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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3267 | 3267 | PARKSIDE POST ACUTE AND REHABILITATION | 115643 | 3000 LENORA CHURCH DRIVE | SNELLVILLE | GA | 30078 | 2018-05-20 | 658 | D | 1 | 0 | 9RIX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review and observation it was determined that the facility failed to record the vital signs more than three times in a six-month period for one Resident (R#5) out of three residents reviewed. R#5 [DIAGNOSES REDACTED].) Findings include: Resident (R) #5 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. R#5's medications included [MEDICATION NAME] (anxiety), [MEDICATION NAME] (depression), and [MEDICATION NAME] (high blood pressure). Review of R#5's most recent assessment (quarterly )Minimum Data Set (MDS) assessment dated [DATE] revealed the that the resident is cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Per the quarterly MDS, the resident was coded in Section I 0700 [DIAGNOSES REDACTED]. The MDS (quarterly) dated 1/12/18 prior to hospitalization revealed the same coding. Review of acute hospital critical care progress note, dated 4/8/18, revealed R#5 was admitted to the Intensive Care Unit (ICU) on 4/6/18. The note further revealed the physician diagnosed shock secondary to hypovolemia (low blood volume), septic shock, and acute kidney injury related to low blood pressure. R#5 returned to the facility on [DATE]. On 5/2/18 at 11:15 a.m. Family of R#5 was interviewed over the telephone. She stated she was R#5's daughter. She stated R#5 had been doing well until on or about 4/6/18 when she was called by the facility and told R#5 was going to the hospital. She stated she went to the facility to find out what was going on and was told her mother's blood pressure had dropped. She stated she asked to see R#5's vital sign record and was shown the record in the computer. She stated there was no record for vital signs in the computer between 9/2017 and 4/2018. Review of the blood pressure summary in the facility electronic medical record (EMR), reveals no record of vital signs between 9/18/17 and 4/6/18. A review of the R#5's paper chart revealed no… | 2020-09-01 |
| 2062 | 2062 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2018-04-02 | 600 | E | 1 | 0 | 5W1R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review and policy review the facility failed to ensure three residents (R) (R#3, R#6 and R#7) were free from physical and verbal abuse The sample was ten (10) sampled residents. Findings include: Facility Policy titled Abuse, Neglect and Prohibition revised 12/17 revealed, Upon discovery of alleged abuse, the staff member(s) involved in the incident will be immediately suspended pending investigation. If the alleged violation is verified, and involves staff member(s), corrective action will be immediately taken up to and including discharge, The State Nurse Aide Registry or licensing authority will be notified. Record Review revealed grievance/complaint report for R#3 dated 3/5/18 that indicated a complaint was made by R#3's family member that documented on 2/15/18 the complainant observed Certified Nursing Assistant (CNA) AA, pull R#3 up from the back of her pants and threw her in the bed. Additionally, the grievance indicated that on 2/28/18 an officer was called to the facility because on 2/26/18 the family member came to the facility and R#3 had a bruise and did not have a sheet or anything on her, R#3 pulled her gown and soiled undergarments off and the complainant saw the bruises. The complainant called 911 and the officers came out and took pictures. Further record review revealed R#3's Minimum Data Set ((MDS) dated [DATE] revealed the resident has severe mental impairment coded on the Brief Interview for Mental Status a score of 99. R#3's [DIAGNOSES REDACTED]. The Assessment also indicated R#3 required substantial assistance with chair to bed transfer with the helper providing more than half the effort. During an interview on 3/26/18 at 9:27 a.m. Registered Nurse (RN) DD revealed she is aware that she is supposed to report allegations of abuse to the State Agency but does not remember why she did not report the allegation of abuse reported in the grievance for R#3 dated 3/5/18 to the State Agency. During … | 2020-09-01 |
| 4598 | 4598 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2019-04-04 | 867 | J | 1 | 0 | 3HNK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review and review of the facility policy titled Quality Assurance and Performance Improvement revised on [DATE], the facility failed to oversee training, monitoring and to revise policies related to Notification of Physician, glucose monitoring, and recognizing a change in condition to prevent delays in emergency situations. The facility census was 53. An Abbreviated/Partial Extended Survey investigating complaint GA 596 was initiated on (MONTH) 25, 2019 and concluded on (MONTH) 4, 2019. Complaint GA 596 was substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 25, 2019 was 53. On (MONTH) 27, 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, Interim Director of Nursing (DON), and Vice President (VP) of Operations were informed of the Immediate Jeopardy on (MONTH) 27, 2019 at 12:00 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 16, 2019. The Immediate Jeopardy continued through (MONTH) 30, 2019 and was removed on (MONTH) 31, 2019. The Immediate Jeopardy is outlined as follows: R#1 was admitted to the facility on [DATE] following a hospitalization . The resident was an insulin dependent diabetic. There was a Physician's Order for [MEDICATION NAME] six units at 9:00 p.m. daily, accuchecks twice daily, and to notify the Physician if blood glucose was less than 60 or greater than 400. A Department Notes entry on [DATE] at 7:01 a.m. revealed the resident has a finger stick blood sugar of 55 and the resident was given juice with added sugar which brought the resident's blood sugar to 61. The Department Notes entry documented that a fax was sent to the Physic… | 2019-09-01 |
| 998 | 998 | LAGRANGE HEALTH AND REHAB | 115354 | 2111 WEST POINT ROAD | LAGRANGE | GA | 30240 | 2019-10-28 | 600 | G | 1 | 0 | NHRP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review and review of the facility policy titled, Abuse Prohibition the facility failed to ensure that one resident (R#1) was free from sexual abuse; and, one resident (R#8, the roommate of R#1), who witnessed the abuse, was free from psychosocial harm from a sample of eight residents. Findings include: The facility had an Abuse Prohibition policy. The policy included a definition of sexual abuse as non-consensual sexual contact of any type with a resident. The policy includes a definition of mental abuse as includes, but not limited to, humiliation, harassment, threats of punishment or deprivation. Identification of Abuse: Neglect, and Exploitation-6. The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: a) resident, staff or family report of abuse; f) physical abuse (sexual abuse) of a resident observed; and g) Psychological abuse of a resident observed. 1. Resident #1(R#1) was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].); and hypertension. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 7, indicating the resident is severely impaired. Review of the care plan with a start date of 8/22/13 for R#1 revealed a problem area related to assistance required with Activities of daily living (ADL) due to [MEDICAL CONDITIONS], incontinence and impaired mobility and Impaired thought processes related to [MEDICAL CONDITION], that the resident is non-verbal but can answer yes/no by nodding his head. Record review of the facility investigation, dated 8/29/19, revealed an allegation that Certified Nursing Assistant (CNA) AA had sexually assaulted R#1 on 8/26/19. 2. Resident #8 (R#8) was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed a BIMS score of 3, indicat… | 2020-09-01 |
| 4586 | 4586 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2018-09-20 | 676 | D | 1 | 1 | IJ4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review, and review of the facility policy titled Bath, Shower/Tub, the facility failed to provide showers as scheduled for two residents (R) (A and B) out of 37 sampled residents. Findings include: 1. During an interview on 9/17/18 at 10:02 a.m., R A revealed that the North hall shower room does not work. Resident stated that all residents must use the South hall shower room. Resident stated that she does not always get a shower and she has waited for so long that she washed herself in her bathroom. R A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] documented R A with a Brief Interview of Mental Status (BIMS) score of 11 indicating cognition moderately impaired. R A required two-person physical help limited to transfer only with bathing. Review of the Shower List revealed R A is scheduled for showers on Monday, Wednesday, and Friday on the 7:00 a.m. to 3:00 p.m. shift. All bath sheets are to be filled out completely including any skin changes. Bath sheets to be done and given to charge nurse before the end of the shift. Charge nurses to sign off on bath sheets daily. Interview with Licensed Practical Nurse (LPN) BB on 9/19/18 at 3:30 p.m. revealed that the showers sheets for R A for (MONTH) and (MONTH) (YEAR) could not be located. 2. During an interview on 9/18/18 at 9:31 a.m., R B stated that she only gets a shower once per week and would like to have her scheduled showers which is supposed to be three times per week. R B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] documented R B with a BIMS score of 08 indicating cognition moderately impaired. R B required set-up help only with physical part of bathing activity. Review of the Shower List revealed R B is scheduled for showers on Tuesday, Thursday, and Saturday on the 7:00 a.m. to 3:00 p.m. shift. All ba… | 2019-09-01 |
| 398 | 398 | HARBORVIEW SATILLA | 115265 | 1600 RIVERSIDE AVE | WAYCROSS | GA | 31501 | 2018-02-15 | 600 | D | 1 | 1 | LMHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review, and the facility policy titled, Abuse Policy Facility A failed to ensure one Resident (R) (R#19) was protected from physical abuse. Failure to ensure protection resulted in R#19 being hit on 12/12/17 at 8:30 a.m. by R#100 who resided in an adjoining room. The sample size was 49 residents for Facility [NAME] Findings include: Record Review revealed nurse's notes, for R#100, dated 12/12/17, the note documented that R#100 went into another resident's room (R#19) via wheelchair through the adjoining bathroom door and began to strike R#19 with a shoehorn. The nurses note further documented that, this incident was in response to R#100 being irritated at the R#19's continuous loud calling out to staff throughout the night and the day which interrupted his (R#100) sleep and all other ADL's. During an interview on 2/14/18 at 4:49 p.m. with Registered Nurse (RN) BB revealed that she believed R#100 fully intended to hurt R#19 and she told everybody that she could, she continued by saying the grabber used to assault R#19 was taken away because R#100 told us he would do it again. During an interview on 2/14/18 at 5:53 p.m. with the Social Service Director (SSD) revealed that she considered what happened between R#19 and R#100 on 12/12/17 at 8:30 a.m. to be abuse. Telephone interview on 02/14/18 at 4:49 p.m. with RN ZZ, revealed that she believed the incident on 02/12/17, happened due to R#100, who stated that he had been kept awake all night by R#19, but R#100 has his own behaviors. Interview on 02/14/18 5:38 p.m, with the Administrator, revealed that he was aware of the incident that occurred on 12/12/17 but that he wouldn't necessarily call this abuse. The Administrator reported that he did not report the incident because it was an incident that occurred between two residents and that there was no injury. Further interview revealed that based on his knowledge of the regulations, this was an incident that did not hav… | 2020-09-01 |
| 3477 | 3477 | LAUREL PARK AT HENRY MED CTR | 115673 | 1050 HOSPITAL DRIVE | STOCKBRIDGE | GA | 30281 | 2019-02-04 | 658 | J | 1 | 0 | HHND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review, policy review and review of the Georgia Nurse Practice Act the facility failed to ensure that accepted standards of clinical practice were followed regarding accurately assessing a resident's advance directive status for one resident (#4) from a total sample of 30 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 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, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electron… | 2020-09-01 |
| 4164 | 4164 | LIFE CARE CENTER | 115654 | 176 LINCOLN AVE | FITZGERALD | GA | 31750 | 2017-03-17 | 520 | K | 1 | 0 | LKB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review, review of facility's policies, and review of the Risk Management/Quality Assurance Process -Improvement Program, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed quality of care related to residents' elopements and reviewed and revised care plans for residents identified as high risk for elopement. The facility's failure to maintain an effective QA program that implemented a plan to safeguard residents from further elopement by R#13, R#3 and R#17 was determined likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 3/15/17 at 10:15 a.m. and determined to first exist on 5/5/16, when R#13 first eloped from the facility at 7:20 a.m., then eloped from the facility the second time on 5/5/16 at 7:50 p.m. even though the facility's nursing staff had implemented 15 minute checks to monitor R#13's whereabouts. R#13 eloped four days later on 5/9/16 at 7 a.m. In addition, the facility failed to conduct a thorough investigation of R#3, R#13 and R#17 elopements to identify how R#3 eloped from one of the two secure units; how R#13 eloped two additional times, one the same day and again four days later, after the facility implemented the intervention of nursing staff monitoring R#13 every fifteen minutes and the elopement of R#17 on 1/28/17 at 10:15 a.m. after R#17 was assessed on the Elopement Risk Tool with a score of 5 which R#17 was at high risk for elopement. Review of R#17's care plan revealed that the only interventions were to monitor R#17 every 15 minutes for 72 hours and to move resident further down the unsecured hall way so that he had to walk past the nurses' station. After completion of the Elopement Risk Tool the QA program failed to review and revise care plans for residents (R#27, R#23, R#25 and R#26) who were identified as high risk, a score of 5 or more for elopement, to assure these residen… | 2020-03-01 |
| 659 | 659 | FAIRBURN HEALTH CARE CENTER | 115298 | 178 WEST CAMPBELLTON STREET | FAIRBURN | GA | 30213 | 2019-05-07 | 689 | D | 1 | 0 | RBFG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews and policies titled Admission Assessment and Follow up: Role of the Nurse and Assisting the Nurse in examining and assessing the resident, the facility failed to properly assess and provide supervision to prevent accidents in the area of falls for two of two residents (R), R#1 and R#4 reviewed .Sample size was 6. Findings include; 1. On 3/15/19 R#1 was admitted to the facility for respite care. [DIAGNOSES REDACTED]. Review of the baseline care plan in the electronic medical record (EMR) dated 3/18/19 indicated R#1 was at risk for falls. The careplan did not provide goals and interventions focused towards R#1's risk for falls. Continued review of R#1's medical record revealed resident fell [DATE]. He sustained a small laceration to his forehead. First aid provided. This was an unwitnessed fall. Review of the incident investigation dated 3/16/19 indicated resident was noted on the floor laying on his right side. Observed blood on the floor from his head. The investigation provided for review does not indicate what further interventions would be put into place and/or how the staff will continue to monitor R#1 to prevent falls. During an interview on 5/7/19 at 2:15 p.m. with the Director of Nursing (DON), a handwritten document titled, baseline care plan, was provided for R#1 dated 3/15/19. This document also identified the resident as a falls risk. There were no goals or interventions noted to address falls on this document. The DON stated when the resident is a fall risk we monitor them more closely. The DON was unable to qualify monitoring more closely. 2. On 3/18/19 R#4 was admitted to the facility for respite care. [DIAGNOSES REDACTED]. Review of R#4's admission assessment date 3/18/19, Section N, identifies the resident as having a falls risk/ Further review of R#4 EMR baseline, dated 3/18/19, identified resident as a falls risk. The EMR, baseline care plan did not provide goals and interventions to add… | 2020-09-01 |
