded for each employee. An interview with the Administrator on 4/17/18 at 2:50 pm revealed a computer glitch with the outside vendor had caused the GCIC for the Dietary Manager's back ground screening to be missed. At this time all background check records for any new hires during the month of (MONTH) were requested. A review background checks for the eighteen employees hired by the facility during the month of (MONTH) (YEAR), revealed incomplete background checks, missing the GCIC screening, for seven of the eighteen employees. The seven incomplete files included county and federal back ground screening. Review of Grievances, Entity Reported Incidents and Resident Council Minutes for 10/1/2017 through 4/17/18 revealed the names of the seven employees without GCIC screening had not been mentioned. An interview on 4/17/18 at 4:30 p.m. with the Administrator revealed eighteen staff were hired in October. The company that is used to provide background checks had a computer glitch in October. The absence of a background GCIC had been discovered by the facility for the Dietary Manager and the background check company had been instructed to check for others. No one at the facility followed up on this and seven staff of the eighteen hired in (MONTH) did not hav… | 2020-09-01 |
| 180 | 180 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2017-05-14 | 252 | D | 1 | 0 | S6LJ11 | > Based on observations and interviews, it was determined that the facility failed to provide a resident environment that was free from offensive odors in two of three floors. This failure resulted in no actual harm with the potential for minimal harm. Findings include: Observations conducted during the initial tour on 5/11/2017 between 3:15 p.m. and 4:30 p.m. on all three resident floors revealed strong urine odors around rooms 301 through 304 and fecal and urine odors around rooms 427 through 430. Observations conducted of resident rooms and bathrooms on 5/12/2017 between 9:30 a.m. and 12:30 p.m. revealed the following: In the bathroom of room 318 the toilet was found to be off center on the floor and old chaulk subssstance was not around the base but in an area where the toilet base originally was located. Chaulk had been applied to the toilet base where it currently sits in an off center position and the old chaulk had never been removed. There were yellow stains around the base and a strong urine odor. In room 328 soiled bed pads were noted in the trash can with a distinct urine odor coming from them. In the bathroom of room 418 odors were noted with a brown substance around the edges of the toilet. In the bathroom of room 417 a brown smelly substance was noted around the toilet seat. A brown residue was observed in the sink in the room. In the bathroom of room 430 a brown substance was noted around the toilet seat with a distinct odor of feces. Interview with family member of R#1 on 5/13/2017 at 11:30a.m. revealed that the bathroom of R#1 is smelly and rarely cleaned and there are odors all over the facility. She stated that she was very unhappy with the lack of cleaning in the room of R#1. Interview with R#3 on 5/13/2017 at 10:45a.m. revealed the staff don't clean the bathrooms the way they should or empty the trash cans as often as they should. Interview with R#4 on 5/14/2017 at 9:05 a.m. revealed that the staff don't clean the bathrooms very well and leave smelly items in the bathrooms and trash cans. Ob… | 2020-09-01 |
| 181 | 181 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2017-05-14 | 253 | E | 1 | 0 | S6LJ11 | > Based on general observations of the facility and interviews, it was determined that the facility had failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on two (2) of three (3) floors. Findings include: Observations conducted of resident rooms and bathrooms on 5/12/2017 between 9:30 a.m. and 12:30 p.m. revealed the following: In the bathroom of room 318 the toilet was found to be off center on the floor and old chaulk subssstance was not around the base but in an area where the toilet base originally was located. Chaulk had been applied to the toilet base where it currently sits in an off center position and the old chaulk had never been removed. There were yellow stains around the base and a strong urine odor. In the bathroom of room 321 an uncovered bed pan was noted on the floor. In the bathroom of room 322 a urine specimen collection pan was noted on the floor uncovered with a brown substance around the edges. In the bathroom of room 325 an uncovered urinal was noted on the toilet tank. The toilet was noted to be running with a broken handle noted. In the bathroom of room 324 an uncovered urinal was noted on the toilet tank. In room 328 soiled bed pads were noted in the trash can with a distinct urine odor coming from them. In the bathroom of room 418 odors were noted with a brown substance around the edges of the toilet. In the bathroom of room 417 a brown smelly substance was noted around the toilet seat. A brown residue was observed in the sink in the room. In the bathroom of room 422 an uncovered specimen collection device was noted on the floor. In the bathroom of room 421 a bedpan was noted on the floor next to the toilet with dirty tissue in it. In the bathroom of room 426 a bedpan was noted on the floor with a urinal in it and both were uncovered. Another uncovered urinal with a small amount of urine was noted on the other side of the toilet on the floor. Yet another urinal was noted uncovered on the toilet tank with a small am… | 2020-09-01 |
| 182 | 182 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2017-05-14 | 441 | D | 1 | 0 | S6LJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations the facility failed to store bed pans and urinals in a sanitary manner on two (2) of three (3) floors. The facility census was one hundred thirty six (136) residents. Findings include: Observations conducted of resident rooms and bathrooms on 5/12/2017 between 9:30 a.m. and 12:30 p.m. revealed the following: In the bathroom of room [ROOM NUMBER] the toilet was found to be off center on the floor and old chaulk subssstance was not around the base but in an area where the toilet base originally was located. Chaulk had been applied to the toilet base where it currently sits in an off center position and the old chaulk had never been removed. There were yellow stains around the base and a strong urine odor. In the bathroom of room [ROOM NUMBER] an uncovered bed pan was noted on the floor. In the bathroom of room [ROOM NUMBER] a urine specimen collection pan was noted on the floor uncovered with a brown substance around the edges. In the bathroom of room [ROOM NUMBER] an uncovered urinal was noted on the toilet tank. In the bathroom of room [ROOM NUMBER] an uncovered urinal was noted on the toilet tank. In the bathroom of room [ROOM NUMBER] an uncovered specimen collection device was noted on the floor. In the bathroom of room [ROOM NUMBER] a bedpan was noted on the floor next to the toilet with dirty tissue in it. In the bathroom of room [ROOM NUMBER] a bedpan was noted on the floor with a urinal in it and both were uncovered. Another uncovered urinal with a small amount of urine was noted on the other side of the toilet on the floor. Yet another urinal was noted uncovered on the toilet tank with a small amount of what appeared to be urine in the bottom. In the bathroom of room [ROOM NUMBER] an uncovered urinal was noted on the toilet tank with what appeared to be a small amount of urine in the bottom. Observation on 5/14/2017 at 9:00 a.m. revealed house keeping staff actively cleaning rooms and bathrooms that were reporte… | 2020-09-01 |
| 185 | 185 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-07-10 | 609 | D | 1 | 0 | UF4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to ensure an injury of unknown origin was reported to the State Agency in a timely manner for one residents (R) (#14) of seven residents reviewed for reporting requirements. Findings include: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIM's) score of 0 which indicates severe cognitive impairment. Section G0400 Functional Limitations in Range of Motion indicated no impairment of the upper extremities. The resident requires extensive assistance with bed mobility and transfers. Review of the Electronic Medical Record (EMR) dated 5/13/19 revealed the resident complained of pain in the right arm/shoulder x-ray revealed a right clavicle fracture with severe [MEDICAL CONDITION] changes and bony demineralization and [MEDICAL CONDITION]. The document titled SHC Medial Partners dated 5/13/19 by the Nurse Practitioner (NP) noted: Chief Complaint/History of Present Illness; shoulder pain, patient noted with acute onset right shoulder pain today. Unable to lift or move arm without pain. X-ray done showing overlapping acute distal clavicular fracture. Family notified, and request ER (emergency room ) transfer. Mechanism of injury- unknown. Plan: X-ray reviewed: Bony demineralization. Slightly angulated, slightly overlapping acute distal clavicular fracture. Severe [MEDICAL CONDITION] changes at the glenohumeral joint. Will transfer to ER for further evaluation. No reported hx (history) of recent fall or trauma to right arm. Follow up as needed upon return to the facility. Review of a mobile radiology report dated 5/13/19 at 3:04 p.m. revealed bony demineralization. Slightly angulated, slightly overlapping acute distal clavicular fracture. Severe [MEDICAL CONDITION] changes at the glenohumeral joint. Review of the SNF/NF to Hosp… | 2020-09-01 |
| 186 | 186 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-07-10 | 656 | J | 1 | 0 | UF4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of facility policy titled Comprehensive Care Plans and staff interviews, the facility failed to develop a person-centered comprehensive care plan with interventions that specified the need for monitoring for a resident with side rails, assessment of the need for side rails, alternatives to side rails that had been attempted, education of the family member requesting the side rails, and the increased risk of using an air mattress with side rails for one resident (R) (#23) of three residents reviewed for the use of side rails with air mattresses. On 7/8/19 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Social Service Director were informed of the Immediate Jeopardy (IJ) on 7/8/19 at 12:45 p.m. The noncompliance related to the IJ identified to have existed on 4/1/19 when R#23 was found with her head and neck entrapped between a side rail and air mattress. The IJ is outlined as follows: 1. R#23 had an order for [REDACTED]. The manufacture's recommendation per the facility was not to use side rails with an air mattress. The side rails were not removed until 4/8/19 after the family agreed to have them removed. The resident remained in the facility with side rails in place after sustaining another fall on 5/28/19. The air mattress was removed instead of removing the side rails. 2. Record review revealed that on 2/3/19, R#24's leg was caught in the side rail. X-rays were completed at the time of the incident and revealed no injuries. The Physician discontinued the side rails as an enabler on 4/11/19. An assessment was completed on 4/16/19 and revealed the residents side rails were not indicated and gave no reason for use. However, R#24 was observed to still have half side rails in use and an air mattress in place on 6/25/19 and 6/27/19. The IJ was… | 2020-09-01 |