| 2474 | 2474 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2019-10-10 | 925 | D | 1 | 0 | PV5P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews and review of pest control company service reports, the facility failed to maintain effective pest control for one resident hall (300) of eight resident halls in the facility. Findings include: The facility had a contract in place with a pest control company, since 1/5/18. The contract included interior insect inspection and control for pests to be provided twice monthly. The contract also specified that the facility had six existing and three new insect light traps at that time. A review of the pest control company Service Inspection Report forms from (MONTH) 2019 through (MONTH) 2019 revealed that twice monthly pest control services had been provided on 6/4/19, 6/14/19, 7/1/19, 7/18/19, 8/15/19, 8/22/19, 9/17/19 and 9/26/19. A review of nurses notes and respiratory notes revealed that on 7/6/19 R#11 was observed to have a fly flying around her face and additional insects on her neck, near her stoma and [MEDICAL CONDITION] site. The insects were removed and the physician was notified. The resident was removed from the room, showered, and reassessed to ensure no other insects were observed, then transferred to a different room. The 7/6/19 12:26 p.m. nurse progress note documented that the resident's family member was notified that the resident was moved to the 200 hall due to flies being in her room. The nurse note also documents that the family member was satisfied with the move and stated the residents' room always had flies in it. During an interview on 10/7/19 at 10:35 a.m. the Respiratory Therapy (RT) Director stated she was making her first rounds that morning on 7/6/19 and noted the gauze around R#11's [MEDICAL CONDITION] and stoma site was soiled, and as she was changing the gauze she noticed what looked like a maggot when she removed the gauze. RT stated that the resident had a large neck and extra tissue growth/flap near her stoma site, above it. Licensed Practical Nurse (LPN) DD came into the r… | 2020-09-01 |
| 2462 | 2462 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2018-04-19 | 726 | J | 1 | 0 | 6SHS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews and review of the facility policy titled, Orientation Program for Newly Hired Employees, Transfers, and Volunteers policy, it was determined that the facility failed to ensure that the competencies of a newly hired Certified Nursing Assistant (CNA) staff were adequately assessed prior to them providing resident care independently for one of six newly hired CNA's reviewed. On 4/13/18, 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 were informed of the Immediate Jeopardy on 4/13/18 at 6:40 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/9/18. The Immediate Jeopardy continued through 4/18/18, and was removed on 4/19/18. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on 4/18/18. The Immediate Jeopardy is outlined as follows: Resident (R) #1 was identified with first and second [MEDICAL CONDITION] the lower extremities, buttocks and groin on the morning of 4/10/18 and was sent to an acute care hospital where she was admitted . Through the facility's investigation, it was determined that the resident had received a shower the evening prior, on 4/9/18. The facility monitored water temperatures in the residents' rooms and the common shower rooms on 4/10/18 and 4/11/18, all water temperatures were found to be less than 120 degrees Fahrenheit (F) at that time. A plumbing company was also contacted and provided onsite services on 4/10/18 and 4/12/18, which included adjusting the water mixing valves. However, unsafe water temperatures were identified on 4/13/18, after surveyor entrance. These unsafe water temperatures were found in five bathrooms, shared by nine resident rooms, with 14 residents o… | 2020-09-01 |
| 3389 | 3389 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2019-11-25 | 600 | D | 1 | 0 | WVWZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews, and policy review, the facility failed to protect two cognitively impaired residents (R) (A and #2) from having sexual contact from a total sample of eight residents. Findings include: The facility had a Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy. The policy included a definition of sexual abuse as non-consensual sexual contact of any type with a patient. The facility's Abuse Prevention and Reporting policy defined sexual abuse as including but not limited to sexual harassment, sexual coercion, and sexual assault. RA was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the 9/8/19 Quarterly Minimum Data Set (MDS) assessment revealed that RA was assessed as having severe cognitive impairment and impaired memory. A review of the clinical record revealed that RA was ambulatory and wandered. R#2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the 10/3/19 MDS assessment revealed that R#2 was assessed as being ambulatory and having a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating some memory and cognitive impairment. A review of the clinical record revealed no history of sexually inappropriate behaviors prior to nursing home placement or during his nursing home stay until 11/19/19. A review of facility reported incidents revealed a Facility Incident Report Form, dated 11/19/19, that documented an allegation of resident to resident sexual abuse. The form included that the allegation involved RA as the alleged victim and R#2 as the alleged perpetrator. A further review of the form revealed the date and time of the incident as occurring on 11/19/19 at 7:00 a.m. Resident #2 was observed in RA's room and engaged in a possible oral sexual assault. The residents were separated, and the physician, police and responsible parties were notified. The witness to the incident … | 2020-09-01 |
| 2918 | 2918 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2018-02-02 | 686 | E | 1 | 0 | QF5911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews, and policy review, the facility failed to provide a thorough initial assessment of a pressure ulcer for three residents (#1, #2, and #3) from a total sample of five residents. Findings include: The facility had a pressure ulcer policy. The Pressure Ulcer and Skin Care Management policy documented that the licensed nurse documents the evaluation or presence of skin concerns. 1. Resident (R) #1 was admitted to the facility on [DATE]. The Resident Data Set form, completed on 11/24/17 documented that the resident had excoriation to the buttocks and sacrum. A review of the nursing notes revealed that protective barrier cream was applied routinely to the excoriated areas. On 12/17/17 R#1 was documented as having a stage 2 pressure ulcer on the Treatment Administration Record (TAR). an order for [REDACTED]. On 12/20/17 the wound care physician documented that the pressure ulcer measured 8 cm x 6 cm x 0.1 cm, with light serous drainage, and was unstageable with 40% thick adherent devitalized tissue, 10% granulation tissue and 50% skin. A review of the weekly Wound Care Specialist Evaluations, completed by the wound care physician, revealed that the pressure ulcer progressed from the facility's initial identification of a stage 2 pressure ulcer, to unstageable, and then to a stage 4 pressure ulcer. The most recent evaluation, on 1/24/18, documented that the pressure ulcer was improved. 2. R#2 was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [REDACTED]. Review of the 11/10/17 Admission Resident Data Set, Section O, Skin, revealed documentation of a stage 3 sacral decubitus measuring 6.6 x 4 centimeters(cm). There was no descriptive documentation describing the appearance of the wound bed. Further review revealed there were no physician's orders for wound care to the sacrum until three days later on 11/13/17 to clean the wound to sacral area with wound cleanser or normal salin… | 2020-09-01 |
| 1202 | 1202 | PRUITTHEALTH - MONROE | 115379 | 4796 HIGHWAY 42 NORTH | FORSYTH | GA | 31029 | 2019-09-16 | 656 | D | 1 | 0 | DP3B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews, the facility failed to ensure that medications were administered as care planned for two residents (R#2 and R A) from a total sample of 12 residents. Findings include: 1. Resident (R) #2 had a care plan for having impaired cardiac output related to a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. The resident also had a care plan for a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. However, a review of the clinical record revealed that R#2 did not receive the [MEDICATION NAME] Extended on 1/27/19 at 9:00 p.m. as scheduled nor did he receive the 9:00 a.m. doses of [MEDICATION NAME] and levetiracetam on 1/28/19, as ordered, as care planned. A review of the (MONTH) 2019 Medication Administration History revealed that the medications were documented as not administered and drug/item unavailable. During an interview on 9/16/19 at 2:10 p.m., the Administrator stated that the pharmacy sent out seven days worth of medications on 1/19/19, therefore the medications would have been out on 1/27/19 or 1/28/19. The pharmacy sent out an additional five days works of medications on the night of 1/28/19. Cross refer to F684 2. R A had a care plan in place since 9/3/18 for a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. The medication was scheduled to be administered at 9:00 a.m. and 5:00 p.m. However, a review of the clinical record revealed that RA did not receive the levetiracetam on 8/29/19 at 5:00 p.m. as scheduled, as care planned. A review of the (MONTH) 2019 Medication Administration History revealed that the medication was documented as not administered and resident unavailable. A further review of the clinical record revealed that RA had left the facility for an outside appointment but had returned prior to the 5:00 p.m. medications being due. Nurses note entries on 8/29/19 documented that RA was out for a Phys… | 2020-09-01 |
| 4939 | 4939 | PRUITTHEALTH - VALDOSTA | 115377 | 2501 NORTH ASHLEY STREET | VALDOSTA | GA | 31602 | 2016-03-03 | 309 | D | 1 | 0 | 7KN011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record and staff interview, the facility failed to administer the correct dosage of [MEDICATION NAME] per Physician the order for one (1) resident R7 of three (3) sampled residents. Findings include: Review of medical records for resident R7 who was admitted to the facility under Hospice services on 12/3/15 with [DIAGNOSES REDACTED]. Review of the Resident R7 had a Physician order [REDACTED]. Review of the Nurse ' s Note dated 12/10/15 revealed resident R7 received [MEDICATION NAME] 4 mg IM one dose related to increase agitation. Further review of the nurse ' s note for behavior revealed five (5) episode of agitation or restlessness noted in (MONTH) (YEAR). In (MONTH) (YEAR) resident #7 was noted to have two (2) episode of being sedated. During an interview on 3/2/16 at 9:26 a.m. with BB Registered Nurse (RN) was asked by nurse surveyor to read his/her nurse's note dated 12/10/15. BB RN stated resident R7 was administered [MEDICATION NAME] 4 mg IM and verified that it charted in the nurse' s notes. BB RN stated three (3) separate times that [MEDICATION NAME] 4 mg was administered to resident R7. BB RN was asked to review the Physician order [REDACTED]. After BB reviewed the Physician order, BB stated that he/she had made a mistake and gave resident R7 the wrong dose of [MEDICATION NAME]. During an interview on 3/2/16 at 10:32 a.m. with CC RN revealed that the [MEDICATION NAME] 2 mg as needed was changed on 12/10/16 because the facility staff nurse reported that resident R7 was trying to bed out of bed, had increase restlessness and was pulling at things. CC RN stated he/she obtained the new Physician order [REDACTED]. However, CC RN then stated he/she was not aware of the 12/3/15 Physician order [REDACTED]. During an interview via phone on 3/2/16 at 3:21 p.m. with FF Advanced Nurse Reactionary (ANP) stated resident R7 was exhibiting increased anxiety with [MEDICATION NAME]. Therefore scheduled [MEDICATION NAME] ([MEDICATION… | 2019-03-01 |
| 4972 | 4972 | FULTON CENTER FOR REHABILITATION LLC | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2016-03-10 | 309 | D | 1 | 0 | DDVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview it was determined that the facility staff failed to carry out the physician order [REDACTED]. Findings include: Resident # 1 is a [AGE] year old who was readmitted to the facility on [DATE]. Diagnoses: [REDACTED]. Medical record review revealed and order was made by the physician for HgA1C blood work on 1/19/2016. The blood work was not done. 3/10/2016 at 5:42 p.m. Staff interview with the Director of Nursing (DON) stated it was her expectation for blood work to be done as soon as possible after the order was made. The facility policy states the order must be written by the physician and transcribed by the licensed nurse. | 2019-03-01 |
| 4971 | 4971 | FULTON CENTER FOR REHABILITATION LLC | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2016-03-10 | 157 | D | 1 | 0 | DDVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview it was determined that the facility staff failed to notify the physician and the responsible party of change of condition for one resident (#3) of the three (3)sampled residents. Findings include: Record review for R # 3 revealed a [AGE] year old was admitted to facility on 2/12/2016, with [DIAGNOSES REDACTED]. Review of medical record revealed in nursing notes dated 3/1/2016, revealed resident # 3 ate very little today. On 3/2/2016 the nurses notes stated resident did not eat today, holds food in her mouth, appears weak. Review of note dated 3/3/2016 at 7:30 a.m. resident was in bed with a blank stare. Resident was unresponsive to touch or movement. Respiration shallow at 22 bpm. No notification of physician or responsible person noted in chart. On 3/10/2016 at 4:25 p.m. Staff interview with AA a Licensed Practical Nurse who stated she found the resident on 3/3/16. Resident # 3 eyes were starirng and she was unresponsive to touch. AA stated vital were done and the ambulance was called. AA stated that the resident appetite became poor on 3/1/2016 and did not eat any of her food on 3/3/16 as was reported by her Certified Nursing Aide (CNA). The staff AA stated that the physician or the responsible party was not notified. Staff AA did not provide a reason why the physician or responsible party was not notified. On 3/10/2016 Staff interview conducted with the Director of Nursing revealed that it is her expectation the physican be notified if the resident did not eat by the second day. The facility policy stated that Upon identification of a patient who has a change in condition, a licensed nurse will perform appropriate observation and data collection and report to physician. | 2019-03-01 |
| 4397 | 4397 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2016-12-10 | 280 | J | 1 | 0 | QBL111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observations, and staff interviews, the facility failed to ensure revision of the comprehensive care plan to adequately reflect the status of four residents (R) R#39, R#81, R#27, and R#51 of 45 sample residents. Specifically, R#39's care plan was not revised to reflect an incident of threatening another resident; R#51's care plan was not revised to reflect the resident's positioning needs; R27's care plan was not revised to reflect the resident's current needs for help with activities of daily living; and R#51's care plan was not reviewed quarterly as required. The facility's failure to revise R#39's care plan after threatening R#56 with harm by a wire clothes hanger was determined to be likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy was identified on 12/8/16 and determined to first exist on 10/23/16, when R#39 first threatened R#56 with harm using a wire clothes hanger. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 12/8/16 at 2:55 p.m. An acceptable Allegation of Compliance (AoC) was received on 12/10/16 and the surveyors validated the Immediate Jeopardy was removed on 12/10/16 as alleged. The deficient practice remained at a [NAME] (pattern of potential for more than minimal harm) scope and severity while the facility developed and implemented the Plan of Correction and the facility's Quality Assurance Committee monitored the effectiveness of the systemic changes. Findings include: 1. R#39 was admitted to the facility on [DATE] (Refer to F223 Background information for pertinent diagnoses). The annual Minimum Data Set (MDS), was reviewed (Refer to F223 for R#39's cognitive status decision-making skills, behaviors and locomotion). Per the 9/15/09 Initial Social Service Assessment and the 8/24/16 and 11/29/16 Social Services Notes R#39 had a history of [REDACTED]. A 10/23/16, 4:30 p.m. Nurse's Note, written by… | 2019-11-01 |
| 4721 | 4721 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2016-07-18 | 246 | E | 1 | 0 | LC8U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation , record review, policy and procedure review and interviews, the facility failed to ensure that daily wound care was provided at the preferred time for one (1) resident (#2) that wanted to be out of bed everyday for lunch and other activities. The sample was seven (7) residents. Refer F353, F490, F520 Findings include: Review of the policy titled Patient's Rights documented: A patient at Brown Health & Rehabilitation has the right to get up and go to bed as desired. Observation and interview on 7/7/16 at 2:00 p.m. revealed Resident #2 in his room in bed. Interview at the time of observation revealed the resident was still in bed because he was waiting for wound care and could not get out of bed until the treatment was done. Resident # 2 stated he required assistance from the staff to get out of bed and likes to be out of bed by lunch. He likes to go to the dining room for lunch, socialize and attend activities but often cannot because he is waiting for wound treatment. Resident #2 further stated that everyone knows that he would like his treatment to be completed no later than 11:00 a.m. so that the Certified Nursing Assistants (CNAs) can get him up for lunch. He said his mother works here and she has made it known to all staff and management that he is to have his treatment around 9:30-10:00 a.m. so he can get up and out of bed however, he still waits in his bed sometimes all day. Record review for Resident #2 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) summary score of 15 indicating the resident is cognitively intact. An observation on 7/7/16 at 3:30 p.m. revealed Resident #2 remains in his room in bed. An observation on 7/7/16 at 5:05 p.m. revealed Resident #2 in his wheelchair propelling through the hallway. Interview with the resident at this time revealed he had just gotten up out of bed and finally got his wound treatment about an hour ear… | 2019-07-01 |
| 4736 | 4736 | SOUTHLAND HEALTHCARE AND REHAB CENTER | 115376 | 606 SIMMONS ST | DUBLIN | GA | 31040 | 2016-07-14 | 314 | G | 1 | 0 | V39211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation , staff interview and Dressing Change Policy, the facility failed to prevent cross contamination of wounds for two (2) (Resident #1 and #2) of three (3) residents from a sample of ten (10) residents. Findings Include: 1. Review of the medical record for resident #1 revealed the following Diagnosis: [REDACTED]. Resident # 1 has six (6) areas that requires daily dressing changes which includes right inner buttock, right heel, right hip, left inner foot, left hand and abdominal percutaneous endoscopic gastrostomy (peg) dressing During an observation on 7/13/16 at 7:32 a.m., Licensed Practical Nurse (LPN) AA did not change gloves between providing treatment to the right heel and the right hip. LPN AA removed the soiled dressing from the right hip with the same gloves and continued to clean the right hip wound with wound cleanser. Using the same gloves, he/she began to open [MEDICATION NAME] non-adhesive pad. LPN AA placed the wrapper in the red biohazard bag and still wearing the same gloves pushed the wrapper further into the red bag and did not change the gloves. LPN AA continued to apply the adhesive dressing to the wound. After the adhesive dressing was applied he/she removed and discarded the gloves. During an interview on 7/13/16 at (:36 a.m. LPN AA stated he/she had forgot to change the gloves between the right heel and right hip wound treatment and that the policy stated to wash hands between dressings. LPN AA stated that he/she knew better not to put his/her hand in the red biohazard bag to push down the discarded wrappers. LPN AA stated that previously he/she had worked as a weekend treatment nurse and did not have any additional training in wound care. 2. Review of the medical records for resident #2 revealed the following Diagnosis: [REDACTED]. During an observation on 7/13/16 at 9:25 a.m., LPN AA, removed the soiled dressing from the sacral wound and as he/she placed it in the red biohazard bag his/her gloved h… | 2019-07-01 |
| 1490 | 1490 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2018-09-28 | 689 | D | 1 | 1 | T04T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to assure electrical safety in two rooms on one of four units where an electrical power strip was used to provide electricity to multiple medical devices. The sample size was 60 residents. Findings include: 1. Observation on 9/25/18 at 8:20 a.m., on the Branches unit, revealed room [ROOM NUMBER] bed B had power strip lying on the floor at the head of the bed. The power strip was plugged into an electrical outlet on the wall. Connected to the power strip and supplying electrical current was a hospital bed and an enteral feeding pump. 2. Observation on 9/25/18 at 10:08 a.m., on the Branches unit, revealed room [ROOM NUMBER] both beds A and B had power strips attached to the wall; at the head of the bed for bed A and on the right side of bed B. The power strips were plugged into electrical outlets on the wall. Connected to the power strips and supplying electrical current were two hospital beds and two Oxygen concentrators. Interview on 9/28/18 at 3:02 p.m., Maintenance Supervisor stated he was not aware that medical equipment could not be connected to power strips. He stated that he would switch the medical equipment to the outlets on the wall. | 2020-09-01 |
| 4167 | 4167 | HEARDMONT HEALTH AND REHABILITATION | 115685 | 1043 LONGSTREET ROAD | ELBERTON | GA | 30635 | 2017-03-26 | 356 | C | 1 | 0 | 50TD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to ensure that the nurse staffing data sheet was posted daily for public review. The facility census was 41. Findings include: During an observation that was conducted on 3/26/17 at 12:32 p.m. with the weekend Nursing Supervisor (NS), she showed where the nursing hours were posted in the front lobby by the entrance door. NS pulled the sheets titled Daily Nursing Hours from a clear covering and the last nursing data sheet posted was dated 3/23/17. In an interview with NS at 12:34 p.m. in her office, she stated that she is the PRN (as needed) weekend RN Supervisor and that she typically works in the facility every other Sunday. NS stated that in the morning, she is expected to see who is working that day, fill out the Daily Nursing Hours sheet and post it in the front lobby. NS said that this morning she had been busy with preparing the physician order [REDACTED]. NS further stated that she did not know why the Daily Nursing Hours sheet had not been posted on Friday, (MONTH) 24, (YEAR) or Saturday, (MONTH) 25, (YEAR). In an interview with the Administrator on 3/26/17 at 12:55 p.m., she stated that the facility does not have a policy for posting nursing data but that it is expected that projected nursing hours are posted everyday first thing in the morning based on the schedule and any changes, such as call outs, would be adjusted as needed. During an interview with the facility Secretary DD on 3/26/17 at 1:00 p.m., she stated that she is responsible for posting the Daily Nursing Hours sheet Monday through Friday. She thought that the weekend supervisors posted the sheet on the weekends. Secretary DD did not have explanation for why the last day posted was on Thursday, (MONTH) 23, (YEAR). On 3/26/17 at 1:04 p.m., the Administrator was observed telling Secretary DD that she is responsible for posting the projected nursing hours for Saturday and Sunday and the weekend supervisors would make… | 2020-03-01 |
| 2024 | 2024 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2017-10-08 | 280 | J | 1 | 0 | UU0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to review and revise the care plan, assess the resident's responses to current care plan interventions and failed to get input from the resident or his/her representative regarding the reason for the elopement and possible interventions for preventing a future elopement for one resident (R) #1 of six residents sampled after the resident successfully eloped from the facility on [DATE]. On [DATE] 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, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions i… | 2020-09-01 |
| 1112 | 1112 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 584 | D | 1 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews the facility failed to ensure that it was maintained in a safe clean and comfortable homelike environment in seven resident rooms with dirty air filters and dirty vents on the heating and air wall units. Findings include: 1. An observation on 2/10/20 at 11:30 a.m. of the air conditioner/heat pump (ac/hp) wall unit in room [ROOM NUMBER] revealed that the ac/hp system had two air filters located in the front that are clogged with thick amount of dust and debris. The outside of the unit revealed the vents were covered with black dirty with debris. 2. An observation on 2/11/20 at 11:20 a.m. observation of the ac/hp wall unit in room [ROOM NUMBER] revealed that unit had two air filters located in the front clogged up with thick amount of grey dust and debris. The outside of the unit revealed the vents were covered with black dirty with debris. An interview on 2/11/20 at 11: 21 a.m. with R#82 revealed that he has never seen anyone from the housekeeping or maintenance department wipe the outside of the ac/hp unit or clean/replace the air filters. 3. An observation on 2/11/20 at 11:22 a.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed that the two air filters located in the front clogged with thick amount of grey dust and debris. The outside of the ac/hp unit revealed the vents were covered with black dirty with debris. Interview on 2/11/2020 at 11:23 p.m. with R#116 revealed that the resident has never seen anyone from housekeeping wipe the outside of the ac/hp unit or clean/replace the air filters. 4. An observation on 2/11/2020 at 11:26 a.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed that the two air filters located in the front clogged with thick amount of dust and debris. The outside of the ac/hp unit was dirty with debris. 5. An observation on 2/11/2020 at 12:00 p.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed thick with dust on the two air filters. 6. An observation on 2/11/202… | 2020-09-01 |
| 1587 | 1587 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2018-10-05 | 584 | D | 1 | 0 | FZSI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, as evidenced by dirty, dust-covered air-conditioning coils possibly blowing particulate debris into a resident room, and damaged drywall, paint, and baseboards in four rooms out of 27 rooms on one hall out of two. Findings include: On 8/20/2018 at 12:00 p.m. room [ROOM NUMBER] was directly observed. The room was clean but there was a missing piece of plaster, about the size of a one-foot ruler, on the corner of the wall near the bathroom, exposing bare metal beneath the damaged plaster. Observation and interview on 8/20/2018 at 12:05 p.m., with roommates, Resident (R) #11 and R#12 revealed that the baseboard under the pass-through air-conditioner (PTAC) was damaged and the drywall above the baseboard was stained. The commode-riser chair over the toilet in the bathroom had a crack in the seat, which was covered in clear tape. There was a hole in the drywall at the foot of the A-bed. There were four small holes in the wall under the wall light of the A-bed. R#12 was lying in the B-bed. She stated she told the maintenance man about the cracked commode seat a week ago but all he had done so far was cover the crack with tape. She stated she wanted to show the surveyor the hole in the wall at the foot of her bed. Observation of this area revealed a hole in the drywall about the size of a fist. Review of R#11's Minimum Data Set (MDS), dated [DATE], revealed a brief interview for mental status (BIMS) score of 15, signifying intact cognition. Review of R#12's MDS, dated [DATE] revealed a BIMS score of 15. Observation on 8/20/2018 at 12:12 p.m. of R#7's bathroom revealed there was a square hole in the drop-ceiling about the size of a paperback novel. There were two large brown stains on the ceiling. Observation and interview on 8/20/2018 at 12:30 p.m. with the Maintenance Director (MD) CC revealed that he removed… | 2020-09-01 |
| 3046 | 3046 | EASTMAN HEALTHCARE & REHAB | 115622 | 556 CHESTER HIGHWAY | EASTMAN | GA | 31023 | 2019-10-23 | 584 | E | 1 | 1 | PMJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews with residents and staff, it was determined that the facility failed to maintain a comfortable interior related to temperatures in rooms and hallways, and TV Room. The facility failed to maintain comforatable hotwater temperature for residents. Specifically, this failure affected four of five hallways related to comfortable temperature in the hallway and one TV room, six of 50 rooms related to resident rooms being too cold, and three of 28 resident bathrooms not having comforatable hot water. Findings include: Water temperatures, safety revised (MONTH) 2009 Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees F, or the maximum allowable temperature per state regulation. Safe and Homelike Environment 2019 7. The facility will maintain comfortable and safe temperature levels. a. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. 1. An observation on 10/21/19 at 9:31 a.m. the thermostat on 100 hall revealed 64 degrees Fahrenheit (F). An observation on 10/21/19 at 9:33 a.m. the thermostat on 200 hall revealed 58 degrees F. An observation on 10/21/19 at 9:35 a.m. the thermostat on 500 hall near room [ROOM NUMBER] revealed 67 degrees F. An observation on 10/23/19 at 7:38 a.m. of the thermometer at the end of 200 hall revealed a temperature of 65 degrees F. Interview on 10/23/19 at 7:41 a.m. with Resident A who reported that it is very cold in her room and it makes it hard to get up in the mornings. Tour with the Maintenance Director began on 10/23/19 at 8:20 a.m. and revealed the following: 1. In the shared bathroom for room [ROOM NUMBER] and 114 the hot water temperature was 94 degrees F after running for five minutes. 2. In the shared bathroom for room [ROOM NUMBER] and 103 the hot water temperature after five minutes was 92.8 degrees F. 3. In room [ROOM N… | 2020-09-01 |
| 668 | 668 | PRUITTHEALTH - LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2019-01-17 | 584 | E | 1 | 1 | VPJP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in 13 rooms on two of three halls (A2A/C, A6C, A8C, A12C, A16A/C, A18, B1A, B5, B7, B10C, B11, B12A/B/C, B13A/B); warped and broken window blinds in dining room. The facility census was 85. Findings Include: Observation on 1/14/19 at 12:02 p.m., revealed in room A8-C, privacy curtain with two (2) dime sized light brown stains. Observation on 1/14/19 at 12:09 p.m., revealed in room A2-A, privacy curtain with multiple pink colored stains at bottom of curtain. Observation on 1/14/19 at 12:10 p.m., revealed in room A2-C, stained ceiling tile in left upper corner, approximately 12 inches by six inches; chipping paint off bathroom wall; bathroom vent with thick layer of dust buildup on the louvers. Observation on 1/14/19 at 12:29 p.m., revealed in room A6-C, multiple bare patches down to dry wall, around sink in bathroom and left of the sink close to door. Observation on 1/14/19 at 12:40 p.m., revealed in room A12-C, multiple patches of chipped and peeling paint in bathroom; ripped ceiling tile in bathroom; vent in bathroom with heavy layer of dust on louvers and vent loosely hanging from ceiling. Observation on 1/15/19 at 8:32 a.m., revealed in room A16-C, privacy curtain with multiple brown stains in various spots. Observation on 1/15/19 at 9:44 a.m., revealed in room B1-A, two ceiling tiles with light brown stains. Observation on 1/15/19 at 11:19 a.m., revealed in room A16-A, vent in bathroom ceiling dusty and loosely hanging from ceiling; brown dried material on toilet handle; five ceiling tiles ripped and peeling. Observation on 1/15/19 at 11:59 a.m., revealed in room A18-A a cracked ceiling tiles in bathroom around the vent; chipped and peeling paint at the sink and at the toilet paper holder; scuffed wall at entrance, for the length of the wall; missing electrical face plate at socket close to tel… | 2020-09-01 |
| 3681 | 3681 | SMITH MEDICAL NURSING CARE CTR | 115691 | 501 EAST MCCARTY ST | SANDERSVILLE | GA | 31082 | 2018-10-04 | 584 | D | 1 | 1 | 1T3M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in five resident rooms (rooms 106, 107, 109, 112, 143) on two of two halls and in two of two shower rooms. Findings include: Observation on 10/1/18 at 10:36 a.m. revealed room [ROOM NUMBER] had two ceiling tiles with brown stains: one approximately eight inches by four inches and another two inches by two inches; also there was no hot water coming from the sink. Observation on 10/1/18 at 10:43 a.m. revealed room [ROOM NUMBER] had black scuff marks to left of bed A at chair line. Observation on 10/1/18 at 10:47 a.m. revealed room [ROOM NUMBER] bed B privacy curtain with three dark brown stains, each stain mark approximately one inch by one inch. Observation on 10/1/18 at 10:49 a.m. revealed linen storage room had two ceiling tiles with brown circular stains approximately four inches by four inches; vent loosely hanging from ceiling. Observation on 10/1/18 at 11:20 a.m. revealed room [ROOM NUMBER] had no water coming from cold water faucet. Observation on 10/1/18 at 11:30 a.m. revealed women's shower stall with built up dark brown material, resembling soap scum, on wall tiles close to floor; shower chair in women's shower stall with built up dark brown material, resembling soap scum, on seat and legs of shower chair; ceiling tile outside shower room door, approximately two inch by two inch brown circular Observation on 10/1/18 at 11:32 a.m. revealed public water fountain with brown water stain around spigot and drain. Observation on 10/1/18 at 11:38 a.m. revealed men's shower room shower stall with built up dark brown material, resembling soap scum, on wall tiles close to floor; sink in men's shower room draining slowly. Observation on 10/3/18 at 10:11 a.m. revealed room [ROOM NUMBER] had multiple ceiling tiles in bathroom bowing outward with all stained light brown. Observation on 10/3/18 at 10:11 a… | 2020-09-01 |
| 139 | 139 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 584 | E | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in five resident rooms (rooms 136, 138, 303, 316, 317) on two of three halls and common dining areas in three of three dining rooms (dining rooms #1, #2, #3) and unit 100 hallways. The census was 95. Findings include: 1. Observation in room [ROOM NUMBER] on 8/7/18 at 8:44 a.m. revealed the following: -There were two continuous black scrapes on the wall 9-inches apart from below the television on the wall to the nightlight below it, all along the length of the wall going toward the hallway. -There was a triangular-shaped missing piece of laminate on the B-bed closet door at the bottom left side exposing the particle board underneath, and a 4-inch by 0.25-inch missing piece of laminate on the vertical aspect of the front of the dresser top in front of the mirror. Observation in room [ROOM NUMBER] on 8/7/18 at 8:56 a.m. revealed the following: -There was a 14-inch long by 7-1/2-inch wide section of sheet rock that had been plastered over but not painted across from the A-bed. -There were two holes in the wall, one above the other, 3/4-inch in circumference above the cork bulletin board across from the A-bed. -There was a 2-inch by 2-inch triangular-shaped hole in the wall to the left of the bathroom door above the baseboard. -There was a deep horizontal gouge in the wall 25 inches above the baseboard to the left of the bathroom door. These concerns were verified by the Maintenance Supervisor during a walk-through of the environment on 8/9/18 at 10:12 a.m. In addition to the above concerns, he verified that the laminate was missing off the third (bottom) drawer of the cabinet in the bathroom in room [ROOM NUMBER]. 2. Observation on 8/6/18 at 10:46 a.m., revealed room [ROOM NUMBER] had four patches of torn sheet rock above head of bed A, approximately two inches long; one ceiling tile above bed A with a… | 2020-09-01 |