| 187 | 187 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-07-10 | 700 | J | 1 | 0 | UF4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, facility and hospital clinical record review, review of the facility policy titled Bed Safety, and review of the Food and Drug Administration (FDA) guidelines titled Recommendations for Health Care Providers about Bed Rails, the facility failed to provide an environment free from the risk of entrapment within the side rail or between the side rail and air mattress for two residents (R) (#23 and #24) of three residents reviewed for the use of side rails with air mattresses. On 7/8/19 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Social Service Director were informed of the Immediate Jeopardy (IJ) on 7/8/19 at 12:45 p.m. The noncompliance related to the IJ identified to have existed on 4/1/19 when R#23 was found with her head and neck entrapped between a side rail and air mattress. The IJ is outlined as follows: 1. R#23 had an order for [REDACTED]. The manufacture's recommendation per the facility was not to use side rails with an air mattress. The side rails were not removed until 4/8/19 after the family agreed to have them removed. The resident remained in the facility with side rails in place after sustaining another fall on 5/28/19. The air mattress was removed instead of removing the side rails. 2. Record review revealed that on 2/3/19, R#24's leg was caught in the side rail. X-rays were completed at the time of the incident and revealed no injuries. The Physician discontinued the side rails as an enabler on 4/11/19. An assessment was completed on 4/16/19 and revealed the residents side rails were not indicated and gave no reason for use. However, R#24 was observed to still have half side rails in use and an air mattress in place on 6/25/19 and 6/27/19. The IJ was related to the facility's noncompliance with the program requir… | 2020-09-01 |
| 188 | 188 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-07-10 | 842 | D | 1 | 0 | UF4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility policy titled Neurological Evaluation/Monitoring, and staff interviews, the facility failed to document neurological assessments related to an unwitnessed fall for two residents (R) (#27 and #31) of four residents reviewed for falls. Findings include: Review of the facility policy titled Neurological Evaluation/Monitoring revised 11/12/18 revealed neuro (neurological) checks will be performed using the Neurological Evaluation Flow Sheet for a full 72 hours and placed in the medical record. The neuro checks will be performed every 15 minutes x 4 check, every 30 minutes x 4 check and every 1-hour time x 4 followed by 72 hours q (every) shift assessment and documentation. 1. Review of the face sheet revealed R#27 was admitted to the facility on [DATE] for rehabilitation following a stroke. Her admitting [DIAGNOSES REDACTED]. Review of the SBAR (Situation Background Assessment and Response) Communication Form dated 6/25/19 at 12:05 a.m. revealed R#27 had a fall on 6/24/19 at 5:00 p.m. when attempting to transfer unassisted. The resident was experiencing slurred speech and left facial drooping. The resident was sent to the emergency room (ER) for evaluation. There was no documented evidence of post fall neurological assessments. Review of the hospital records dated 6/25/19 revealed resident arrived at the ER with clear speech. Resident stated she requested pain medication along with her night time medications and she thinks that is why she had slurred speech. CT and X-ray reports of left side of body were negative. Physician requested MRI for further evaluation, but resident refused. 2. Review of the clinical record revealed R#31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed R#31 had an unwitnessed fall without injury on 6/23/19 at 7:35 p.m. There was no evidence of documentation of post fall neurological assessments. Interview with … | 2020-09-01 |
| 218 | 218 | SIGNATURE HEALTHCARE OF SAVANNAH | 115120 | 815 EAST 63 STREET | SAVANNAH | GA | 31405 | 2019-07-18 | 656 | E | 1 | 0 | LBOB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to follow the care plan for weekly skin checks for three of five residents (R#2, R#4 and R#5) and failed to develop a care plan for behaviors for two of five residents (R#4, R#5) with known behaviors. Findings include: 1.) R#2 was initially admitted with [DIAGNOSES REDACTED]. Review of R#2's care plan revealed planning for weekly skin checks on admission beginning 5/10/19. Review the of 'Weekly Skin Integrity Evaluation's' revealed that R#2 has received two 'Weekly Skin Integrity Evaluation's ' one on 6/24/19 and one on 7/15/19. Review of the 'Weekly Skin Integrity' Evaluation' completed on 6/24/2019 thirteen days after her re-admission. The next 'Weekly Skin Integrity Evaluation' was completed on 7/15/19, three weeks after the last skin evaluation. 2 [NAME]) Resident #4 admitted [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Review of Section E: Behaviors revealed no behaviors have been recorded for this resident. Review of Section G: Functional Status revealed R#5 requires extensive or total assistance for all ADL's except walking, which did not occur, and locomotion on the unit. Resident is able to use a wheelchair with supervision. Review of R#4's Care Area Summary reveals care planning for Cognition, Communication, ADL's, Falls, Nutrition, and pressure Ulcer Prevention. Review of R#4's care plan also revealed planning dated 5/9/19 for Head to toe skin checks weekly. Special Instructions: complete non-pressure observation or wound management form if appropriate. Review of Progress Notes revealed there was not any evidence of documentation entered from 6/5/19 through 7/17/19 for weekly skin checks. 2 B.) Observation on 7/17/19 at 12:40 p.m. of R#4 in her wheelchair in the dining room. Resident appeared to have s… | 2020-09-01 |
| 219 | 219 | SIGNATURE HEALTHCARE OF SAVANNAH | 115120 | 815 EAST 63 STREET | SAVANNAH | GA | 31405 | 2019-07-18 | 740 | D | 1 | 0 | LBOB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews, and clinical record reviews, it was determined that the facility failed to ensure that two (2) of five sampled residents (R) #4 and R#5 received necessary behavioral health services to address known behaviors. The findings included: 1. Review of the medical record for R#4 revealed that the resident was admitted with [DIAGNOSES REDACTED]. Review of R #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#4 was assessed under Section E: Behaviors as having exhibited no behavioral symptoms during that review period. R#4 had a Brief Interview of Mental Status (BIMS) score of 05 indicating significant cognitive impairment. Review of R#4's Care Area Assessment (CAA) conducted during her Annual MDS Assessment on 4/10/19 revealed the resident did not trigger for Behavioral Symptoms and was not care planned for them. Review of Section N: Medications revealed the resident received no antianxiety, antidepressant or antipsychotic medications during the seven day look back periods of both assessments and received no psychological therapy. Review of all MDS Assessments for this resident beginning with the admission assessment dated [DATE] revealed no behavioral symptoms were noted. Review of Section N: Medications revealed that the resident had received no antianxiety, antidepressant or antipsychotic medications since admission and she has received no psychological therapy. Review of R#4's Medication Administration Record 6/16/19 through 7/16/19 revealed no behaviors or behavioral symptoms recorded. Review of R #4's clinical Progress Notes revealed no documentation of behaviors or behavioral symptoms. Review of R#4's clinical 'Weekly Skin Integrity' Evaluation' dated 7/12/19 and the 'Weekly/Monthly Summary' for all shifts, dated 7/14/19 revealed no notations of any injuries or bruises and no behaviors or behavioral symptoms. Review of the most recent 'C.N.[NAME] Skin Care Alert' dated 7/16/19 revealed n… | 2020-09-01 |
| 220 | 220 | SIGNATURE HEALTHCARE OF SAVANNAH | 115120 | 815 EAST 63 STREET | SAVANNAH | GA | 31405 | 2019-07-18 | 842 | E | 1 | 0 | LBOB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure that documentation was complete and accurate for three of five residents (R#2, R#4, R#5) by failing to document weekly skin checks, wounds, and skin tear, and reddened area. Findings include: 1. R#2 was initially admitted [DATE] with [DIAGNOSES REDACTED]. Review of R#2's care plan revealed planning for weekly skin checks on admission beginning 5/10/19. Review the of 'Weekly Skin Integrity Evaluation's' revealed that R#2 has received two 'Weekly Skin Integrity Evaluation's ' one on 6/24/19 and one on 7/15/19. Review of the 'Weekly Skin Integrity' Evaluation' completed on 6/24/2019 revealed no concerns but was completed on 6/24/19, thirteen days after her re-admission. The next 'Weekly Skin Integrity Evaluation' was completed on 7/15/19, twenty one days after the last skin evaluation and revealed no concerns. 3. R#3 admitted with [DIAGNOSES REDACTED]. Observation on 7/16/19 at 1:42 p.m. of resident in her room revealed R#3 is up in her wheelchair, looked confused. Resident has significant purple, blue-black and red bruising on both the left and right forearms and purple bruising in the of the right antecubital fossa. Review of R#3's Admission assessment dated [DATE] and completed by LPN GG revealed no documentation of bruising on forearms and antecubital fossa or other concerns with skin integrity. Review of the 'Facility Event Summary' dated 6/16/19 through 7/17/19 revealed R#3 had a skin tear to her chest documented on 7/10/19. No additional 'Event' documented for observed additional existing skin tear or new skin tear, both observed by surveyor on 7/16/19. Interview on 7/16/19 with LPN GG at 4:24 p.m. When asked why she did not document the R#3's skin tears and bruising on the Admission Assessment, LPN GG revealed that she thought those issues were documented by the CNA's when they did their skin assessments. The 'Admission Assessment' was to document things l… | 2020-09-01 |
| 238 | 238 | NURSE CARE OF BUCKHEAD | 115129 | 2920 PHARR COURT SOUTH NW | ATLANTA | GA | 30305 | 2017-05-21 | 241 | E | 1 | 0 | WJQH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and interviews the facility failed to serve residents their meal trays at the same table at the same time, failed to assist the residents to eat leaving their food in front of them, and failed to assist residents to consume their food in a dignified manner for one resident (R#5) and three randomly observed residents from a total of 16 residents in the dining area on the 5th floor. Findings include: 1. Review of the medical record for R#5 revealed a [DIAGNOSES REDACTED]. The resident was also assessed as requiring one person assist for eating. Observation on 5/20/17 at 12:28 p.m. of the 5th floor dining area revealed resident lunch trays were being delivered. The lunch trays were first distributed to the dining room on the unit, then Certified Nursing Assistants (CNAs) passed lunch trays to the three halls on the unit. The 5th floor dining room was located behind the nursing station with two doorways into the room. The dining room was long in shape with windows facing the outside, on one end of the room was a television (TV), and at the other end of the room was a half-moon table with the circle part against the wall. Other tables in the dining room were square in shape, allowing four settings at each table. The dining room had two rows of tables. Most of the tables were along the wall of windows, against the wall allowing only three residents to a table. The side of the room next to the nursing station allows room for four residents to a table, however there is only three tables on that wall due to the doors and the wall space. There were 16 residents in the dining room and three staff assisting the residents (leaving staff to serve and assist the other 36 residents on the halls of the 5th floor). Observation on 5/20/17 at 12:28 p.m. of R#5 revealed that he was sitting at a table in the dining area on the 5th floor in a high back wheelchair. Sitting next to R#5 was female resident who was calling out in the room for so… | 2020-09-01 |