| 4308 | 4308 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 584 | E | 1 | 1 | I5PG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in seven resident rooms (rooms 200, 201, 203, 206, 209, 210, 227), common shower room and supply storage room, on one of two units. The census was 108. Findings include: Observation on 7/21/19 at 11:20 a.m., revealed on second floor, A Hall supply/storage fluorescent room light out, making room dark during retrieval of supplies. Observation on 7/21/19 at 11:30 a.m., revealed in room [ROOM NUMBER] light bowl sitting on sink counter; ripped wallpaper strip above bed A; peeling particle board on sink counter; hole in ceiling, between two beds, with electrical face plate partially covering opening; hole in ceiling tile in bathroom, approximately two inches in diameter; light in bathroom missing globe fixture; hole in ceiling tile in bathroom, approximately one inch circular around sprinkler head. Observation on 7/21/19 at 12:51 p.m., revealed in room [ROOM NUMBER], electrical outlet in wall with broken face plate. Observation on 7/21/19 at 12:55 p.m., revealed in room [ROOM NUMBER], a hole in ceiling tile in bathroom, approximately two inches in diameter; call light reset button missing on wall unit; chair rail missing around room on bed B side of the room. Observation on 7/21/19 at 2:16 p.m., revealed in room [ROOM NUMBER], hole in ceiling, between two beds, with electrical face plate partially covering opening. Observation on 7/21/19 at 2:18 p.m., revealed common shower room on second floor, with strong, unidentifiable and gagging odor. Observation on 7/22/19 at 11:04 a.m., revealed in room [ROOM NUMBER], bathroom had very strong urine odor; male urinal in clear plastic bag hanging on grab bar, with dark discolored ring around urinal opening. Observation on 7/22/19 at 12:11 p.m., revealed in room [ROOM NUMBER], hole in ceiling, between two beds, with electrical face plate partially covering opening. … | 2019-11-01 |
| 165 | 165 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-06-27 | 584 | D | 1 | 1 | 3SRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in six resident rooms on one of four halls and one of two units (402 B, 403 B, 405, 406, 407 and 409) related to dirty air conditioner face grills and scratched paint on door frame. The sample size is 39. Findings include: Observation on 6/24/19 at 10:25 a.m. revealed in room [ROOM NUMBER] B, the call light was pulled out of the wall and laying on the floor. Resident stated it has not worked since he was admitted on [DATE]. Observation on 6/24/19 at 1:43 p.m. revealed in room [ROOM NUMBER] B, no privacy curtain hanging from ceiling. Observation on 6/24/19 at 1:49 p.m. revealed in room [ROOM NUMBER], bathroom door frame with multiples patches of chipped paint. Observation on 6/24/19 at 1:52 p.m. revealed in room [ROOM NUMBER], air conditioner unit face grill dusty with small black spots, approximately two centimeters in diameter, on the slats. Observation on 6/24/19 at 1:55 p.m. revealed in room [ROOM NUMBER], air conditioner unit face grill dusty with small black spots, approximately two centimeters in diameter, on the slats. Observation on 6/24/19 at 1:58 p.m., revealed in room [ROOM NUMBER] A, the call light switch plate on wall above bed was loose and missing two screws. Observation on 6/25/19 at 12:23 p.m., revealed in room [ROOM NUMBER] the air conditioner unit face grill dusty with small black spots, approximately two centimeters in diameter, on the slats. Interview on 6/25/19 at 9:00 a.m. with Maintenance Technician NN, stated that he has been having to change several call lights, because of the ten foot long cords. He stated they get tied around the side rails and when the rails go up and down, it puts tension on the cord, causing it to break at the point of connection. Interview on 6/27/19 at 10:28 a.m. with Housekeeper II, stated that she is the only housekeeping staff for the West Unit. … | 2020-09-01 |
| 3037 | 3037 | EASTMAN HEALTHCARE & REHAB | 115622 | 556 CHESTER HIGHWAY | EASTMAN | GA | 31023 | 2019-07-24 | 880 | F | 1 | 0 | EMU611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews, the facility failed to maintain a safe and sanitary infection prevention and control program by not preventing a flying insect infestation of five of five resident-care halls. Multiple observations revealed flying insects had access to the facility through an open kitchen screen door. Further observations revealed uncovered dumpsters near this open door. Observations of kitchen personnel revealed they did not wear hair covers properly, leaving hair uncovered. Interview with the Dietary Manager (DM), the Medical Director (MD), and the facility infection control nurse revealed they acknowledged uncovered dumpsters and the open screen door to the kitchen to be deficient practice. Interview with the facility infection control nurse revealed she had no meaningful training and had no knowledge of what she should do about the acknowledged insect infestation. Pest Control Consultant (PCC) interview revealed flying insects were disease vectors (living organisms that transmitted disease) and the facility was not following recommendations for mitigation. Findings include: On 7/19/19 at 5:00 p.m. the dumpsters behind the kitchen were directly observed. Prior to the observation the surveyor asked the Dietary Manager for a hair net so he could traverse the kitchen. The Dietary Manager had a voluminous amount of curly hair, which rested below her shoulders and did not wear a hairnet. She went into the kitchen without a hairnet, walked less than an arm's length from the serving line and prep area, and got a hairnet for herself and the surveyor. The surveyor stayed out of the kitchen until given a hairnet and observed from the doorway. The back porch of the kitchen was screened in with a walk-in cooler and freezer on one side and a screen door adjacent to the cooler. The screen door was wide open. Three large blue dumpsters were noted a short distance from the back door of the kitchen. Multiple flies were noted in this s… | 2020-09-01 |
| 5124 | 5124 | MEDICAL MANAGEMENT HEALTH AND REHAB CENTER | 115692 | 1509 CEDAR AVE | MACON | GA | 31204 | 2016-01-29 | 280 | J | 1 | 0 | 8Z9H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and record review, it was determined that the facility failed to revise the care plan to include interventions for staff to ensure that a resident was wearing non-skid socks at all times and were monitoring the resident's whereabouts per a specific monitoring schedule for one (1) resident (#2); failed to revise the care plan to include interventions to maintain the bed in the lowest position and ensure that the door to the resident's room remained open for one(1) resident (S); and failed to revise the care plan related to the use of bed and chair alarms for one (1) resident (#7). Nine (9) residents were reviewed for falls from a sample of thirty (30) residents. The facility did not revise the residents Falls care plans to decrease the likelihood of future falls. The facility's failure to update the Falls care plans resulted in Immediate Jeopardy (IJ) as evidenced by a chin laceration on 11/29/15 and a nose fracture on 1/14/16 for Resident #2; a [MEDICAL CONDITION] on 6/9/15 and a shoulder fracture on 11/10/15 for Resident S; and a [MEDICAL CONDITION] on 10/18/15 and an arm fracture on 11/07/15 for Resident #7. Immediate Jeopardy (IJ) was identified on 1/26/15 and the facility Administrator and Corporate Nurse Consultant were notified on 1/26/15 at 2:01 p.m. IJ was determined to exist as of 3/14/15 and remains ongoing. It was also determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The IJ was related to non-compliance with Resident Assessment (F280 S/S J) for Resident #2, Resident S, Resident #7. Cross reference to Quality of Care F323. The findings include: 1. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) sc… | 2019-01-01 |
| 5054 | 5054 | MEDICAL MANAGEMENT HEALTH AND REHAB CENTER | 115692 | 1509 CEDAR AVE | MACON | GA | 31204 | 2016-02-18 | 280 | D | 1 | 0 | RZ8P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and record review, it was determined that the facility failed to revise the care plan to include interventions for staff to ensure that a resident was wearing non-skid socks at all times and were monitoring the resident's whereabouts per a specific monitoring schedule for one (1) resident (R2); failed to revise the care plan to include interventions to maintain the bed in the lowest position and ensure the door to the resident's room remained open for one (1) resident (S); and failed to revise the care plan related to the use of bed and chair alarms for one (1) resident (R7). Nine (9) residents were reviewed for falls from a sample of thirty (30) residents. The facility did not revise the residents' falls care plans to decrease the likelihood of future falls. The facility's failure to update the falls care plans resulted in Immediate Jeopardy (IJ) as evidenced by a chin laceration on 11/29/15 and a nose fracture on 1/14/16 for R2; a [MEDICAL CONDITION] on 6/9/15 and a shoulder fracture on 11/10/15 for Resident S; and a [MEDICAL CONDITION] on 10/18/15 and an arm fracture on 11/07/15 for R7. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 2/8/16 which alleged removal of Immediate Jeopardy on 2/8/16. CMS contract surveyors verified Immediate Jeopardy was removed on 2/8/16 as alleged prior to exit on 2/18/16. The Scope and Severity (S/S) was lowered to a D while the facility implemented and monitored the Plan of Correction for the effectiveness of systemic changes and quality assurance. Findings include: 1. A review of the care plan for R2 revealed the care plan had been revised 2/5/15 which included the following interventions: Administer med as ordered and inform the Physician of any abnormal side effects. Assist with care as allowed Encourage resident to lay down when exhaustion noted Psych consult and visits as ordered Approach resident from the front and announce why you are addressing him to … | 2019-02-01 |
| 3390 | 3390 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2018-11-29 | 553 | D | 1 | 1 | FYDZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to assure resident notification of care plan meetings. This deficient practice affected three residents (Resident (R) #34, #50, and #85) of 38 sampled residents. Findings included: 1. Review of medical record for R#34 revealed care plan assessment dates that included 4/18/18, 7/5/18, and 9/23/18. There was only documentation of notice for a care plan meeting for (MONTH) (YEAR). Review of care plan sign in sheet from 4/12/18 and 9/27/18 did not indicate that resident was present for the meeting. Review of the Quarterly Minimum Date Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12 (indicating the resident was cognitively intact and able to make her needs known). Interview conducted on 11/27/18 at 9:12 a.m. with R# 34 who reported that she has only been invited to one care plan meeting since being admitted . 2. Review of medical record for R#50 revealed care plan assessments dated for 7/16/18 and 10/12/18. There was no documentation to suggest that resident or family member was present for the care plan meetings. There was one letter of notification for 10/18/18 but no documentation to confirm the notification made for any previous care plan meetings. Review of the Quarterly MDS dated [DATE] revealed the resident the resident had a BIMS of 15 (indicating the resident was cognitively intact and able to make her needs known). During an interview on 11/26/18 at 3:41 p.m. with R# 50 it was reported that in the past she has received invitations to and has attended care plan meetings. However, it is reported that she has not attended or received notifications to attend meetings during the past eight months. Interview on 11/28/18 at 3:13 p.m. with R#50 who denied that the letter was received about the care plan meeting in (MONTH) (YEAR). The resident further reported that she wants to receive a copy of the care plan notice letter even i… | 2020-09-01 |
| 539 | 539 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 914 | D | 1 | 1 | I5PG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to ensure that privacy curtains were clean and provided full visual privacy, which included a total of six of 119 beds on one of two units. The facility census was 108 residents. Findings include: Observation on 7/21/19 at 2:16 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/21/19 at 3:33 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/22/19 at 10:53 a.m., revealed in room [ROOM NUMBER], bed A and bed B had no privacy curtain at all. Observation on 7/22/19 at 11:04 a.m., revealed in room [ROOM NUMBER], privacy curtain on bed B dirty with dried food particles. Observation on 7/22/19 at 12:11 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/23/19 at 11:55 a.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Interview on 7/24/19 at 10:05 a.m. with Housekeeping Aide DD, stated she inspects the privacy curtains daily to make sure they are clean. She stated if the privacy curtains need to be changed, she notifies the floor tech, to take down to be laundered. She stated she was not sure if there was a routine schedule for laundering the privacy curtains. She stated that she has not noticed any privacy curtains that were too short or missing in any of the rooms on A-Hall. Interview on 7/24/19 at 6:05 p.m. with Housekeeping Supervisor, stated her expectation is that the housekeeping aides look at the privacy curtains every day. If a curtain is identified as being dirty, they are to notify the floor tech to remove the curtain and replace it with a clean one. She stated there is not a routine schedule of laundering the privacy curtains. She further stated that if the housekeeping staff are checking the privacy curtains daily, she is not sure how there could be a … | 2020-09-01 |
| 4307 | 4307 | CALHOUN NURSING HOME | 115264 | 265 TURNER STREET | EDISON | GA | 39846 | 2016-12-07 | 363 | D | 1 | 0 | ECT611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to follow the planned mechanical soft diet menu for meat for two (2) resident (R#A3 and R#7) from six (6) residents observed on a mechanical soft diet. This deficient practice had the potential to effect 16 residents receiving a mechanical soft diet. Findings include: 1. Observation for the supper meal on 12/ 06/16 from 5:20 p.m. to 5:40 p.m. for R#A revealed that she had received a whole piece of cubed steak on her plate. She further stated that she could not eat the piece of meat. Record review for this resident revealed that she had a current order at least since 11-24-2015 for a mechanical soft diet with chopped meats. The resident had [DIAGNOSES REDACTED]. Review of the Diet Spread Sheet for the supper meal of 12-6-16 revealed that it had planned for chopped cube steak for Mechanical Soft diets. 2. Observation for the lunch meal on 12-7-16 at 12:55 p.m. for R#7 revealed that she had received a whole piece of fried chicken (thigh) on her plate. Record review for this resident revealed that she had a current order order at least since 6-24-2014 for a liberalized mechanical soft diet. Review of the Diet Spread Sheet for the lunch meal of 12-7-16 revealed that it had planned for chopped chicken for Mechanical Soft diets. During an interview with the Dietary Manager (DM) on 12-7-16 at 5:15 p.m. and after review of the Diet Spread Sheets for 12-6-16 and 12-7-16 and surveyor review of the observed meals for R#A during the supper meal on 12-6-16 and for R#7 during the lunch meal on 12-7-16, the DM confirmed that the meats for these two residents should have been chopped. Review of the Diet Listing by Resident revealed that 16 residents were receiving a mechanical soft diet in the facility. | 2019-11-01 |
| 532 | 532 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 577 | B | 1 | 1 | I5PG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, it was revealed that the facility failed to post notice of the availability of state survey results in prominent places in the facility. Findings include: During a group interview with members of the resident council on 7/23/19 at 10:10 a.m., it was revealed that few members of the resident council knew of the whereabouts of the state survey results and how they could access them. One resident said he believed they were to be found in the lobby area, but could not be sure of the exact location. An observation on 7/23/19 at 12:30 p.m. of the lobby area of the facility accompanied by the Regional Nurse Consultant, revealed a cherry wood cabinet attached to the wall at the left of the main entrance. A green sign attached to the closed door of the cabinet read: Please drop kudo cards here; please deposit payments here; please place [MEDICATION NAME] contact cards here. Inside the cabinet, once the doors were opened, was a binder labeled: Results of Past 3 Surveys; (MONTH) 27, (YEAR), (MONTH) 30, (YEAR), (MONTH) 12, (YEAR). During an interview with the Regional Nurse Consultant at the time of this observation, she revealed that the residents are supposed to be educated on the availability of the survey results and where to find them. She agreed that there was no indication in the area as to where the survey results were kept and that visitors/families/residents would not necessarily know the results were available in the cabinet when the door was closed. An observation of the lobby area on 7/23/19 at 4:29 p.m. revealed a new sign had been placed on the closed door of the cabinet containing the survey results. The new sign stated: Survey Results. During an interview on 7/24/19 at 2:57 p.m. with the Activity Director (AD) it was revealed that she usually educates the residents and family members after surveys that state survey results are available, and that they are entitled to see new results after they … | 2020-09-01 |