| 239 | 239 | NURSE CARE OF BUCKHEAD | 115129 | 2920 PHARR COURT SOUTH NW | ATLANTA | GA | 30305 | 2017-05-21 | 252 | D | 1 | 0 | WJQH11 | > Based on observations and interview the facility failed to ensure resident furniture was maintained properly to provide home like environment on one floor (5th floor) of four resident floors. Findings include: Observation on 5/20/17 at 12:28 p.m. of the 5th floor dining room chairs revealed that they had wooden legs and arms. The dining chairs were worn without the finish on the legs and arms. Observation on 5/20/17 at 12:40 p.m. of room 525 (room of R#5) revealed a built-in cabinet to the right of the doorway. The cabinet was topped with Formica with approximately a one inch edge, the edge nearest to the doorway revealed the Formica was broken and removed exposing a long narrow opening, with jagged edges. Interview with the family member of R#5 on 5/20/17 at 1:15 p.m. revealed that one time they came to see R#5 and they found a scraper that maintenance had used and left at the beside. The family also stated that the patches in the ceiling had not painted for a long time, and that the cabinet in the room (525) needed repairs. Observation on 5/20/17 of room 510 revealed the night stand in the room was marred, with the furniture finishing worn off. | 2020-09-01 |
| 240 | 240 | NURSE CARE OF BUCKHEAD | 115129 | 2920 PHARR COURT SOUTH NW | ATLANTA | GA | 30305 | 2017-05-21 | 314 | D | 1 | 0 | WJQH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interviews the facility failed to ensure that pressure ulcer dressings were changed as physician ordered to promote healing for one resident (R#6) from a sample of 12 resident with a pressure ulcers. Findings include: Observation on 5/21/17 at 2:45 p.m. of R#6 with the Licensed Practical Nurse (LPN) CC and wound treatment nurse present in the room revealed that the pressure ulcer dressing on the resident's left foot had a date of 5/18/17. Continued observation of the pressure ulcer revealed a dark color area on the inner aspect of the bottom of the foot/heel about the size of a half dollar. The skin was dry and intact. Review of the physician order [REDACTED]. Cleanse wound with normal saline. Pat dry. Apply [MEDICATION NAME] to wound bed cover with 4x4 gauze then dry dressing. Review of the Treatment Administration Record (TAR) revealed no evidence by signature that the pressure ulcer treatment was completed on 5/16/17, 5/19/17 and 5/20/17, therefore validation that the dressing dated 5/18/17, was the last dressing change completed. Interview on 5/21/17 at 2:45 p.m. with LPN CC revealed that there are two treatment nurses and they were alternating weekends of work. LPN CC could not explain why the dressing was dated on 5/18/17, as she did not do that dressing change and she did not know what happened. Interview on 5/21/17 at 2:45 p.m. with LPN AA revealed that the skin had never broke open and the wound was stable. | 2020-09-01 |
| 241 | 241 | NURSE CARE OF BUCKHEAD | 115129 | 2920 PHARR COURT SOUTH NW | ATLANTA | GA | 30305 | 2017-05-21 | 441 | E | 1 | 0 | WJQH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and interviews the facility failed to prevent the likelihood of cross contamination for eight residents (R#4, R#5, R#6, aa, bb, cc, dd', and ee) including failure to wear isolation Personal Protective Equipment, wash hands, sanitize a blood sugar machine and failed to cap feeding tubes from a sample of 12 residents. Findings include: 1. Observation on 5/20/17 at 12:00 p.m. of R#6 revealed the resident was lying in bed, the resident had a tracheostomy (trach-stoma in the trachea to breathe through) collar, receiving continuous oxygen (O2) via the trach collar, and a gastrostomy ([DEVICE], a tube inserted into the stomach to provide nutrition ) feeding of [MEDICATION NAME] 1.5 tube feeding formula. Observation of the label on the bottle of [MEDICATION NAME] 1.5 tube feeding revealed it was hung on 5/19/17 at 6:00 a.m., and the bottle had 650 cubic centimeters (cc) still inside. Attached to the [MEDICATION NAME] was a Kangaroo bag with a clear liquid fluid in it, which appears to be water however there is no label to indicate what the fluid is, when it was hung, or who hung it, with 400 cc of fluid in the bag. Continued observation revealed the tubing used to administer the tube feeding was not labeled with date it was hung. In addition, the tubing for the [MEDICATION NAME] tube feeding and the fluid in the Kangaroo bag was draped over the pump pole, uncapped and open. A 60 cc syringe was hanging on the pole in a plastic bag, undated, the used syringe was not opened and pulled apart, there was no evidence of moisture or water in the bag, the cap of the syringe was inside the bag but not on the end of the syringe and the syringe had tube feeding colored substance on the end of the tip, as if the syringe had not been cleaned after the last use. Further observation of R#6 revealed the O2 concentrator had a humidifier water bottle on the back of the machine, without a label indicating when it was opened. Observation of the re… | 2020-09-01 |
| 317 | 317 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2019-06-28 | 580 | D | 1 | 0 | EDYH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review the facility failed to notify the physician and/or the Responsible Party (RP) for two residents out of five, Resident (R)#5 and R#16, after significant change in medical conditions occurred with each resident. Progress note review revealed R#5 presented concerning vital signs on [DATE] at 10:33 a.m. and was discharged to the hospital on [DATE] at 8:37 p.m. Further review of the Progress notes and multiple interviews with facility personnel, including R#5's physician, revealed the physician was not notified of the change in R#5's condition, even after she was discharged to the hospital. Progress note review also revealed R#16 had bloody stool on [DATE] and [DATE]. Further review of the progress notes and staff interviews revealed no evidence the physician or RP were notified. Director of Nursing (DON) interview revealed that the only place a significant change of condition was documented would be in the progress notes. Findings include: 1. Review of the undated face sheet in the Electronic Health Record (EHR) revealed R#5 was admitted to the facility on [DATE] and discharged on [DATE]. Further review revealed her [DIAGNOSES REDACTED]. Review of an admission progress note dated [DATE] at 4:12 p.m. revealed her [DIAGNOSES REDACTED]. Review of R#5's [DATE] at 10:33 a.m. progress note revealed Respiratory Therapist (RT) HH wrote that R#5 had a low oxygen saturation (the amount of oxygen dissolved in the blood) of 84 - 88% and the resident was lethargic. Further review revealed the residents pulse rate was 140 - 155 beats per minute. Further review revealed RT HH notified the nurse. Review of the Mayo Clinic website found at: www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930 revealed oxygen saturation (pulse ox) Values under 90 percent are considered low. Interview on [DATE] at 3:45 p.m. with Respiratory Therapist (RT) HH in the surveyor's workroom revealed that RT HH said that he had been an R… | 2020-09-01 |
| 318 | 318 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2019-06-28 | 880 | D | 1 | 0 | EDYH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections by allowing oxygen tubing to be on the floor, as well as the tubing being undated and unlabeled, making it impossible to know when the tubing had been changed or if the correct resident was using it. Multiple observations on two different dates revealed four out of 10 residents were affected: (Resident (R)#7, R#9, R#11, and R#14). Oxygen policy review revealed these practices were against facility policy and Director of Nursing (DON), acting as infection control nurse, revealed these practices could be a cause of introducing disease-causing bacteria into residents' nasal cavities. Findings include: Review of the 8/2018 Use of Oxygen policy revealed oxygen tubing would be kept off the floor and if tubing or cannula were found on the floor they would be replaced. Further review revealed it was the responsibility of the licensed nurse to replace the nasal cannula, tubing, and humidifier bottle every 48 hours whether O2 was used continually or as needed (PRN). Review of the undated Oxygen Administration policy statement in the section entitled Infection Control revealed the humidifier bottle and tubing should be dated with the date they were changed. Further review revealed the resident's name and date should be on each bag (sic). 1. Review of R#7's 6/26/19 physician's orders [REDACTED]. On 6/26/19 at 3:15 p.m. R#7 was observed in her room. She was sitting in a wheelchair using oxygen via a nasal cannula (oxygen tubing connected to an oxygen-providing device with prongs to be inserted in the nostrils). The tubing was connected to a humidifier (a small bottle of sterile distilled water to humidify the oxygen to prevent mucous membrane damage), which was connected to an oxyge… | 2020-09-01 |
| 326 | 326 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2019-04-24 | 609 | D | 1 | 0 | 9MY511 | > Based on staff interviews, review of the facility's Incident/Accident Report form, review of the facility's Prevention, Detection and Reporting of Resident Mistreatment, Injuries of Unknown Origin, Neglect, Abuse, Exploitation of Resident, and Misappropriation of Resident's Property policy and review of the facility's Guidelines for Facility Self-Reporting (effective 11/28/2016), it was determined that the facility failed to report an allegation of physical abuse within two hours after Resident (R) #1 reported being hit in the eye. The sample size was seven residents. Findings include: Review of the Nurses' Note dated 4/20/19 at 2:00 p.m. revealed that a family member (Durable Power of Attorney) for R#1 reported to the Licensed Practical Nurse (LPN) AA that R#1 alleged that someone was rough with him and had hit him in the eye. LPN AA assessed R#1 and noted that the corner of his right eye was a little red. R#1 told the LPN that the person who had hit him was a new face. Continued review of the Nurses' Note revealed that LPN AA told the family that she would follow-up on the allegation. Review of the subsequent Nurses' Note dated 4/21/19 (no time) revealed that LPN CC was notified by the resident's Power of Attorney that R#1 had alleged that he had been hit in the right eye and handled roughly on the previous shift (7 a.m. to 3:00 p.m.). R#1 told the nurse the alleged perpetrator was a tall African American female. However, he was unable to give a specific date of the incident. Continued review of the Nurses' Note revealed that R#1 did not know the day of the week and could not provide the date of his birthday. R#1 was observed reaching for something in the air and when asked what he was doing, stated that he was reaching for his coffee. Further review of the Nurses' Note revealed that the LPN would continue to monitor the resident. During an interview with the Administrator on 4/23/19 at 11:29 a.m. she stated that she was unaware of the allegation of abuse by R#1 made on 4/20/19. Continued interview revealed t… | 2020-09-01 |
| 337 | 337 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-02-03 | 656 | J | 1 | 0 | JJVJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and review of the clinical records, it was determined that the facility failed to follow the plan of care related to wound care of the left pinky finger for one resident (#1) from three residents sampled for wounds. This resulted in the resident being hospitalized with dry gangrene of the area. An abbreviated survey was initiated on 1/10/19 and concluded on 2/3/19 to investigate complaint number GA 960 to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility. The allegation of deficient practice related to resident neglect was substantiated. The following deficiencies were cited. The census on 2/3/19 was 126. A determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 1/30/19 at 5:05 p.m. the facility's Administrator and the Director of Health Service (DHS), were informed of an Immediate Jeopardy (IJ). The non-compliance related to the Immediate Jeopardy was identified to have existed on 12/27/18. At the time of the exit on 2/3/19, the State Survey Agency had not received an acceptable Creditable Allegation of Compliance, therefore, the IJ was ongoing. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of 12/27/18, when R#1 cut the tip of the left pinky finger with a fingernail clipper. Clinical staff treated and applied a self-adhering bandage/wrap to the finger. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED].#1 being hospitalized , subsequently the affected area was surgically removed. Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR:483.21(b)(1)Develop/Implement Comprehensive Care Plan (F656 Scope and Severity: J) CFR:483.21(b)(3)… | 2020-09-01 |
| 338 | 338 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-02-03 | 658 | J | 1 | 0 | JJVJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of policy and procedures, review of the Georgia Nurse Practice Act (chapter 410-10), family and staff interviews, the facility failed to ensure services met professional standards as evidenced by the provision of ongoing wound care to one resident (#1) without a physician's orders [REDACTED]. Failure to follow the physicians orders for wound care resulted in the resident being hospitalized , subsequently, with a [DIAGNOSES REDACTED]. R#1 had an AV shunt on the left arm at the time that a self-adhering (constrictive) dressing was applied. The sample size was three. An abbreviated survey was initiated on 1/10/19 and concluded on 2/3/19 to investigate complaint number GA 960 to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility. The allegation of deficient practice related to resident neglect was substantiated. The following deficiencies were cited. The census on 2/3/19 was 126. A determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 1/30/19 at 5:05 p.m. the facility's Administrator and the Director of Health Service (DHS), were informed of an Immediate Jeopardy (IJ). The non-compliance related to the Immediate Jeopardy was identified to have existed on 12/27/18. At the time of the exit on 2/3/19, the State Survey Agency had not received an acceptable Creditable Allegation of Compliance, therefore, the IJ was ongoing. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of 12/27/18, when R#1 cut the tip of the left pinky finger with a fingernail clipper. Clinical staff treated and applied a self-adhering bandage/wrap to the finger. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED].#1 being… | 2020-09-01 |
| 339 | 339 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-02-03 | 684 | J | 1 | 0 | JJVJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and family interviews and review of facilities Guidelines titled Care of Skin Tears & Abrasion, it was determined that the facility failed to ensure wound care was provided to one resident (R), #1 in accordance to the written physician's telephone order. This resulted in R#1 being hospitalized , subsequently, with a [DIAGNOSES REDACTED]. The sample size was three residents. An abbreviated survey was initiated on 1/10/19 and concluded on 2/3/19 to investigate complaint number GA 960 to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility. The allegation of deficient practice related to resident neglect was substantiated. The following deficiencies were cited. The census on 2/3/19 was 126. A determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 1/30/19 at 5:05 p.m. the facility's Administrator and the Director of Health Service (DHS), were informed of an Immediate Jeopardy (IJ). The non-compliance related to the Immediate Jeopardy was identified to have existed on 12/27/18. At the time of the exit on 2/3/19, the State Survey Agency had not received an acceptable Creditable Allegation of Compliance, therefore, the IJ was ongoing. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of 12/27/18, when R#1 cut the tip of the left pinky finger with a fingernail clipper. Clinical staff treated and applied a self-adhering bandage/wrap to the finger. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED].#1 being hospitalized , subsequently the affected area was surgically removed. Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR:483.21(b)(1)De… | 2020-09-01 |
| 340 | 340 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-02-03 | 835 | J | 1 | 0 | JJVJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of clinical records it was determined that the Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. Resident #1 injured his finger on 12/27/18. The Administrator was unaware of the extent of the injury until 1/4/19. The facility census was 123. An abbreviated survey was initiated on 1/10/19 and concluded on 2/3/19 to investigate complaint number GA 960 to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility. The allegation of deficient practice related to resident neglect was substantiated. The following deficiencies were cited. The census on 2/3/19 was 126. A determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 1/30/19 at 5:05 p.m. the facility's Administrator and the Director of Health Service (DHS), were informed of an Immediate Jeopardy (IJ). The non-compliance related to the Immediate Jeopardy was identified to have existed on 12/27/18. At the time of the exit on 2/3/19, the State Survey Agency had not received an acceptable Creditable Allegation of Compliance, therefore, the IJ was ongoing. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of 12/27/18, when R#1 cut the tip of the left pinky finger with a fingernail clipper. Clinical staff treated and applied a self-adhering bandage/wrap to the finger. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED].#1 being hospitalized , subsequently the affected area was surgically removed. Immediate Jeopardy was related to the facilit… | 2020-09-01 |
| 341 | 341 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-11-14 | 567 | D | 1 | 0 | VEPN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to obtain written authorization to open a Resident Trust Fund (RTF) account and failed to obtain written authorization to deduct funds from an RTF account to pay for facility care costs for one resident (R) (#10) of three residents reviewed who had trust accounts. Findings include: During an interview on 10/29/19 at 8:35 a.m., R#10 stated the facility is keeping his Social Security check without his signed authorization. R#10 went on to say he never signed anything allowing the facility to keep his Social Security check. During an interview on 10/30/19 at 9:09 a.m., the facility Finance Director (FD) stated the Social Security checks, received at the facility, addressed to R#10 each month since (MONTH) 2019 have been deposited into the facility account. FD went on to say she does not know why but, R#10 did not sign an authorization for the facility to manage his funds and the facility has not applied to become representative payee for R#10. During an interview on 10/29/19 at 9:35 a.m., Social Worker (SW) SS revealed R#10 brought her several letters from the Social Security office about checks the facility cashed and she explained to R#10 that the facility kept the money for room and board, and he could keep a portion. SW SS added, R#10 never agreed to pay to stay at the facility in her presence and R#10 felt he should not have to pay his whole check to stay at the facility. During an additional interview on 10/30/19 at 10:46 a.m., the FD revealed she spoke directly with R#10 and explained to him that while he is in the facility, his check comes to the facility, minus his allowance. The FD added, she could not recall when or if the paperwork was given to R#10 to sign or if he agreed with the arrangement. The FD also revealed the facility does not have any written agreement from R#10 to manage his funds and the finance staff should have made sure they had a signed copy of the approval… | 2020-09-01 |
| 342 | 342 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-11-14 | 607 | D | 1 | 0 | VEPN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility policy titled Abuse, Neglect, and Misappropriation of Property, and interviews, the facility failed to implement its abuse policy related to reporting verbal abuse for one resident (R) (#6) of five sampled residents. Findings include: Review of the facility policy titled Abuse, Neglect, and Misappropriation of Property dated (MONTH) 2019 revealed that allegations of abuse or neglect should be reported immediately to the Administrator and the SA (state agency). The policy describes the definition of verbal abuse to include the use of any disparaging language to any resident or within earshot of residents, regardless of their disability. Each facility Stakeholder (employee) should intervene immediately to interrupt any incident and provide for resident safety. Further review revealed each Stakeholder was required to report any actual or suspected abuse immediately. Any abuse allegation must be reported to the SA within two hours of the report being received. Review of the clinical record revealed R#6 was admitted to the facility 7/10/19 and the 10/11/19 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score to be 14, indicating cognition intact. During an interview on 10/24/19 at 1:00 p.m., R#6 stated there were two incidents between Licensed Practical Nurse (LPN) II and himself. R#6 stated LPN II only worked every other weekend so the incidents happened about two weeks apart, with the second incident being on 9/8/19, a Sunday. R#6 stated the first time they argued he asked for his pain medication for his ankle. R#6 stated LPN II told him disrespectfully he would have to wait his turn because she had other patients. R#6 stated he raised his voice to LPN II and she raised her voice to him, but she did not curse him on that first argument. R#6 then stated another argument occurred between himself and LPN II on or about 9/8/19. R#6 stated he never got his morning … | 2020-09-01 |