| 148 | 148 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 924 | D | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure that two handrails were firmly and securely attached to the wall on 100 hall and in room [ROOM NUMBER] bathroom. The facility census was 95 and the sample size was 34. Findings include: Observation on 8/6/18 at 10:50 a.m., revealed a loose full length handrail in the bathroom. Observation on 8/6/18 at 2:41 p.m., revealed a loose handrail, on the left side of the hallway, at the beginning of 100 hall, between room [ROOM NUMBER] and 150. Walking tour on 8/9/18 at 10:10 a.m. with Maintenance Supervisor, confirmed the loose handrails on the 100 Hall and in room [ROOM NUMBER]. Interview on 8/9/18 at 10:10 a.m. with Maintenance Supervisor, stated staff put work orders into computer system, and he sorts them according to priority and distributes assignments to the staff. The staff work on work orders, plus perform general maintenance for facility, such a checking emergency exits, checking call lights and water temperatures, side rails, hand rails, cleaning Air Conditioner coils, changing AC filters, checking emergency doors. He further stated there is no formal checklist for routine maintenance items, but that the work orders are kept in the computer software system. He stated he was not aware of any loose handrails in the facility. | 2020-09-01 |
| 1500 | 1500 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2018-09-28 | 924 | D | 1 | 1 | T04T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure that two handrails were firmly and securely attached to the wall on two of 4 halls. The facility census was 213 and the sample size was 60. Findings include: Observation on 9/24/18 at 11:52 a.m. revealed a loose handrail, on the right side of the hallway, on Magnolia Way, outside of room [ROOM NUMBER] [NAME] Observation on 9/26/18 at 10:36 a.m. revealed a loose handrail, on the right right of the hallway, on Branches Unit, outside resident pantry kitchen. Interview on 9/28/18 at 3:02 p.m. with Maintenance Supervisor, verified the two loose handrails. He stated there was no specific time or schedule that hand rails are checked for stability. He stated that he was not aware of the loose handrails in the facility until walking rounds. | 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 |
| 2103 | 2103 | PRUITTHEALTH - VIRGINIA PARK | 115531 | 1000 BRIARCLIFF ROAD NE | ATLANTA | GA | 30306 | 2019-04-11 | 812 | E | 1 | 1 | BUR411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews the facility failed to discard expired food items. These deficient practices had the potential to affect 82 residents receiving an oral diet. Findings included: An observation of the dry storage area while accompanied by the dietary manager during the initial kitchen tour on [DATE] at 09:58 a.m. revealed Instant Nonfat Dry Milk with an expiration date of [DATE]. Three thickened cranberry cocktails with an expiration date of [DATE]. Observations of food items in the cooler area on [DATE] at 10:15 a.m revealed strawberries in the cooler area with a white substance growing on top of the strawberries. Additionally, on [DATE] at 10:30 a.m tour of the emergency food supply reveled expired food items including the following: Dill pickles, Corned beef hash, Grape Jelly, Black Beans and [NAME]to Soup all with an expiration date of [DATE]. On [DATE] at 1:16 p.m an interview was conducted with the Dietary Manager he stated that he has got approval to use a new vendor. He stated that he will makes sure prior to arrival of new food items, he will make sure that the food items have visible expiration dates that are visible and keep better track on a monthly basis of any food items that might be expired. He also stated that he has only been here for three weeks, but he plans on implementing a tracking system to make sure that no expired food items are left in the cooling areas, dry food storage or the emergency food supply area. On [DATE] 1:54 p.m. an interview was conducted with the Administrator he stated that the expectation is there should be no expired food items in the kitchen area. He also stated that things should be checked frequently as possible to make sure no expired items are in the refrigerator or dry food storage areas. He also stated that they will be using a new vendor from here on out and the dietary manager will be responsible to make sure there no expired food items in the refrigerator or dry f… | 2020-09-01 |
| 682 | 682 | PRUITTHEALTH - BROOKHAVEN | 115313 | 3535 ASHTON WOODS DRIVE NE | ATLANTA | GA | 30319 | 2019-11-21 | 584 | D | 1 | 1 | TQY711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews the facility failed to ensure that it was maintained in a safe clean and comfortable homelike environment in seven resident rooms on one of three units with damaged walls, missing chair rails, stained curtains, and personal equipment on the floor in the bathroom. Findings included: Observation on 11/18/19 at 11:50 a.m. during the initial screening process on the South Unit. The following observations were made in the resident rooms: 1. room [ROOM NUMBER]-A two linear holes in the wall were the head of the bed is located the wall also had unpainted dry wall. 2. room [ROOM NUMBER]-B a hole in wall chair rail missing. 3. room [ROOM NUMBER] in the bathroom on the floor was one white measuring hat for urine, one grey fracture bed pan, and one grey basin. 4. room [ROOM NUMBER]-B- hole in wall. 5. room [ROOM NUMBER]- B six linear areas on the wall two of the areas had large holes were the head of the bed close to the window is located. 6. room [ROOM NUMBER]-A missing paint and holes on the long wall. 7. room [ROOM NUMBER]-B missing paint, a hole in wall, red stain on the call light, curtains with brown stains. An observation and interview on 11/21/19 at 3:05 p.m. with the Maintenance Supervisor (MS) and the Assistant Administrator. The MS revealed that the staff alerts the maintenance department via the facility computer based system for repairs broken equipment. He revealed that the system is checked twice a day by the maintenance department. The Maintenance Supervisor also revealed that the Partners are also assigned areas/rooms in the facility to check for compliance. The MS also confirmed that he was the Partner assigned to the South Unit and he had not made compliance rounds in the resident rooms. The MS and Administrator confirmed that the following that the six rooms needed repairs to the damage wall and missing chair rail. A policy was requested but not provided to the surveyor. | 2020-09-01 |
| 628 | 628 | WINDERMERE HEALTH AND REHABILITATION CENTER | 115291 | 3618 J DEWEY GRAY CIRCLE | AUGUSTA | GA | 30909 | 2018-04-30 | 880 | D | 1 | 0 | UHMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews, the facility failed to ensure that Hoyer lifts were routinely cleaned as evidenced by observation of significant dirt, debris, dried adhered materials and dried fluid residue on the base and lower support column for four of four of the facility's Hoyer lifts. Findings include: Observation on 4/30/18 at 2:05 p.m. of Hoyer lift East 3 parked outside of resident's rooms [ROOM NUMBERS] with visible debris, dirt, and dried materials, including fluid splatters on the base and support column. Observation on 4/30/18 at 2:07 p.m. of the facility's Hoyer lifts West 4 and East 2 in the designated parking area for the lifts revealed that both lifts had visible debris, dirt, and dried materials, including fluid splatters on the base and on the support columns. Observation on 4/30/18 at 2:35 p.m. of the Hoyer lift parking area empty and one Hoyer lift, East 3, parked outside of resident rooms [ROOM NUMBERS] which revealed continued with the same visible debris, dirt, and dried materials, including fluid splatters on the base and support column. Observation on 4/30/18 at 3:18 p.m. of Hoyer lifts East 2, East 3 and West 3 in the parking area with no changes in the previously observed level of contamination and splatter on the base and support columns of the Hoyer lifts. Observation and interview on 4/30/18 at 5:50 p.m. of East 2, East 3 and West 1 Hoyer lifts in the designated parking area with the Director of Nursing (DON) who agreed that the lifts had substantial dirt, dried debris and fluid residue and concurred that they needed cleaning. The DON stated she thought the lifts were on a scheduled cleaning rotation with the maintenance department. Interview with the Administrator and the DON on 4/30/18 at 6:45 p.m. who confirmed that the Maintenance Director is responsible for cleaning and maintaining the Hoyer lifts. The Administrator also confirmed that the Maintenance Director, DD, had not developed a schedule … | 2020-09-01 |
| 146 | 146 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 880 | E | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to maintain cross contamination of clean linen during the folding process; and failed to maintain sanitary dining supplies. The facility census was 73 residents. Findings include: 1. Observation on 8/6/18 at 10:00 a.m., revealed in room [ROOM NUMBER], an unlabeled and unbagged urinal hanging on the grab bar in the bathroom that was shared by by two female residents. 2. Observation on 8/6/18 at 10:08 a.m., revealed in room [ROOM NUMBER], an unlabeled and unbagged urinal in the bathroom that was shared by two male residents. 3. Observation on 8/6/18 at 10:48 a.m., revealed in room [ROOM NUMBER], an unlabeled bedpan in a plastic bag, in the bathroom that is shared by four male residents. 4. Observation on 8/7/18 at 2:44 p.m., with Laundry Aide II, folding clean linen using a Helping Hand securing device to hold the end of a blanket. The blanket was touching the floor during the folding process. After the blanket was folded, she then proceeded to fan/slap the blanket against her legs, as if to remove wrinkles from blanket. Afterwards, she placed the blanket on top of already folded blankets stacked on the folding table. 5. Observation on 8/7/18 at 2:56 p.m., with Laundry Aide JJ, folding clean linen at the folding table, allowing the clean bed linen (sheet) to rest upon her abdomen while folding. Afterwards, she placed the sheet on top of a stack of already folded sheets stacked on the table. 6. Observation on 8/8/18 at 2:18 p.m., revealed that dining room three, had black metal condiment baskets that held clear plastic containers with sugar, salt and pepper packets for resident use. Six of the six baskets had yellow, black, crusted mold substance inside the basket bottom. Interview on 8/7/18 at 3:19 p.m., with Laundry Aide II, stated that she did not notice the… | 2020-09-01 |
| 169 | 169 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-06-27 | 880 | D | 1 | 1 | 3SRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to practice infection control policy for washing and/or sanitizing hands during wound care procedure. The facility census was 76 residents. Findings include: 1. Observation on 6/24/19 at 12:24 p.m. revealed in room [ROOM NUMBER] B, an un-bagged and unlabeled toothbrush sitting on sink counter and un-bagged and unlabeled urinal sitting on the floor beside the toilet. Observation on 6/21/19 at 1:28 p.m. revealed in room [ROOM NUMBER] A, two (2) un-bagged and unlabeled toothbrushes sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 1:50 p.m. revealed in room [ROOM NUMBER] B, one (1) un-bagged and unlabeled toothbrush sitting on sink counter and one un-bagged and unlabeled bath basin on floor under the sink. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 1:58 p.m. revealed in room [ROOM NUMBER] A, one (1) un-bagged and unlabeled toothbrush sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 2:07 p.m. revealed in room [ROOM NUMBER] B two (2) un-bagged and unlabeled toothbrushes sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/25/19 at 10:14 a.m. revealed in room [ROOM NUMBER], one (1) unbagged and unlabeled toothbrush sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/25/19 at 10:47 a.m. revealed an un-bagged and unlabeled urinal sitting on grab bar in bathroom. 2. Observation on 6/26/19 at 2:03 p.m., with Licensed Practical Nurse (LPN) wound care nurse JJ performed wound care for R#13. She gathered all materials needed for the procedure and placed them in plastic cups. She sanitized the residents over bed table and placed a barrier on the table and placed the plas… | 2020-09-01 |
| 3680 | 3680 | SMITH MEDICAL NURSING CARE CTR | 115691 | 501 EAST MCCARTY ST | SANDERSVILLE | GA | 31082 | 2018-10-04 | 561 | D | 1 | 1 | 1T3M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation interview and record review facility failed to provide scheduled showers and provide space in the dining room to eat meals, for one resident (R) #38. Resident sample size was 26. Findings include; Record review revealed that R#38 have [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] R#38's , under section C, revealed resident has a Brief Interview of Mental Status (BIMS) of 15 with a score of 13-15 indicating that resident is cognitively intact. Review of Annual MDS dated [DATE] Section F question, 0800 Staff Assessment of Daily and Activity Preferences offers no assessment of preferences. An interview on 10/01/18 at 12:12 p.m. with R #38 revealed that he gets a shower every Tuesday however; the rest of the week he gets a bed bath. An observation on 10/02/18 at 11:04 a.m. R#38 being escorted to the shower room. An observation on 10/02/18 at 1:08 p.m. R#38 in room in bed eating lunch. During an interview on 10/03/18 at 1:42 p.m. with R#38 indicated he was told he can get a shower once a week and the rest of the days he gets a bed bath. Continued interview with the resident revealed that he would like to have more showers if he could and that he had not let the staff know as he was not aware that he could ask for more frequesnt showers. Further interview with R#38 he was asked if he wanted to eat in the in his room he stated they told him there was not any room for him to eat in the dining room because of his chair. When asked if he would like to eat in the dining room he stated yes except for breakfast. When asked if he spoke to anyone about this he stated yes, many people. During an observation on 10/03/18 at 1:06 p.m. R#38 noted eating lunch in room with a Certified Nursing Assistant (CNA) at bedside. During an interview with two CNAs FF and CNA CC on 10/3/18 at 1:35 p.m. revealed that all residents get a bed bath everyday except on shower days which is determined according… | 2020-09-01 |
| 1496 | 1496 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2018-09-28 | 759 | E | 1 | 1 | T04T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation of the medication pass and staff interviews, the facility failed to ensure that it was free of a medication error rate greater than five percent by not ensuring medications were given as ordered by physicians. Two of three nurses on two of five halls had medication errors, resulting in 11.54% medication error rate. There were three errors made out of twenty-six opportunities resulting in a 11.54% medication error rate. Affected was two out of six sampled residents R (R#55, R#114). The sample size was 60 residents. Findings include: Observation of medication administration on 9/25/18 at 8:21 a.m. on Magnolia Way, cart B, with Registered Nurse (RN) LL revealed she administered multiple medications to R#55. The following observations were made: [MEDICATION NAME] (a medication used to treat Asthma) 50 micrograms (mcg) one (1) spray each nostril and Vitamin C (a medication given as a supplement) 500 milligrams (mg) tablet was administered. During reconciliation with review of the (MONTH) (YEAR) physician's orders [REDACTED]. Registered Nurse (RN) LL failed to have resident rinse her mouth after inhalation of [MEDICATION NAME] and also administered only one Vitamin C 500 mg tablet instead of two tablets as ordered. Interview on 9/25/18 at 10:30 a.m. with RN LL stated she overlooked the order to give two Vitamin C tablets. She further stated the [MEDICATION NAME] order had been rewritten and the follow-up to rinse after use was not carried over, so she didn't see the directions to have resident rinse after use. Observation of medication administration on 9/26/18 at 8:39 a.m. on Branches, cart D, with Licensed Practical Nurse (LPN) MM revealed she administered multiple medications to R#114. The following observations were made: [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]) 750 milligrams (mg) was administered. During reconciliation with review of the (MONTH) (YEAR) physician's orders [REDACTED]. Licensed Practic… | 2020-09-01 |