| 343 | 343 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-11-14 | 609 | D | 1 | 0 | VEPN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the State Agency (SA) within the required two hours of an incident involving suspected verbal abuse of one resident (R) (#6) of five sampled residents. Findings include: Review of a 9/9/19 Complaint/Grievance Report revealed R#6 filed a grievance against LPN II to the Administrator. Further review revealed LPN II was observed by staff having a loud disagreement with R#6. Review of the clinical record revealed R#6 was admitted to the facility 7/10/19 and the 10/11/19 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score to be 14, indicating cognition intact. Interview with R#6 on 10/24/19 at 1:00 p.m. revealed an argument occurred between himself and LPN II on or about 9/8/19. R#6 stated he never got his morning pain medication so around 1:00 p.m. he wheeled himself out to the nurse's station and found LPN II there working on a computer. R#6 stated this made him angry because he wondered why she was working on the computer when she had not given him his morning medication. R#6 stated he started to ask for his medication when LPN II slammed the nurses station door in his face. R#6 stated he opened the door and he and LPN II went at it. R#6 stated at some point during this heated exchange he called LPN II a [***] and LPN II said in a loud voice, Your mama's a [***] ! R#6 said several staff members were present and heard all this. He stated he never saw the Administrator about this until he (R#6) filed a grievance later. During an interview on 10/24/19 at 10:00 a.m., the Administrator stated the arguments between LPN II and R#6 were at least suspicious for verbal abuse. The Administrator agreed the statements of CNA GG and LPN HH about LPN II raising her voice and using profanity to a resident was suspicious for verbal abuse. The Administrator stated no report of this incident was made to the state because, at the time, he did not think it a… | 2020-09-01 |
| 344 | 344 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-11-14 | 658 | D | 1 | 0 | VEPN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, observations, record review, review of facility policy titled Medication Administration and review of the Georgia Nurse Practice Act (chapter 410-10), the facility failed to provide supervision with the administration of medications for one of five sampled residents (R) (#10). Findings include: The Practice of Nursing includes, but is not limited to, provision of nursing care; administration, supervision, evaluation, or any combination thereof, of nursing practice; teaching; counseling; the administration of medications and treatments as prescribed by a physician [MEDICATION NAME] medicine in accordance with Article 2 of Chapter 34 of this title. Guideline #20 of the facility's Administering Medications General Guidelines policy documented the resident is always observed after administration to ensure that the dose was completely ingested. Review of the clinical record revealed R#10 has [DIAGNOSES REDACTED]. R#10 is his own responsible party. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R#10 with a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. A Physician's Note dated 10/15/19 revealed R#10 with intermittent confusion, staff documented that he gets belligerent and aggressive at times. He is a bit demanding about his medications. During an interview on 10/29/19 at 7:30 a.m., R#10 revealed Licensed Practical Nurse (LPN) QQ gave him all his morning medication at 6:00 a.m. He then opened the drawer to his bedside table and produced a clear dosage cup, containing 10 pills. R#10 stated LPN QQ left the pills for him to take later. During an interview on 10/29/19 at 7:42 a.m., LPN QQ stated R#10 is medication seeking and she did not leave any pills with him. LPN QQ went to R#10's room and R#10 stated he had taken the pills because he didn't want anyone to take them from him. He then reached underneath his bed covers and produced the cup of medication. He also reached… | 2020-09-01 |
| 353 | 353 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2020-01-02 | 641 | D | 1 | 0 | SFYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for three residents (R) Z, R S, and R T for respiratory treatment use of a Continuous Positive Airway Pressure ([MEDICAL CONDITION] provides constant airflow which holds the airway open so that uninterrupted breathing is maintained during sleep) machine of five sampled residents. Findings include: 1. Review of the clinical record for R Z revealed a History and Physical dated 12/22/19 indicating the resident has a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section O: O0100 Special Treatments and Programs, Respiratory Treatments [NAME] [MEDICAL CONDITION]/[MEDICAL CONDITION], was not assessed. An interview with the MDS lead on 1/2/20 at 3:27 p.m. confirmed that R Z, had a [MEDICAL CONDITION] machine that was used prior to admission and after admission to the facility. She also confirmed that R Z has a [DIAGNOSES REDACTED]. [MEDICAL CONDITION]/[MEDICAL CONDITION], was not coded accurately. The MDS lead revealed she would make the necessary correction to R Z assessment. 2. Review of the clinical record for R S revealed a History and Physical dated 11/17/19 indicating the resident has a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section O: O0100 Special Treatments and Programs, Respiratory Treatments [NAME] [MEDICAL CONDITION]/[MEDICAL CONDITION], was not assessed. An interview on 1/2/20 at 3:29 p.m. with MDS lead. The MDS lead confirmed that R S had a [MEDICAL CONDITION] machine that was used prior to admission and after admission to the facility. She also confirmed that RS has a [DIAGNOSES REDACTED]. 3. Review of the clinical record for R T revealed a History and Physical dated 12/6/19 indicating the resident has a [DIA… | 2020-09-01 |
| 354 | 354 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2020-01-02 | 695 | D | 1 | 0 | SFYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, resident and staff interviews, record review, review of the facility policy titled, BI-PAP/[MEDICAL CONDITION] the facility failed to ensure that three Resident (R) Z, R T, and R S Continuous Positive Airway Pressure ([MEDICAL CONDITION] provides constant airflow which holds the airway open so that uninterrupted breathing is maintained during sleep) machine, mask/nasal pillow, and tubing was cleaned and sanitize. In addition, R U Bilevel Positive Airway Pressure (Bi-PAP Provides assistance during inspiration and expiration) machine, mask, and tubing was cleaned and sanitize for four of four residents reviewed with [MEDICAL CONDITION]/Bi-PAPA machines. Findings include: Review of the policy titled, BI-PAP/[MEDICAL CONDITION] dated 12/2009 indicated Note: Manufacturer's recommendations should be followed. BI-PAP/[MEDICAL CONDITION] should be cared for and replaced per manufacturer's recommendations. Filters-foam usually clean weekly. Wash mask with soap and water after each use and pat dry. 1. Review of R Z the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 13 of 15, indicating the resident was cognitively intact. Further review of the electronic health record revealed a [DIAGNOSES REDACTED]. Review of the Physician Order included: (MONTH) use home [MEDICAL CONDITION] settings 12.0 centimeters (cm) worn every night as needed for sleep comfort. Record review of the resident's care plan focus area has risk for respiratory impairment related to [MEDICAL CONDITION] and sleep apnea revealed an intervention for [MEDICAL CONDITION] use per Physician's Order however the care plan did not address cleaning or who was responsible to clean the [MEDICAL CONDITION] equipment. An interview with R Z on 12/30/19 at 10:15 a.m. revealed that the resident was using a [MEDICAL CONDITION] machine at night. The resident revealed that since admission to the facili… | 2020-09-01 |
| 411 | 411 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2018-07-20 | 608 | D | 1 | 0 | 67000000000000.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review and policy review, the facility failed to report an allegation of physical abuse to law enforcement for one resident (A), from a total sample of ten residents. Findings include: Review of the facility abuse policy entitled Abuse Prohibition Policy and Procedures. revealed the following: the policy documented that once a complaint or situation is identified involving alleged mistreatment, neglect or abuse the incident will be reported immediately, but not later than two hours after the allegation is made if the events that case the allegation involve abuse or result in serious bodily injury to the Administrator of the facility. The Administrator or designee will immediately notify the Investigation Intake and Referral Unit and the legal representative and/or interested family member of the incident and the pending investigation. The policy also included that the Police Department will also be notified as appropriate. Record review revealed that on 6/23/18, a family member of Resident (R) A alleged that someone had hit the resident. The resident was assessed and bruising was identified to the left thigh. The resident was transferred to the hospital emergency roiagnom on [DATE] for further evaluation. A review of the hospital documentation dated 6/23/18 at 20:23 (military time-8:23 p.m.) revealed that the resident arrived from the nursing home for concerned physical abuse/assault. The examination documented multiple deep contusions, appeared new, to the left anterior thigh and marked tenderness to the left shoulder extending to the left proximal humerus. Review of the radiology reports, dated 6/23/18, documented a minimally displaced surgical neck [MEDICAL CONDITION] humerus and a remote fracture involving the clavicle and mid humeral diaphysis. The resident was discharged from the emergency room , back to the facility on [DATE] with physician's orders [REDACTED]. Although the facility immediately initia… | 2020-09-01 |
| 412 | 412 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2018-07-20 | 656 | D | 1 | 0 | 67000000000000.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to ensure that the appropriate method of transfer was utilized for one resident (A) as care planned, from a total sample of ten residents. Findings include: Review of the medical record for resident (R) A revealed the resident had [DIAGNOSES REDACTED]. Record review revealed that R A was admitted to the hospital on [DATE] due to abnormal laboratory results and remains out of the facility. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/21/18, documented that the resident had functional limitations in Range of Motion to her upper extremities on one side. Review of the care plan with a care plan problem, dated 9/14/17, documented that the resident had a self care deficit. The care plan included an intervention for facility nursing staff to transfer the resident using a Hoyer lift. The care plan intervention for the use of a Hoyer lift was also documented on the Certified Nursing Assistant (CNA) Flowsheet, a form utilized for CNA documentation. A review of the clinical record revealed that RA was transferred to the emergency room (ER) on 6/23/18 for further evaluation of bruising to the left thigh and indications of pain to the left arm and left leg. Review of the hospital radiology reports, dated 6/23/18, documented a minimally displaced surgical neck [MEDICAL CONDITION] humerus and a remote fracture involving the clavicle and mid humeral diaphysis. A review of the facility's investigation of the origin of the fractures revealed that on 6/21/18 CNA AA used an inappropriate lift, a stand-up lift, to stand RA up, to provide incontinence care and change the adult brief. However, in the process of using the stand-up lift, the resident's feet slipped off the base of the lift and her arms were raised above her head. During an interview on 7/20/18 at 11:32 a.m., the Director of Nursing (DON) stated that RA had left-sided weakness and would not have been able to hold o… | 2020-09-01 |