| 2105 | 2105 | PRUITTHEALTH - VIRGINIA PARK | 115531 | 1000 BRIARCLIFF ROAD NE | ATLANTA | GA | 30306 | 2017-09-09 | 332 | E | 1 | 0 | GR9S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation of the medication pass, review of the physician's orders and staff and resident interviews the facility failed to ensure that it was free of a medication error rate greater than five percent by not ensuring medications are given as ordered by physicians. Two of five nurses made errors. The medication pass was observed on three out of four units. There were five errors made out of twenty-five opportunities for error which resulted in a 20% medication error rate. Affected were three out of six sampled residents, Resident (R#2), (R#3) and (R#4). These failures placed residents at risk to receive more or less than therapeutic effect from medications. Finding Include: 1. During observation of Med-pass (medication administration) on 9/9/17 at 1:00 p.m., on the 300 unit Licensed Practical Nurse (LPN AA) handed R#4 two tablets to take by mouth. Review of the Medication Administration Record (MAR) revealed Auryxia ([MEDICATION NAME]) a [MEDICATION NAME] binder indicated for the control of serum phosphorus levels in patients with [MEDICAL CONDITION] on [MEDICAL TREATMENT]. It is documented on the MAR take 210 mg (milligrams), take 2 tablets mouth before meals. The administration times are noted 7:30 a.m., 11:00 a.m., and 4:00 p.m. During interview with the nurse regarding the current physicians orders signed 8/25/17 reveals the medication (Auryxia) should be given before meals. LPN AA stated, I know but she likes to take them later. Interview with R#4 on 9/9/17 at 3:00 p.m., she said, they always give me my medications after I eat, even in the morning. Review of the Annual Minimum Date Set (MDS) assessment dated [DATE] Section C Cognitive Pattern is scored a 14. 2. During observation of medication administration at 1:15 p.m., LPN AA poured 32 ml's (milliliters) of Potassium Chloride (used to prevent or treat low potassium levels) Sol 10% and 10 ml (double the dose) of [MEDICATION NAME] [MEDICATION NAME] (iron supplement) to admin… | 2020-09-01 |
| 5131 | 5131 | MEDICAL MANAGEMENT HEALTH AND REHAB CENTER | 115692 | 1509 CEDAR AVE | MACON | GA | 31204 | 2016-01-29 | 353 | K | 1 | 0 | 8Z9H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, and staff interview, the facility failed to ensure that there was sufficient staff to provide supervision to protect potentially all residents in the facility from aggressive behaviors of resident #7, as evidenced by nine (9) resident-to-resident altercations between 04/12/15 and 01/21/16. In addition, the facility failed to ensure sufficient staffing to prevent falls, and to monitor that interventions for falls prevention were implemented and re-evaluated for continued use for seven (7) residents (residents #2, #7, #13, #26, #27, S, and T), who sustained injuries including fractures, lacerations, hematomas and abrasions. In addition, the facility failed to ensure there was sufficient staff to monitor residents' skin weekly as per policy, and implement measures to help prevent the development of pressure ulcers for two high- risk residents (S and #25), who developed deep tissue injuries. The facility's failure to have sufficient staff resulted in Immediate Jeopardy (IJ). It was also determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The sample size was thirty (30) residents. On 01/19/16 at 2:45 p.m., the interim Director of Nurses (DON) was notified that IJ existed, as the Administrator was not in the facility. IJ was determined to exist as of 01/19/16 in CFR 483.70 Physical Environment (F 463 Scope and Severity (S/S)-K). This information was repeated with the Corporate Registered Nurse Consultant on 01/19/16 at 2:55 p.m. On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Registered Nurse Consultant were again notified that IJ existed in CFR 483.25 Quality of Care (F 323 S/S-K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with no documentation that the safety helmet was in place. The Imm… | 2019-01-01 |
| 4440 | 4440 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2016-10-05 | 328 | J | 1 | 0 | ELW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, facility ' s policy titled, Accidental [MEDICAL CONDITION] Decannulation Guidelines , professional reference material titled, [MEDICAL CONDITION] , professional reference material posted in the American Association for Critical-Care Nurses, education records, record review, personnel files, and staff interview, the facility failed to ensure 3 of 14 sampled residents (R1, R9 and R10) with a [MEDICAL CONDITION] and artificial ventilation received proper care and treatment in accordance with the residents' comprehensive assessment and plan of care. Specifically, (R1, R9 and R10) did not have the correct inner cannula size at the residents' bed side in the event their inner cannulas became dislodged and required emergency replacement. The total sample was 52 and the total facility census was 229. The facility's failure to ensure residents received [MEDICAL CONDITION] and respiratory care as evidenced by the incorrect inner cannula size in their emergency backup box at their bedside, the lack of orientation to the ventilator unit and the lack of documentation that 5 of 5 nursing staff (CNA292 and CNA158; RN275; LPN281 and LPN131) had been oriented to the ventilator unit or evaluated for their competency skills, was likely to cause serious injury, harm, impairment or death to a resident. On 9/27/16 at 5:55 p.m. the facility's Administrator and Director of Nursing (DON) were notified that the failure to protect residents from neglect (F224 at scope and severity of J), the failure to ensure professional standards of nursing care were followed (F281 at scope and severity of J), the failure to provide specialized respiratory services (F328 scope and severity of J), and the failure to assure the facility was administered in a manner to assure that each resident reached or maintained their highest practicable well-being (F490 at a scope and severity of K), constituted Immediate Jeopardy. F224 also constitut… | 2019-10-01 |
| 5130 | 5130 | MEDICAL MANAGEMENT HEALTH AND REHAB CENTER | 115692 | 1509 CEDAR AVE | MACON | GA | 31204 | 2016-01-29 | 323 | K | 1 | 0 | 8Z9H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, facility policy and procedure review, and resident and staff interview, the facility failed to provide supervision to prevent accidents; failed to do thorough investigations to determine the root cause of falls; failed to monitor and re-evaluate interventions put in place after a fall; and failed to assess for the appropriate use of a seat belt and side rails. This failure resulted in falls with injuries including fractures, lacerations, hematomas and abrasions for seven (7) of nine (9) residents reviewed for falls (residents #2, #7, #13, #26, #27, S, and T), on a total sample of thirty (30) residents. The facility's failure to have an effective falls program resulted in immediate jeopardy (IJ) as evidenced by a right arm fracture, head lacerations and abrasions; hip abrasions; and black eyes for resident #7; laceration and broken nose for resident #2; broken left hip and right shoulder for resident S; lumbar fracture for resident T; and hematoma to the head for resident #13. The noncompliance caused actual harm to Resident #2, who sustained a laceration to the chin on 11/29/2015 and a fracture to the nose on 1/14/2016; Resident S who sustained a fractured hip on 6/9/2015 and a shoulder fracture on 11/10/2015; to Resident T who sustained a lumbar compression fracture on 12/7/15; and to Resident #7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015. IJ was identified on 01/26/16, and the facility Administrator and Corporate Nurse Consultant were notified at 2:01 p.m. IJ was determined to exist as of 03/14/15. The IJ also determined that the provider's non-compliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment or death to residents. The IJ was related to non-compliance with Quality of Care (F 323 S/S-K). The IJ was determined to be ongoing. Findings include: 1. Review of… | 2019-01-01 |
| 5120 | 5120 | MEDICAL MANAGEMENT HEALTH AND REHAB CENTER | 115692 | 1509 CEDAR AVE | MACON | GA | 31204 | 2016-01-29 | 224 | J | 1 | 0 | 8Z9H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, facility policy and procedure review, and staff interview, the facility failed to ensure a cognitively impaired resident (#7) was free from neglect by not providing supervision necessary to ensure her safety, as well as to protect other residents in the facility from her potentially aggressive behaviors. The facility census was eighty-seven (87) residents, and the sample size was thirty (30) residents. There was documentation in the Nurse's Notes and Falling Star notes on 03/24/15 that the resident fell outside in the smoking area sustaining an abrasion to the left hip, with no documentation that staff were supervising her. In addition, the resident was involved in nine (9) resident-to-resident altercations from 04/12/15 to 01/21/16, resulting in injuries including a [MEDICAL CONDITION] and black eye for resident #7, and scratches for resident #23 and an unsampled resident. The noncompliance caused actual harm to R#2, who sustained a laceration to the chin on 11/29/2015, a fracture to the nose on 1/14/2016; resident S who sustained a [MEDICAL CONDITION] on 6/9/2015, a shoulder fracture on 11/10/2015, and; to R#7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015. On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Nurse Consultant were again notified that Immediate Jeopardy existed in CFR 483.25 Quality of Care (F 323 S/S: K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with no documentation that the safety helmet was in place. The Immediate Jeopardy was also related to non-compliance with CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S: J), CFR 483.20 Resident Assessment (F 282 S/S: K), CFR 483.30 Nursing Services (F 353 S/S: K), and CFR 483.75 Administration (F 490 S/S: K), and CFR 483.75(o)(1) Qaa (F520 S/S:K). Immediate Jeopardy (IJ) was id… | 2019-01-01 |
| 5053 | 5053 | MEDICAL MANAGEMENT HEALTH AND REHAB CENTER | 115692 | 1509 CEDAR AVE | MACON | GA | 31204 | 2016-02-18 | 224 | D | 1 | 0 | RZ8P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, facility policy and procedure review, and staff interview, the facility failed to ensure a cognitively impaired resident (R7) was free from neglect by not providing supervision necessary to ensure her safety, as well as to protect other residents in the facility from her potentially aggressive behaviors. The facility census was eighty-seven (87) and the sample size was thirty (30) residents. There was documentation in the Nurse's Notes and Falling Star notes on 03/24/15 that the resident fell outside in the smoking area sustaining an abrasion to the left hip, with no documentation that staff were supervising her. In addition, the resident was involved in nine (9) resident to resident altercations from 4/12/15 to 1/21/16, resulting in injuries including a [MEDICAL CONDITION] and black eye for R7, and scratches for R23 and an unsampled resident. The noncompliance caused actual harm to R2, who sustained a laceration to the chin on 11/29/15, a fracture to the nose on 1/14/16; resident S who sustained a [MEDICAL CONDITION] on 6/9/15, a shoulder fracture on 11/20/15 and; R7 who sustained a head injury on 3/14/15, laceration to the head on 10/18/15, and a fractured arm on 11/7/15. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 2/8/16 which alleged removal of Immediate Jeopardy on 2/8/16. CMS contractors verified Immediate Jeopardy was removed on 2/8/16 as alleged prior to exit on 2/18/16. The Scope and Severity (S/S) was lowered to a D while the facility implemented and monitored the Plan of Correction for the effectiveness of systemic changes and quality assurance. Findings include: A review of the clinical record for R7 indicated the resident was discharged on [DATE]. The facility provided documentation which indicated an audit of all residents who were involved in resident to resident altercations was completed by the Assistant Director of Nursing on 2/5/16. No evidence co… | 2019-02-01 |
| 4644 | 4644 | WINDERMERE HEALTH AND REHABILITATION CENTER | 115291 | 3618 J DEWEY GRAY CIRCLE | AUGUSTA | GA | 30909 | 2016-08-05 | 312 | D | 1 | 0 | UYME11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, resident and staff interview, the facility failed to provide oral care, showers for three (3) residents (S, O, and R) residentsthe sampled fifty-one (51) residents, the census was one-hundred and one (101). Findings include: 1. Review of the clinical record for resident O revealed that they had [DIAGNOSES REDACTED]. Review of their Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that they had no cognitive impairment, needed extensive assistance for personal hygiene, and had impairment on one side of the upper and lower extremities. Review of the resident's care plan for impaired neurological status related to [MEDICAL CONDITION] (stroke) and [MEDICAL CONDITION] included interventions to assist with activity's of daily living (ADL's) as needed, and monitor ADL's for assistance and render care as needed. Review of the physical functioning deficit related to self-care and mobility impairment care plan included an intervention for personal hygiene assistance. During interview with resident O on 07/26/16 at 10:01 a.m., he stated that staff didn't offer to clean their teeth at all, and that they needed assistance with this. Upon further interview, the resident stated that they would like to have their teeth brushed daily, and the last time they were brushed was months ago. During interview with resident O on 07/27/16 at 9:20 a.m., they stated they had still not received oral care today or yesterday. During interview with resident O on 07/27/16 at 1:49 p.m., the resident stated they had still not received oral care. During observation at this time, the resident was noted to be missing all but one upper tooth, and a small amount of tannish debris was observed on the lower front teeth at the gum line. During further observation and with the resident's permission, his room was checked for mouth care supplies, and an opened package of three toothbrushes was noted in a bag on a countertop, as… | 2019-08-01 |
| 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 |
| 1384 | 1384 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2017-08-24 | 323 | D | 1 | 0 | BP4Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, review of the facility Lippincott Procedures-Falls Management, radiology reports and staff interviews, it was determined that the facility failed to assess one resident (R) (R#4) after a fall, failed to complete a detailed incident report, and failed to document ongoing monitoring for a severe complication of the fall and failed to ensure one resident's (R#1) bed was placed in the lowest position with a personal alarm applied while in the bed. The sample size was 4 residents with a history of falls. Findings include: Review of the facility's policy titled, Lippincott Procedures-Falls Management, revised (MONTH) 3, (YEAR), indicated after a fall staff should, assess the patient's limb strength and motion. Even if the patient shows no signs of distress or has sustained only minor injuries, monitor his vital signs and assess his neurological status frequently until his condition stabilizes. Notify the practitioner if you note any changes from the patient's baseline condition. Perform a comprehensive pain assessment, perform a postfall assessment to determine the root cause of the fall, monitor the patient's status fort he next 48 hours, update the patient's risk profile using a standardized fall risk assessment tool, and institute fall precautions. 1. Review of the medical record for R#4 revealed the resident had the following [DIAGNOSES REDACTED]. According to R#4's most recent Minimum Data Set (MDS), an Admission assessment dated [DATE], indicated the resident required extensive assistance with bed mobility, transfers and toileting. Review of R#4's care plan dated 6/1/17 and revised on 7/19/17 and 8/24/17 read Problem/Need: At risk for falls r/t (related to) history of falls prior to admission with injury, meds, age, impaired mobility, cognitive loss, impaired balance The approaches included: therapy as ordered, w/c primary mode of locomotion, assist with transfers, ambulation, toileting, place n… | 2020-09-01 |
| 1298 | 1298 | PRUITTHEALTH - PEAKE | 115394 | 6190 PEAKE ROAD | MACON | GA | 31220 | 2017-10-26 | 353 | E | 1 | 0 | IJ7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, review of the policy titled State Minimum Staffing for Healthcare Centers, and staff and resident interviews, it was determined that the facility failed to provide sufficient nursing staff to meet the nursing care needs of seven of ten sampled residents (R) ( #2, #8, A, B, C, D and #10). Specifically: Residents waited extended time frames for assistance to get into the bed, assistance to use the bedpan, for staff to answer the call light on the 3-11 shift, did not receive scheduled morning medications timely and did not receive restorative nursing services due to insufficient staff. Findings include: Review of the Resident Census and Condition of Residents form revealed the facility census was 117 and of those 117 residents, one resident was was independent with transfers, 99 residents required assistance of one or two staff and 17 residents were dependent on staff. It also revealed that no residents were independent with toileting, 95 residents were required assistance of one or two staff and 22 residents were dependent on staff. Review of the facility policy titled State Minimum Staffing for Healthcare Centers, revised 7/15/2016, documented: The facility will maintain the minimum staffing hours in accordance with federal law and the respective state's rules and regulations. Staffing shall be sufficient to meet the healthcare needs of each patient/resident as identified in the patient/resident's plan of care. Review of the Certified Nursing Assistant (CNA) Assignment Sheet Form dated 10/23/17 revealed for the 7:00-3:00 shift there were two Licensed Practical Nurses (LPN) on the West Wing. Review of the untitled daily shift assignment form dated 10/23/17 revealed for the 3:00-11:00 shift there were two Certified Nursing Assistants (CNA) on the East Wing. During an interview with West Wing LPN BB on 10/23/17 at 11:05 a.m., she stated that she had 30 residents assigned to her and that it usually t… | 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 |
| 2104 | 2104 | PRUITTHEALTH - VIRGINIA PARK | 115531 | 1000 BRIARCLIFF ROAD NE | ATLANTA | GA | 30306 | 2017-09-09 | 281 | D | 1 | 0 | GR9S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record reviews, interviews and review of the facilities policy titled Self-Administration of medications by Patients/Residents, the facility failed to ensure medications were not left at the bedside if a resident had not been assessed to self-administer medications. Resident (R),#1 of six sampled residents was not assessed for self-administration of medications and she had medications left at her bedside. During observation, record review and interviews the facility failed to provide services in accordance with professional standards of practice for 3 of 10 Residents (#2, #3, #4) observed during medication pass on 9/9/17, Licensed Practical Nurses (LPN) AA and LPN CC did not administer medications in accordance with nursing principles and practices or in accordance to the facility written policies. Finding include: 1. Resident #1 [DIAGNOSES REDACTED]. During an interview with R#1 on 9/9/17 at 1:49 p.m., and at 3:00 p.m., the resident stated the night nurse left her eye drops Latanoprost Solution on her overbed table, she continued saying he needed to order more because this bottle is almost empty and since he left the bottle here I'm sure he did not order any more so again I will not get my medication tonight, this happen before, they let my medications run out and I did not get my medication over the weekend. She further stated, The nurses leave medication on my bed table at night, they leave eye drops and breathing treatments right here, I think these nurses are trying to kill me. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. During the interview on 9/9/17 at 3:00 p.m., the resident was observed with a bottle of eye drops labeled Latanoprost (used to treat pressure in the eye [MEDICAL CONDITION] ocular pressure) Sol 0.005 % 1 drip to each eye at bedtime. The current physician orders [REDACTED]. During an interview with the Registered Nurse (RN) Consultant on 9/9/17 at 3:26 p.m. an… | 2020-09-01 |
| 3685 | 3685 | SMITH MEDICAL NURSING CARE CTR | 115691 | 501 EAST MCCARTY ST | SANDERSVILLE | GA | 31082 | 2018-10-04 | 761 | D | 1 | 1 | 1T3M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and policy review, the facility failed to ensure medications were dated appropriately when opened to determine the discard date, in one of two medication carts on one of two halls. Also, the facility failed to discard expired biological's prior to expiration date in the medication storeroom refrigerator. Findings include: Review of the facility policy titled Medication Storage dated ,[DATE], revealed the policy as medications and biological's are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Procedure number 14 revealed outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Observation on [DATE] at 3:24 p.m. of medication storage room, with Director of Nursing (DON) revealed a small black refrigerator, used for medications, with 14 two (2) milligram (mg) per milliliter (ml) [MEDICATION NAME] vials with an expiration date of ,[DATE]. Also noted, in the small medication refrigerator, was two, two (2) milligram (mg) per milliliter (ml) [MEDICATION NAME] vials for a resident who had been discharged since (MONTH) 30, (YEAR). Interview on [DATE] at 3:24 p.m., with DON, stated she is not sure why the discharged residents medication is still in the refrigerator. She further stated that the nurses should be looking at all the medications checking for the expiration dates, as well as the pharmacist. She further stated that the pharmacist was just in the facility the last week in (MONTH) doing Regimen Reviews. She stated that he did check the medication storage room when he was here and didn't report any concerns to her. Observation on [DATE] at 8:30 a.m. with Licensed Practical (LPN) Nurse AA observed during medication pass to … | 2020-09-01 |
| 557 | 557 | HIGH SHOALS HEALTH AND REHABILITATION | 115279 | 3450 NEW HIGH SHOALS RD | BISHOP | GA | 30621 | 2019-09-25 | 761 | E | 1 | 0 | 0KMB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and policy review, the facility failed to ensure medications were dated appropriately when opened to determine the discard date, in three of four medication carts; also failed to maintain correct narcotic count in one of four medication carts observed. Findings include: Review of the undated facility policy titled Pharmacy Services-Medication Administration-General revealed Procedural Guidelines 7. Medications dispensed for multi-use, e.g. blister/punch cards, large volume liquids, multi-dose vials, shall be labeled by the nurse as to the date of first use or first administration. Procedural Guidelines 18. During routine medication administration of medications, the medication cart is kept in the doorway of the patient's room, with open drawers inward and all other sides closed. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to patients and others passing by. Procedural Guidelines Observation on 9/24/19 at 12:00 p.m. with Licensed Practical Nurse (LPN) AA revealed on the 400 Hall medication cart one opened multi use vial of insulin with sticker that indicated to discard after 28 days. There was not a date indicating on vial or box of when the insulin vial was first used. Observation on 9/24/19 at 12:00 p.m. with Licensed Practical Nurse (LPN) AA revealed on the 400 Hall medication cart narcotic count of [MEDICATION NAME] was incorrect, revealing 17 pills in Kardex, with count sheet revealing 16 pills. An interview on 9/24/19 at 12:05 p.m. with LPN AA revealed that she knows that insulin's are supposed to be dated when they are opened. LPN AA futher revealed that she would not know when to discare the insulin, because it did not have an opened date. She further stated that when there are discrepancies with the narcotic count, she notifies the Director of Nursing (DON). Observation on 9/24/19 at 12:11 p.m. with LPN BB revealed on the 300 H… | 2020-09-01 |
| 3782 | 3782 | CHATUGE REGIONAL NURSING HOME | 115701 | 386 BELAIRE DRIVE | HIAWASSEE | GA | 30546 | 2019-10-10 | 761 | E | 1 | 1 | JOEO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and policy review, the facility failed to ensure over the counter medications were dated appropriately when opened to determine the discard date, in two of three medication carts; and failed to ensure that two of two medication cabinets, containing over the counter medications, remained locked. Findings include: An observation was conducted on 10/7/19 at 10:10 a.m. of the A Wing (Pink & Green Hall) nursing station medication cabinet. The large black metal cabinet containing over the counter medications (OTC) was found unlocked. No staff was found at the nursing station. An observation was conducted on 10/7/19 at 10:35 a.m. on the B Wing (Blue Hall) of the nursing station medication cabinet. The large black metal cabinet containing OTC medications was found unlocked. No staff was found at the nursing station. The Blue Hall has two known residents that wander. Resident #66 was observed wandering in the Blue Hall at time of cabinet observation, with obvious confusion when approached. The resident has a history of wandering and is cognitively impaired. An observation of the Blue Hall OTC medication cabinet was conducted on 10/7/19 at 2:18 p.m., two staff members were observed on computers sitting at the nursing station. The medication cabinet was unlocked. Two swing doors are located at each end of the nurse's station, with the ability for easy access into the nursing station area by residents and guests. An observation of the Pink Hall OTC medication cabinet conducted on 10/7/19 at 2:35 p.m., no staff was observed at the nursing station. The medication cabinet was unlocked. Two swing doors are located at each end of the nurse's station, with the ability for easy access into the nursing station area by residents and guests. An observation was conducted on 10/8/19 at 5:00 a.m. of the A Wing (Pink & Green Hall) nursing station medication cabinet. The large black metal cabinet containing over the counter medications… | 2020-09-01 |
| 4138 | 4138 | FLORENCE HAND HOME | 115277 | 200 MEDICAL DRIVE | LAGRANGE | GA | 30240 | 2017-03-25 | 309 | D | 1 | 0 | 938711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined that the facility failed to follow physicians orders, to administer medications as ordered, for two residents (R) (#3, #4), out of 43 residents. This was observed on 2 of 3 halls on the second floor. During facility tour it was observed on Hall B South that Registered Nurse (RN) # AA was preparing to administer medication at 10:30 a.m. that were ordered for administration at 8:00 a.m. for Resident (R) # 3. Observation of the medication packet revealed that medications were to be administered at 8:00 a.m. RN AA confirmed that medication were being given late. Continuing the facility tour, it was observed on Hall B West, Licensed Practical Nurse (LPN) #BB pushing medication cart to the nurses station at 10:45 a.m. When interviewed, it was determined that she had just completed administering 8:00 a.m. medications for residents on West hall. She identified Resident (R) # 4 as the resident she just compeleted administration for. LPN BB confirmed that medication were being given late. Interview on 3/25/17 at 3:30 p.m. with the Administrator and Director of Nursing (DON) revealed that Resident # 2's daughter came and talked with them about her concern regarding the [MEDICAL CONDITION] medication being given late and inconsistently. They confirmed that they had called in the nurse and she admitted that she had given medication late. She was reprimanded and had to write a paper on the medication, adverse reactions and side effects and the issues that could develop if given late of inconsistently. They had an incident report but would not release a copy, but did give surveyor a copy of paper written by nurse and the assignment sheets for that hall with a typed reminded to give resident's medication on time. The Administrator and the DON confirmed that the facility had issues with late medications in the past, but thought it had been resolved. | 2020-03-01 |
| 4997 | 4997 | THOMASVILLE HEALTH & REHAB, LLC | 115427 | 120 SKYLINE DRIVE | THOMASVILLE | GA | 31757 | 2016-02-19 | 323 | E | 1 | 0 | 7J8Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined the facility failed to maintain safe water temperatures on one (1) of three (3) resident halls, maintain the bed in the lowest position for one resident (#8) and provide floor mats for one resident (#6) from a total sample of sixteen (16) residents. Findings include: 1. During an observation on 2/17/16 at 11:15 a.m. with the facility's Maintenance Director,using the facility's thermometer, there were unsafe hot water temperatures in the following resident bathrooms: Rooms 107/109: 129.2 degrees Fahrenheit (F) Rooms 111/113: 125.4 degrees F. Rooms 114/115: 129.2 degrees F. Rooms 110/112: 131.2 degrees F. Rooms 106/108: 131.2 degrees F. Room 102: 122 degrees F. During an interview with the Administrator on 2/17/16 at 11:55 a.m. and at 1:15 p.m., she stated that someone had adjusted the temperature on the hot water heater to the High setting and forgot to turn the setting back down to Low. She stated that she did not know who adjusted the temperature. She also stated that no residents had been burned by hot water. After identifying the unsafe hot water temperatures on 2/17/16 at 11:15 a.m. the administrator instructed the facility staff not to bathe any of the residents in the shower rooms and to only give a sponge bath. The staff also posted notes on all of the hot water knobs, with instructions not to use the hot water. She also stated the facility would be checking the hot water temperatures every hour. During an interview with the Administrator on 2/18/16 at 2:00 p.m., she stated once the hot water heater was was turned back down to the Low setting, the water temperatures had returned to below 110 degrees F. Review of the recorded temperatures revealed the following, and the temperatures remained below 120 degrees F throughout the monitoring: Rooms 107/109: at 8:00 p.m. 76. degrees Fahrenheit (F) Rooms 111/113: at 2:00 p.m. 116 degrees F. Rooms 114/115: at 2:00 p.m. 110 d… | 2019-02-01 |
| 4381 | 4381 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 501 | F | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the Medical Director failed to ensure implementation of policies/procedures, in abuse related to (R6); related to 6 residents (R18, R20, R22, R23, R25, and R28) with pressure sores; 2 residents with [MEDICAL CONDITION] Care (R28, R29); Insulin administration and blood sugar monitoring for 11 residents (R32, R5, R7, R9, R10, R14, R18, R19, R231, R25 and R27), for a total of twenty (20) residents as evidenced by the number of residents affected by Immediate Jeopardy (IJ) and one (1) resident who suffered actual harm related to the failure to supervise to prevent falls. Findings include: According to the Society for Post-Acute and Long-Term Care Medicine (paltc.org/amda-white-papers-and-resolution-position-statements/nursing-home-medical-director-leader-manager) the medical director ' s role is to .be responsible for the overall care and clinical practice carried out at the facility. The function of the medical director includes organizes and coordinates physician services and the services provided by other professionals as they relate to patient care. 1. On 6/9/16, R6 was verbally, physically and emotionally abused by a CN[NAME] It was reported and the facility failed to take immediate action including protecting all residents while an investgation was completed, failed to report to the SSA, physician and family, and failed to follow thier own policy related to abuse. Cross refer to F223, F224 and F226 for details 2. Treatment/Services to Prevent and/or Heal Pressure Ulcers: The facility failed to ensure residents without pressure ulcers did not develop pressure ulcers, and failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for R18, R20, R22, R23, R25, and R28) including providing consistent power sources for an air mattress for R28 of 2 residents with numerous medical devices/equipment, to prevent the worsening of 2 pressure ulcers (S… | 2019-11-01 |
| 4432 | 4432 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2016-10-05 | 244 | E | 1 | 0 | ELW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to assure that grievances reported by the resident council (members who were representative of the main building and not the Specialized Ventilation Unit) were acted upon in a manner to resolve them on an ongoing basis for 215 of 229 residents residing in the facility. Members of the resident council repeatedly voiced concerns about quality of life and care issues including insect infestation and insufficient staff/failure of staff to meet their needs. Although the facility responded to the residents each month about the previously reported complaints, the facility failed to implement actions that resolved the residents' grievances and maintained this resolution on an ongoing basis. This failure had the potential to affect all 229 residents of the facility, for whom the members of the resident council served as residents' representatives. The sample size was 52. Findings include: 1. Observation during initial tour on Monday, 9/26/16, starting at 8:30 a.m. revealed dead insects on both floors of the facility. At 9:18 a.m. a dead cockroach was observed on the floor of resident room [ROOM NUMBER]. Interview with Resident (R) 51, who was present in room [ROOM NUMBER] at this time revealed that residents saw roaches all the time. A Certified Nursing Assistant (CNA) 152, who was also present during this observation, confirmed the presence of the roach, and noted that their presence was a real problem. A dead cockroach was also observed in the conference room to which the survey team was assigned on 9/26/16 at 10:00 a.m. During the tour of the lower level of the main building on 9/26/16 at 9:55 a.m. observation revealed flying gnats in the shower room used by residents. A dead bug (type unidentifiable) was squished on the floor. Additional individual resident interviews revealed resident concerns about roaches and other insects. Interview on 9/26/26 at 9:45 a.m., with R2 reveal… | 2019-10-01 |