| 413 | 413 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2018-07-20 | 689 | D | 1 | 0 | 67000000000000.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to ensure that the appropriate method of transfer was utilized for one resident (A) from a total sample of ten residents. Findings include: Review of the medical record for Resident (R) A revealed the resident had [DIAGNOSES REDACTED]. The 5/21/18 Quarterly Minimum Data Set (MDS) assessment documented that the resident had a Brief Interview for Mental Status of 99 indicating that an interview could not be completed. The resident was assessed as dependent on facility staff for care and had functional limitations in Range of Motion to her upper extremities on one side. Review of the resident's care plan revealed that there was a care plan problem in place, since 9/14/17, for a self care deficit, with an intervention for facility nursing staff to transfer the resident using a Hoyer lift. The care plan intervention for the use of a Hoyer lift was also documented on the Certified Nursing Assistant (CNA) Flowsheet, a form utilized for CNA documentation. Record review revealed that R A was admitted to the hospital on [DATE] due to abnormal laboratory results and remains out of the facility. A review of the clinical record revealed that RA was transferred to the emergency roiagnom on [DATE] for further evaluation of bruising to the left thigh and indications of pain to the left arm and left leg. Review of the hospital ER notes dated 6/23/18 at 20:00 (military time: 8:00 p.m.) revealed the primary complaint specified Suspected Assault onset prior to arrival, 1 day. Primary complaint details: patient with arrival from nursing home for concerned Physical Abuse/Assault. Patient found by family members with multiple bruises left thing and hip. Patient also complaining of left shoulder pain. Patient with left hemaparesis, no ambulation on baseline. Review of the hospital radiology reports dated 6/23/18 documented a minimally displaced surgical neck [MEDICAL CONDITION] humerus and a remote fr… | 2020-09-01 |
| 419 | 419 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2019-09-20 | 580 | J | 1 | 0 | 5G2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and Responsible Party and Physician interviews Facility #2 failed to notify the attending Physician and Responsible Party of newly developed pressure ulcer for one of 12 residents (R#1) reviewed for pressure ulcers. On (MONTH) 17, 2019 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. F580 -- S/S: J -- 483.10(g)(14)(i)-(iv)(15) -- Notify O… | 2020-09-01 |
| 420 | 420 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2019-09-20 | 641 | D | 1 | 0 | 5G2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, Facility #2 failed to accurately assess and code the Minimum Data Set (MDS) assessments for three of 12 residents (R) (R#1, R#4 and R#6) that were reviewed for pressure ulcers. Findings include: 1. Record review revealed that R#1 was readmitted to Facility #2 on 2/26/18 with [DIAGNOSES REDACTED]. Record review revealed that R#1 was sent to an acute care hospital on [DATE] and returned to the facility on [DATE]. Review of the 7/30/19 hospital Discharge Summary revealed that R#1 had a sacral decubitus with [DIAGNOSES REDACTED]. However, the facility failed to code the pressure ulcer as an unhealed pressure ulcer in Section M0210: Unhealed Pressure Ulcers/Injury on the 8/19/19 Significant Change MDS Section M1200: Skin and Ulcer/Injury Treatments. The facility also failed to code the resident as having a Stage 4 pressure ulcer in Section M0300 which asks for the following information: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage in the 8/19/19 MDS assessment. During an interview on 9/6/19 at 2:39 p.m. with Licensed (LPN) NN MDS Coordinator revealed that when R#1 returned from the hospital on [DATE], and it was discussed during the morning meeting to classify the sacral pressure ulcer as a surgical wound. 2. Review of the (MONTH) 2019 Treatment Administration Record for R#4 revealed staff were providing daily wound care to the resident's surgical wound on the left stump. However, the surgical wound care was not coded in the Section M1200: Skin and Ulcer/Injury Treatments on the 8/22/19 Quarterly MDS. Further review of the 8/22/19 Quarterly MDS revealed the facility incorrectly coded the resident as having four unstageable pressure ulcers in Section M0300 (Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.) Record review revealed that R#4 only had one Stage 2 pressure ulcer which was on his sacrum. During an interview on 9/10/19 at 12:26 p.m. with LPN NN MDS Coordi… | 2020-09-01 |
| 421 | 421 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2019-09-20 | 657 | J | 1 | 0 | 5G2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interviews, Facility #2 failed to revise and individualize care plans to reflect the current stage of actual pressure ulcers and the facility failed to evaluate care planned interventions to ensure interventions were effective for six of 12 residents (R#1, R#2, R#4, R#5, R#6, R#10) reviewed for pressure ulcers. On (MONTH) 17, 2019 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the fac… | 2020-09-01 |
| 422 | 422 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2019-09-20 | 658 | J | 1 | 0 | 5G2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interviews, record review, and review of the Georgia Nurse Practice Act, Facility #2 failed to ensure that accepted standards of clinical practice were followed to ensure that a newly recognized pressure ulcer received follow up care and ensure that treatment was provided timely for one of 12 (R#1) residents reviewed for pressure ulcers. On (MONTH) 17, 2019 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related t… | 2020-09-01 |
| 423 | 423 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2019-09-20 | 686 | J | 1 | 0 | 5G2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, review of the facility policies titled, No. 86 Subject: Pressure Ulcer Prevention and Treatment Program, NH 151 form 10/10 Nursing Home - Pressure Ulcer Prevention (BRADEN SCORE 18) and/or Wound Treatment Order - For Admission or Status Changes, and the facility policy titled, Integumentary Skin Photographic Documentation, POLICY NO. 1.0 titled, Infection Control Subject: Hand Hygiene, and review of the POLICY NUMBER; 10:01 titled, Subject: Infection Prevention and Control Program, Facility #2 failed to conduct head to toe skin assessments weekly as ordered by the Physician; failed to perform skin checks to identify breakdown timely; and failed to consistently assess the status of the developing sacral pressure ulcer until it was a Stage IV pressure ulcer which required two surgical debridements, a wound VAC (negative pressure wound treatment) and a [MEDICAL CONDITION] for one of 12 (R#1) residents reviewed for pressure ulcers. Facility#2 also failed to perform weekly assessments and failed to document weekly wound descriptions for three of 12 (R#2, R#3, R#4) residents reviewed for pressure ulcers. In addition, Facility #2 failed to ensure that one staff member implemented standard precautions when providing wound care for five of five (R#2, R#3, R#4, R#5, R#6) residents observed for wound care as evidenced by staff failing to wash and/or sanitize hands, and failing to clean scissors before and after use, failing to clean wounds using a clean technique by going from dirty area to clean area while providing wound care. Facility #1 failed to document weekly wound descriptions for two of 12 residents (R#11, R#12) reviewed for pressure ulcers. On (MONTH) 17, 2019 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Admini… | 2020-09-01 |
| 424 | 424 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2019-09-20 | 867 | J | 1 | 0 | 5G2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based record review, staff interviews, and review of the facility policy titled, Quality Assurance Performance Improvement, Facility #2 failed to have a Quality Assessment and Assurance (QAA) committee that effectively provided oversight and monitoring to ensure that staff were performing weekly skin assessments to ensure timely identification and treatment of [REDACTED].#2 failed to ensure that weekly photographs and weekly wound description documentation was being completed and failed to ensure that the Physician and Responsible Party were notified of pressure ulcers in a timely manner. Facility #1 failed to ensure weekly wound descriptions were being completed from 7/1/19 through 8/14/19. On (MONTH) 17, 2019 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting… | 2020-09-01 |
| 425 | 425 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2019-09-20 | 912 | E | 1 | 0 | 5G2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews Facility #2 failed to ensure that three of four residents (R) (R#7, R#8 and R#9) who resided in a four-bed ward had a minimum of 80 square feet of living space per resident in the room. Findings include: During an observation on 9/6/19 at 8:45 a.m., four residents in room [ROOM NUMBER] were observed sharing a room with the beds in close proximity to each other. On 9/6/19 at 11:02 a.m., the Maintenance Director measured the room with a tape measure. The distance between Bed A mattress and Bed B mattress was 38 inches. The distance between Bed B footboard and the head of Bed C was 31 inches. The distance between Bed C mattress and Bed D mattress is 54 inches. The total room measurement was 22 feet 10 inches by 17 feet 4 inches. The storage closet was included in the measurement and was not subtracted from the living space per resident. During an interview with the Maintenance Director on 9/6/19 at 1:44 p.m., he stated the residents in that room did not have 80 square feet of living area per resident. During an interview with Administrator DD, for Facility #2 on 9/6/19 at 1:49 p.m., he stated that there was not a waiver and that room and the room had been like that since 1961. During an observation with the Administrator on 9/11/19 at 11:29 a.m., the Maintenance Director re-measured the room and obtained 17 feet 6 inches by 21 feet as the total room size. The measured living space for Bed A, for R#7, was 9 feet by 5 feet for a total of 45 square feet. However, the wall closet occupied 4.7 feet leaving R#7 with 40.3 square feet of living area. The measured living space for Bed B, for R#8, was 9 feet by 8 feet for a total of 72 square footage living area. The measured living space for Bed C was 12 feet 1 inch by 8 feet for a total of 96.8 square footage of living area. The measured living space for Bed D, for R#9, was 9 feet by 3.5 feet for a total of 27 square feet. However, the wall closet occupied 4.7… | 2020-09-01 |
| 430 | 430 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2019-03-13 | 812 | D | 1 | 0 | NFKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to distribute and serve food in a safe and sanitary manner by not ensuring three members of the dietary staff, including the Dietary Manager (DM), wear their bouffant caps and/or beard guards in a manner that would prevent hair or other contaminants from falling into resident food during preparation and serving. Findings include: On 3/12/19 at 10:35 a.m. the DM was interviewed in the kitchen. The DM wore a hairnet and a beard guard with his thick mustache uncovered. The DM stated he had worked for the facility for two years. He also stated the kitchen prepared and served food for the entire facility. On 3/12/19 at 11:30 a.m. the lunch tray assembly line was observed. Kitchen worker AA was observed working assembling spaghetti and meatballs. He wore a bouffant paper head cover and no beard guard over his short beard and mustache. He stated he had worked for the facility for [AGE] years. Kitchen Worker BB was directly observed working on the tray assembly line. She wore a bouffant cap that only partially covered her hair, leaving large lengths of hair out around her face hanging beneath her chin. On 3/12/19 at 2:00 p.m. Kitchen worker AA was observed in the food preparation area with no beard guard covering his short beard and mustache. Kitchen worker BB was observed in the food preparation area with a bouffant cap not covering all her hair with long strands hanging out of the sides of her cap. On 3/12/19 at 2:25 p.m. the DM was observed in the food preparation area of the kitchen wearing a bouffant cap and a beard guard. The beard guard was noted to not cover the DM's moustache. On 3/13/19 at 9:00 a.m. Kitchen worker BB was observed in the kitchen mopping the floor. Her bouffant cap did not cover the hair above her forehead. Review of Staff Attire document dated (MONTH) (YEAR) revealed staff was to have their hair contained in a hair net or cap and facial hair was to be … | 2020-09-01 |
| 431 | 431 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2019-04-04 | 657 | J | 1 | 0 | KBNL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, staff interviews, and review of the facility policies titled Elopement Management dated (MONTH) (YEAR) and Comprehensive Care Plan with a Revision date of (MONTH) (YEAR) the facility failed to revise the care plan related to exit seeking behaviors for one Resident (R#8) out of six residents reviewed with wandering behaviors. This failure to revise R#8's care plan contributed to the resident exiting the facility undetected. On 4/2/19, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on 4/2/19 at 4:30 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of 3/26/19. The Immediate Jeopardy continued through 4/3/19 and was removed on 4/4/19. The Immediate Jeopardy is outlined as follows: On 3/26/19 resident (R) #8 exited the facility undetected through an exit door on the first floor that was not functioning properly. The resident was found on the ground by a bystander near a busy road. The bystander called 911 and Emergency Medical System (EMS) arrived at the scene. The resident was taken to the local hospital and treated for [REDACTED]. The facility was unaware of the resident's elopement until they were notified by the emergency roiagnom on [DATE]. R#8 has a history of wandering and was wearing a Wander Guard bracelet on her ankle when she left the facility. It was determined that a handicap assessable door on the first floor which has an alarm system was not working properly and therefore, the resident was able to elope from the facility undetected. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (… | 2020-09-01 |
| 432 | 432 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2019-04-04 | 689 | J | 1 | 0 | KBNL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, resident and staff interviews, and review of the facility policy titled Resident Elopement dated (MONTH) 2012 the facility failed to prevent one Resident (R), #8 out of six residents reviewed who wear Wander Guards from eloping from the facility. The facility failed to comply with established policies and procedures regarding resident elopement. R#8 exited the facility undetected and was found by passers-on a busy urban street near an interstate ramp. The facility also failed to identify potential hazardous areas residents could access due to unsecured doors. On 4/2/19, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on 4/2/19 at 4:30 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of 3/26/19. The Immediate Jeopardy continued through 4/3/19 and was removed on 4/4/19. The Immediate Jeopardy is outlined as follows: On 3/26/19 resident (R) #8 exited the facility undetected through an exit door on the first floor that was not functioning properly. The resident was found on the ground by a bystander near a busy road. The bystander called 911 and Emergency Medical System (EMS) arrived at the scene. The resident was taken to the local hospital and treated for [REDACTED]. The facility was unaware of the resident's elopement until they were notified by the emergency roiagnom on [DATE]. R#8 has a history of wandering and was wearing a Wander Guard bracelet on her ankle when she left the facility. It was determined that a handicap assessable door on the first floor which has an alarm system was not working properly and therefore, the resident was able to elope from the facility undetected. The Immediate Jeopardy was rel… | 2020-09-01 |
| 433 | 433 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2019-04-04 | 908 | J | 1 | 0 | KBNL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure the first floor side exit door was working properly to alert staff when a resident was exiting the building unattended. This failure resulted in one Resident (R#8) out of six residents eloping from the facility undetected. On 4/2/19, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on 4/2/19 at 4:30 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of 3/26/19. The Immediate Jeopardy continued through 4/3/19 and was removed on 4/4/19. The Immediate Jeopardy is outlined as follows: On 3/26/19 resident (R) #8 exited the facility undetected through an exit door on the first floor that was not functioning properly. The resident was found on the ground by a bystander near a busy road. The bystander called 911 and Emergency Medical System (EMS) arrived at the scene. The resident was taken to the local hospital and treated for [REDACTED]. The facility was unaware of the resident's elopement until they were notified by the emergency roiagnom on [DATE]. R#8 has a history of wandering and was wearing a Wander Guard bracelet on her ankle when she left the facility. It was determined that a handicap assessable door on the first floor which has an alarm system was not working properly and therefore, the resident was able to elope from the facility undetected. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F657 Scope and Severity: J). CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). CFR 483.90 (d)(2) Essential Equipment, Saf… | 2020-09-01 |
| 434 | 434 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2019-04-26 | 656 | J | 1 | 0 | REZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of facility policies titled Comprehensive Care Plan revised (MONTH) (YEAR) and Elopement Management revised (MONTH) (YEAR) the facility failed to develop a comprehensive care plan with interventions that specify the frequency of service(s) provided and failed to implement the care plan related to provision of monitoring of one resident (R) (R#1) sufficiently to prevent elopement. Seven residents were reviewed for risk of elopement. These failures to provide a care plan that specifically identified how often R#1 should be monitored, and provide sufficient monitoring to prevent elopement resulted in the elopement of R#1. who was found by a bystander at a busy intersection on 4/8/19 at 6:20 p.m. This failure resulted in Immediate Jeopardy. On 4/23/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. On 4/23/19 at 4:00 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/8/19 when R#1 eloped from the facility undetected through an exit door on the first floor. The Immediate Jeopardy is outlined as follows: On 4/8/19 resident (R) #1 exited the facility undetected through an exit door on the first floor. The resident was found by a bystander near a busy road after falling to the ground. The bystander called 911 and the Police and Emergency Medical Service (EMS) arrived at the scene. The resident was assessed by EMS to be unharmed. The facility was unaware of the resident's elopement until they were notified by EMS. R#1 has a history of wandering and was wearing a Wander Guard bracelet on his ankle when he left the facility. It was determined that the mechanical function of the handicap assessable/smoker exit doo… | 2020-09-01 |
| 435 | 435 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2019-04-26 | 689 | J | 1 | 0 | REZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, clinical record review, staff and Emergency Medical Services (EMS) interview and review of facility policy and practice guidelines titled Elopement Management dated (MONTH) (YEAR), the facility failed to provide supervision and monitoring to prevent the elopement of one resident (R), (R#1) from a sample of seven (7) residents identified by the facility to be at high risk for elopement. The facility failed to ensure the first floor side entrance/exit door Wander Guard system functioned adequately to prevent the elopement of one resident (R) (R#1) who exited the building undetected on 4/8/19. In addition, the facility failed to provide a safe and secure environment related to a first-floor side entrance door that was not in view of staff on 4/8/19, the day R#1 eloped and was found by a bystander. On 4/23/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. On 4/23/19 at 4:00 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/8/19 when R#1 eloped from the facility undetected through an exit door on the first floor. The Immediate Jeopardy is outlined as follows: On 4/8/19 resident (R) #1 exited the facility undetected through an exit door on the first floor. The resident was found by a bystander near a busy road after falling to the ground. The bystander called 911 and the Police and Emergency Medical Service (EMS) arrived at the scene. The resident was assessed by EMS to be unharmed. The facility was unaware of the resident's elopement until they were notified by EMS. R#1 has a history of wandering and was wearing a Wander Guard bracelet on his ankle when he left the facility. It was determined that the mechanical function of the hand… | 2020-09-01 |
| 436 | 436 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2019-04-26 | 835 | J | 1 | 0 | REZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of the Administrator Job Description revised 1/29/03, the facility failed to be administered in a manner to ensure there was an effective elopement prevention program that consistently monitored residents at risk for elopement and determine the root cause of resident elopements, and failed to ensure that all staff were knowledgeable regarding how the first floor side entrance /exit door functioned with a Wander Guard system which had an override function allowing residents identified at risk for elopement to exit the facility undetected. From a sample of seven residents assessed as elopement risk (R) (R#1 left the facility undetected on 4/8/19. This failure resulted in Immediate Jeopardy. On 4/23/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. On 4/23/19 at 4:00 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/8/19 when R#1 eloped from the facility undetected through an exit door on the first floor. The Immediate Jeopardy is outlined as follows: On 4/8/19 resident (R) #1 exited the facility undetected through an exit door on the first floor. The resident was found by a bystander near a busy road after falling to the ground. The bystander called 911 and the Police and Emergency Medical Service (EMS) arrived at the scene. The resident was assessed by EMS to be unharmed. The facility was unaware of the resident's elopement until they were notified by EMS. R#1 has a history of wandering and was wearing a Wander Guard bracelet on his ankle when he left the facility. It was determined that the mechanical function of the handicap assessable/smoker exit door on the first floor allowed the resident to elop… | 2020-09-01 |
| 444 | 444 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2018-08-30 | 580 | D | 1 | 0 | IJ9V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and Physician interview, and review of facility education and policy, the facility failed to notify Physicians of unavailable medications for two (2) residents (R) (R#3 and R#5) from a sample of five (5) residents reviewed for controlled medication administration. Findings include: 1. Record review for R#3 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of Nurse's Progress Notes indicated on 6/25/18 at 7:18 a.m. R#3 did not have a [MEDICATION NAME] Patch applied because it was not available, and the Physician and Pharmacy were notified. On 6/28/18 at 8:31 a.m. Nurse's Notes again indicated R#3 did not have a [MEDICATION NAME] Patch applied pending pharmacy delivery. A physician progress notes [REDACTED].#3 and he was experiencing phantom limb syndrome with pain. On 7/4/18 at 11:53 a.m. Nurse's Progress Notes revealed R# 3 did not have a [MEDICATION NAME] Patch applied because the pharmacy would deliver. On 7/7/18 at 12:48 p.m. a Nurse's Progress Note indicated R#3 did not have a [MEDICATION NAME] Patch applied because the medication was not available. On 7/10/18 at 9:26 a.m. R#3 did not have a [MEDICATION NAME] Patch applied because the pharmacy was to deliver the patch. The Medication Administration Records (MAR's) for (MONTH) (YEAR) and (MONTH) (YEAR) were reviewed and the omissions above were confirmed. R#3 had missed five of seven Physician ordered applications of [MEDICATION NAME] Patches from 6/25/18 through 7/10/18. The next [MEDICATION NAME] 72 hour 25 mcg/hr patch applied was on 7/13/18 at 9:00 a.m. An interview conducted on 8/14/18 at 3:58 p.m. with R#3's Physician revealed she was not notified when she came to the facility to see R#3 that there was no prescription for the [MEDICATION NAME] Patch. The Physician revealed the transfer orders from the hospital usually come with the appropriate prescriptions so they can be sent to the Pharmacy im… | 2020-09-01 |
| 445 | 445 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2018-08-30 | 602 | E | 1 | 0 | IJ9V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of facility policy the facility failed to ensure that controlled medications were free from misappropriation for four (4) residents (R) (R#2, R#3, R#4 and R#6) from a sample of five (5) residents reviewed for controlled medication administration. The facility census was two hundred six (206). Findings include: Review of facility policy titled Abuse and Neglect Prohibition revised (MONTH) (YEAR), revealed each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents\'s medical symptoms. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary of permanent use of a resident's belongings or money without the residents consent. The facility Quality Assurance and Performance Improvement (QAPI) Committee will review available data to identify patterns and trends that may indicate the presence of abuse, neglect, mistreatment, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 1. Review of the clinical record for R#2 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED].#2 had lumbar sacral surgery in the past and had exhausted all options for control of pain and symptoms including exercise, therapy, injections, oral medications and electrical stimulation. On 6/28/18 R#2 had removal of hardware from the second and third lumbar discs and a fusion of the ninth [MEDICATION NAME] disc. Review of the Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) score completed on 7/24/18 revealed a score of fourteen (14) indicating no cognitive impairment. Review of Physician orders [REDACTED]. [MEDICATION NAME] 1 mg was schedu… | 2020-09-01 |
| 446 | 446 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2018-08-30 | 684 | E | 1 | 0 | IJ9V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff, Physician and Nurse Practitioner interviews, and review of facility policy and education, the facility failed to follow Physician orders [REDACTED].#2, R#3, R#4, R#5, and R#6) from a sample of five (5) residents reviewed for administration of controlled substances. Findings include: 1. Record review for R#2 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) Assessment on 7/24/18 revealed a score of fourteen (14), indicating R#2 had no cognitive impairment. Review of admission Physician orders [REDACTED]. The order was discontinued on 8/7/18. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records (MAR's) from admission to 8/14/18 revealed [MEDICATION NAME] 1 mg was scheduled to be administered at 9:00 a.m., 1:00 p.m. and 9:00 p.m The MAR's were compared with the Controlled Substance Proof of Use records and the following discrepancies were found: On 7/25/18, 7/26/18, 7/27/18, 7/28/18 and 8/2/18 [MEDICATION NAME] 1 mg was initialed on the MAR at 1:00 p.m., but it was not signed out on the Controlled Substance Proof of Use form. The Nurse's Progress notes were reviewed for these dates and the resident was not out of the building or experiencing sedation on these dates, and there was no explanation for why these administrations were omitted. Review of the Nurse's Progress Notes revealed the [MEDICATION NAME] was not available for administration on 8/4/28 at 1:00 p.m. Continued review revealed R#2 did not experience any symptoms of anxiety during the day his [MEDICATION NAME] supply was depleted. Review of the emergency supply dispense log indicates no [MEDICATION NAME] was dispensed on 8/4/18 for R#2. Review of the list given by the pharmacy of medications available for emergency dispense indicated there is a supply of three (3) [MEDICATION NAME] 1 mg available. Resident #2's Physician orders [REDACTED]. Review of the MA… | 2020-09-01 |
| 447 | 447 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2018-08-30 | 755 | E | 1 | 0 | IJ9V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and review of pharmacy contract, the facility failed to provide medications to meet the needs of three (3) residents (R), (R#3, R#4, and R#5) from a sample of five (5) residents reviewed for administration of controlled medications. Findings include: Review of Pharmacy Products and Services Agreement, dated 4/8/18 and signed by Senior Legal Counsel for the pharmacy on 4/9/18, revealed the pharmacy was responsible to provide Pharmacy Products to Facility and its residents in a prompt and timely manner in compliance with applicable local, state and federal law, rules and regulations. 1. Clinical record review for R #3 revealed admission to the facility on [DATE]. The admission orders [REDACTED]. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR for (MONTH) (YEAR) indicated one patch was applied as ordered on [DATE], then no patch applied on 7/4/18, 7/7/18 or 7/10/18. Review of the pharmacy Sum of Quantity Shipped revealed one patch was shipped on 6/21/18, then five (5) patched were shipped on 7/12/18. The emergency box dispense log revealed access for the [MEDICATION NAME] Patch for R#3 was initiated on 6/21/18 at 8:00 p.m. but there was no patch removed. There were no other attempts to obtain [MEDICATION NAME] Patches from the emergency supply for R#3. Nurse's Progress Notes were reviewed and indicated the pharmacy was contacted on 6/25/18 at 7:18 a.m. the [MEDICATION NAME] Patch was not available. The Notes indicated a prescription was needed. There was no notification of the Physician documented. The Nurse's Progress Notes indicated the [MEDICATION NAME] Patch was pending pharmacy delivery on 6/28/18 at 8:41 a.m. The Progress Notes revealed the Physician visited R#3 on 6/29/18 at 7:05 p.m. but do not document notifying the Physician that a prescription for [MEDICATION NAME] Patched was needed. The Nurses Progress Notes re… | 2020-09-01 |
| 448 | 448 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2018-08-30 | 842 | E | 1 | 0 | IJ9V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of facility policy, the facility failed to maintain complete and accurate clinical records, related to missing Controlled Substance Proof of Use forms for four (4) residents (R), (R#2, R#3, R#4, and R#6) from a sample of five (5) residents reviewed for administration of controlled substances. Findings include: Review of facility policy titled Medical Record Management date (MONTH) 2005, revealed the facility must maintain medical records on each resident, in accordance with accepted professional standards and practice and state and federal law. Medical records must be complete, accurately documented, readily accessible, systematically organized and maintained in a safe and secure environment. A complete medical record contains an accurate and functional representation of the resident's actual experience in the facility. 1. Review of the clinical record for R#2 revealed admission to the facility on [DATE] with orders for [MEDICATION NAME] 1 mg by mouth three times a day. Review of the Controlled Substance Proof of Use forms revealed from 8/3/18 until the medication was discontinued on 8/7/18, there is no Controlled Substance Proof of Use form to account for the administrations documented on the Medication Administration Record (MAR) on 8/3/18 at 9:00 p.m., 8/4/18 at 9:00 p.m. 8/5/18 at 9:00 a.m. 1:00 p.m. and 9:00 p.m., 8/6/18 at 9:00 a.m., 1:00 p.m. and 9:00 p.m. and at 8/7/18 at 9:00 a.m. Review of a list sent by the Pharmacy titled Sum of Quantity Shipped revealed on 8/7/18 ninety (90) [MEDICATION NAME] 1 mg were sent to the facility, and there was no Controlled Substance Proof of Use form for this 90 [MEDICATION NAME] 1 mg dated 8/7/18. According to the (MONTH) (YEAR) MAR nine administrations should have been documented on the missing Controlled Substance Proof of Use form. R#2 had an order dated 7/17/18 for [MEDICATION NAME] Instant Release 15 mg one tablet by mouth every six (6) hours … | 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 );