| 2971 | 2971 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2019-07-03 | 677 | D | 1 | 0 | KWBX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to consistently provide a bathing schedule for three of five residents (R#1, R#3, and R#12) reviewed for Activities of Daily Living (ADL's) and failed to provide timely incontinence care for one of three residents (R#1) reviewed for incontinence care. Findings include: 1. Resident (R) #12 resided at the facility from 1/8/19 through 3/30/19 and had [DIAGNOSES REDACTED]. There was a care plan in place, dated 1/8/19 for a self-care deficit of Activities of Daily Living (ADL's) related to limited mobility, fracture and muscle weakness, with an intervention for nursing staff to provide a bath and/or shower as scheduled. A review of the 14-day Minimum Data Set (MDS) assessment, dated 3/18/19, revealed that the resident had impaired cognition with a Brief Interview for Mental Status (BIMS) score of eight. The MDS assessment also documented that R#12 was dependent on nursing staff for personal hygiene and bathing. During interviews on 7/2/19 at 9:30 a.m. and 7/3/19 at 10:30 a.m., and review of R#12's bathing documentation with the Director of Health Services (DHS), she stated that the Certified Nursing Assistants (CNA's) are supposed to document the ADL care provided every shift. The current bathing schedule, implemented on 6/20/19, was set up for residents to receive a bath three times weekly, with adjustments made for individual preferences. Any refusals of care are to be documented on a new refusal form and given to the nurse. However, that was not in place during R#12's stay at the facility. The DHS stated that she did not know what the previous bathing schedule was for R#12. A review of the clinical record revealed that R#12 was not documented as being provided with a bath on a consistent basis. The computerized ADL Dressing and Personal Hygiene and Bath forms from 1/8/19 through 3/30/19 documented that the resident received a sponge bath or bed bath for six days in (MONTH)… | 2020-09-01 |
| 4382 | 4382 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 514 | E | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure electronic Medication Administration Records (MAR), the Kiosk Care Tracker/Plan of Care (CP) utilized for documenting Activities of Daily Living (ADL), and failed to document the administration of enteral feedings for five (5) residents (R9, R11, R20, R23 and R27). The information contained in these documents is essential for determining the resident's progress including response to treatment, change in condition, and changes in treatment. The sample was seventy-seven (77) residents. Findings include: [NAME] The legend for administration of medication and treatments for R11, R20, R23 and R27 was not followed. Chart Codes noted on the bottom of the electronic MAR identified the legend as follows: v=Administered, I=Ineffective, E=Effective, U=Unknown, H=On Hold By Physician; 1=Away from facility with meds, 2=Away from facility without meds 3=Hold due to Condition, 4=Hold Order/ See Progress Notes, 5=hospitalized , 6=Nauseated/Vomiting, 7=Not Given re: Vitals outside admin parameter, 8=Other/See Progress Notes, and 9=Partial Administration, 10=Refused Med(s), 11=Sleeping 12=Spit out Meds 13=Start IV/Feed, 14=Stop IV/Feed. 1. Review of record of R11 revealed she was admitted on [DATE]. The [DATE] Minimum Data Set (MDS), identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS included that R11 required 1-person assistance/support with Activities of Daily Living, to include bed mobility, transfers, dressing, toilet use and personal hygiene, and total dependence for bathing. Her monthly physical exams from (MONTH) (YEAR) through (MONTH) (YEAR) described R11 as cooperative, well groomed, not in acute distress; oriented to time, place, purpose and person. Her [DIAGNOSES REDACTED]. Interview on [DATE] at 3:10 p.m., with R11 while she was sitting in bed, she received mail to include Medisea a dietary … | 2019-11-01 |
| 4398 | 4398 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2016-12-10 | 312 | D | 1 | 0 | QBL111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure one of 45 sampled residents (Resident #89) who is unable to carry out activities of daily living received the necessary services to maintain good grooming, personal and oral hygiene. Findings include: Review of Resident (R) #89's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory problem and had severely impaired decision making regarding tasks for daily life. The resident had difficulty focusing attention (easily distracted, out of touch, or difficulty following what was said) and disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) continuously present. It identified the resident did not reject care during the assessment period. It also identified the resident was independent with no needed set up for bed mobility and transfers and needed supervision but no set up for walking in her room and the corridor/locomotion on and off unit. According to the assessment, the resident needed extensive assistance of one person for dressing, and was totally depended on at least one person for toilet use, personal hygiene, and bathing. Review of the resident's care plan, last revised on 10/4/16, revealed the resident required assistance with ADLs related to an old [MEDICAL CONDITION]. It identified the resident ambulated independently, would refuse care and assistance at times (i.e. bathing, toileting, incontinent care, and grooming tasks). The care plan directed staff to assist with dressing daily and as indicated, bathe the resident per facility protocol and prn, clean and trim fingernails as indicated, and provide assistance with personal hygiene and oral care daily and as needed. The care plan also identified the resident had impaired cognition as evidenced by short/long term memory loss, poor decision making skills, a… | 2019-11-01 |
| 4372 | 4372 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 314 | K | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure residents without pressure sores (PS) did not develop PS; failed to ensure residents with PS did not worsen, and; failed to ensure residents with PS received necessary treatment and services to promote healing for six (6) residents (R18, R20, R22, R23, R25 and R28). The sample was seventy-seven (77) residents. Review of the CMS Form 671, signed and dated by the Director of Nursing revealed a total of ten (10) residents with PS, five (5) of which were acquired within the facility, 109 residents receiving preventative skin care, 2 residents are bed-fast, 94 residents in the bed/chair most of the time, 79 residents incontinent of urine and 68 incontinent of bowel, with 2 residents on a toileting program. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 3:36 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed the facility's failures in measuring, treating, providing consistent power sources for an air mattress, and preventing worsening of pressure sores created a situation of Immediate Jeopardy for serious harm to the residents. Findings include: 1. Review of the clinical record for R28 revealed he was admitted on [DATE] with a stage 4 PS on the buttocks and a stage 2 pressure ulcer on his posterior thigh the PS was not measured at this time or at any time after admission by the nursing staff. There were numerous omissions for the wound treatments. The Wound Doctor (WD) measured the wounds on [DATE] and again on [DATE], the sacral wound had doubled in size and the stage II was actually a stage III. R28's PS were not measured or adequately assessed upon admission, they were not measured/assessed weekly, the initial inaccurate staging of the posterior thigh wound wa… | 2019-11-01 |
| 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 |
| 4534 | 4534 | POWDER SPRINGS TRANSITIONAL CARE AND REHAB | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2016-09-07 | 241 | D | 1 | 0 | N1YJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure that two (2) residents (#10 and 11) were assisted with meals in a dignified manner from a sample of twenty-seven (27) residents. Findings include: 1. Observation on 9/6/16 at 1:33 p.m. revealed Certified Nursing Assistant (CNA) NN standing while feeding resident #10 as he lay flat in bed. Record review of resident #10's Care Plan initiated 5/25/16 revealed a focus that the resident receives a mechanically altered diet, fluctuating appetite with risk for weight loss, malnutrition, dehydration and aspiration related to Dysphagia and progression of dementia. His current [DIAGNOSES REDACTED]. Record review of the resident #10's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed an assessment for Brief Interview for Mental Status (BIMS) of four (4) indicating the resident as having severely impaired cognition and requires extensive, one (1) person physical assistance for eating. Interview on 9/6/16 at 1:33 p.m. with CNA NN revealed that she was aware that CNA's are supposed to sit at eye level with the resident but didn't know why she did not do so. Interview on 9/6/16 at 1:37 pm with Licensed Practical Nurse (LPN) EE Charge Nurse revealed it is her expectation that staff will sit eye level with resident while assisting with eating. 2. Observation on 9/6/16 at 1:47 p.m. revealed CNA OO standing while feeding resident #11 as the resident sat upright in bed. Record review of resident #11's Care Plan initiated 4/25/13 and reviewed 8/16/16 revealed a focus that the resident is at risk for decline in nutrition/hydration status related to diabetes, failure to thrive and therapeutic diet. Risk for unavoidable weight loss, malnutrition, dehydration and aspiration related to progression of dementia and diabetes. Record review of the resident #11 Annual Review MDS dated [DATE] revealed an BIMS assessment of three (3) indicating the resident as having severely im… | 2019-09-01 |
| 4376 | 4376 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 328 | K | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two residents (R28 and R29) residents that had tracheotomies (trachs) and required multiple medical apparatus including ventilator (machine to aid and/or deliver respirations). Review of the CMS Form 672, signed and dated by the Director of Nursing on 11/1/16, revealed no evidence of trachs, and 5 receiving respiratory treatments. The sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/12/16 at 3:36 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ) situation. The facility's failure to ensure all necessary respiratory related medical equipment for two residents (R28 and R29) with tracheotomies were readily available; and that a safe and appropriate power source was available for their medical equipment, placed residents at risk of serious harm or death effective on 6/25/16 Those failures left residents vulnerable to respiratory distress, and/or death. This failure increased the likelihood for serious harm to two (2) of 2 residents (R28 and R29) with tracheotomies, who: Required back-up replacement inner cannulas in the event their cannulas became dislodged and required emergency replacement. The facility did not ensure the necessary equipment for potential respiratory distress (Ambu bags -manual resuscitators- for both residents, and correctly sized replacement inner cannulas for their tracheotomies) was available, and; Required more electrical outlets to ensure effective delivery of care via medical apparatus than was available. The facility used power strips to prov… | 2019-11-01 |
| 4658 | 4658 | PRUITTHEALTH - AUSTELL | 115314 | 1700 MULKEY RD | AUSTELL | GA | 30106 | 2016-08-16 | 323 | E | 1 | 0 | THJ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to evaluate and implement interventions to prevent new injuries for 1 of 2 sampled residents (R7) reviewed for accidents and supervision and failed to provide full access to bathroom call lights in 5 resident bathrooms (129, 142, 143, 152 and 153) resulting in the potential for injuries to reoccur and residents would be unable to call for assistance in their bathrooms. Findings include: 1. Observation of R7 on 8/15/16 at 10:00 a.m. revealed resident in her wheelchair with clothes on that appeared to be dried old blood on the right side of her shirt. R7 was noted to have a medium sized skin tear to her right wrist, deep purple and red in color with dried blood on the skin. No dressing was noted on her right wrist. Observation of R7 on 8/15/16 at 12:45 p.m. revealed a gauze dressing wrapped around her right lower forearm dated 8/15/16. Also noted was a large bruised area to the left wrist dark purple/red in color, with a small dried blood center. During an interview on 8/15/16 at 10:00 a.m. R7 was asked how she hurt her arm. R7 stated, .I think a hot iron fell on it . According to the Minimum Data Set Assessment (MDS) (a resident assessment tool) dated 5/23/16, R7 had a Staff Assessment for Mental Status of 1-1-1 which indicated the resident was severely cognitively impaired. Furthermore, according to the Functional Status section of the MDS, R7 was coded as needing extensive assistance with locomotion on and off the unit. However, she was noted moving throughout the facility on her own in her wheelchair. During an interview on 8/15/16 at 1:00 p.m. with Registered Nurse (RN)7, she stated she was unaware how the skin tear occurred. Review of R7's (MONTH) (YEAR) physician's orders [REDACTED]. Furthermore, a treatment order was noted written on 8/15/16 at 10:30 a.m. for .cleanse right lower forearm skin tear with normal saline, cover with Xeroform and gauze wrap, change every… | 2019-08-01 |
| 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 |
| 970 | 970 | LAGRANGE HEALTH AND REHAB | 115354 | 2111 WEST POINT ROAD | LAGRANGE | GA | 30240 | 2019-02-13 | 677 | D | 1 | 0 | 590W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide assistance with bathing and personal hygiene needs for one resident (R A) from a total sample of eight residents. Findings include: Resident (R) A was assessed on the 1/26/19 Minimum Data Set (MDS) assessment as being provided with extensive assistance with personal hygiene and being dependent on nursing staff for bathing. The care plan included a bathing schedule. The bathing schedule specified the Certified Nursing Assistant (CNA) on the evening shift was to provide the resident with a bath every Monday, Wednesday and Friday. RA was recently hospitalized from [DATE] through 2/5/19. A review of the clinical record, including the Bath Roster and Skin Observation forms revealed that since returning from the hospital on [DATE] (a Tuesday), the Resident's bath schedule had not been followed. The forms documented that the resident had received one bath, on 2/7/19 (a Thursday). The Bath Roster form also documented that the resident refused a bath on 2/9/19 (a Saturday). There was no evidence that the resident received a bath as scheduled on 2/11/19 (a Monday). During observations on 2/11/19 at 12:08 p.m., 12:55 p.m. and 2:45 p.m. and again on 2/12/19 at 1:40 p.m., the resident was observed to have oily, unwashed, uncombed hair and several days growth of facial hair. During the observations on 2/11/19 at 12:55 p.m. and 2/12/19 at 1:40 p.m., R A stated he preferred to be clean shaven. During interviews on 2/12/19 at 4:10 p.m. and 4:42 p.m. the Director of Nursing (DON) stated that the resident was scheduled to receive a bath on Monday, 2/11/19. However, his name was mistakenly omitted from the daily assignment sheet when Licensed Practical Nurse AA revised it, therefore he did not receive a bath as scheduled from CNA BB on 2/11/19. LPN AA and CNA BB confirmed via written statements on 2/12/19, that RA had not received a bath on 2/11/19 as scheduled. The DON stated th… | 2020-09-01 |
| 4657 | 4657 | PRUITTHEALTH - AUSTELL | 115314 | 1700 MULKEY RD | AUSTELL | GA | 30106 | 2016-08-16 | 241 | E | 1 | 0 | THJ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide assistance with grooming and dressing for four (R7, R8, R9 and R12) sampled residents (R) reviewed for dignity from a total sample of 12. Findings include: 1. Observation of R8 on 8/15/16 at 11:00 a.m. revealed the resident sitting in the hallway, in his wheelchair, with a heavy beard growth on his face. R8 was also noted to have food residue on his shirt. Observation of R8 on 8/16/16 at 9:00 a.m. revealed the resident in bed with the same beard growth which was observed on 8/15/16. During an interview with R8 on 8/16/16 at 9:00 a.m. he stated that he was unable to shave himself and that he needed .one of the girls to do it . He also stated, .I'm glad you noticed I needed to be shaved . Observation of R8 on 8/16/16 at 3:00 p.m. revealed him sitting in his room, dressed and freshly shaved. When R8 was asked about being shaved, he stated, .yes she did a good job . He could not recall who shaved him, but further stated, .I think she heard you say something this morning . According to the Minimum Data Set Assessment (MDS) (a resident assessment tool) dated 7/25/16; R8 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident was moderately cognitively impaired. Furthermore, according to the Functional Status section of the MDS, R8 was coded as needing extensive assistance with personal hygiene. 2. Observation of R9 on 8/15/16 at 11:00 a.m. revealed the resident ambulating in his wheelchair through the facility, with a heavy beard growth. Also noted was R9's last name on the upper left side of his sweatshirt. Observation of R9 on 8/16/16 at 9:15 a.m. revealed the resident to be wearing the same clothes as 8/15/16. According to the MDS dated [DATE], R9 had a BIMS score of 9, which indicated the resident was mildly cognitively impaired. Furthermore, according to the Functional Status section of the MDS, R9 was coded as needing limited as… | 2019-08-01 |
| 5189 | 5189 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2015-12-15 | 309 | E | 1 | 0 | 5HFL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide care and services for the highest well-being for 1 (one) resident on 1 (one) hall from a sample size of 3 (three) residents on 2 (two) halls. Findings include: Review of R4's Medication Administration Records (MAR) for (MONTH) and (MONTH) of (YEAR) revealed that the facility failed to notify the physician for blood sugars of 422 on 7/31/2015 at 11:30 a.m., 400 on 7/31/2015 at 4:30 p.m., 464 on 8/2/2015 at 11:30 a.m., and 440 on 8/10/2015 at 11:30 p.m. Physicians Orders noted on the MAR indicated [REDACTED]>= 400. Interview on 12/16/2015 at 5:45 p.m. with the Administrator and the DON reveals that the physician should have been notified. Medication Administration is on the QAA Committee agenda and education is on-going. Failure to follow physician's order [REDACTED]. | 2018-12-01 |
| 2046 | 2046 | ROBERTA HEALTH AND REHAB | 115523 | 420 MYTLE DRIVE | ROBERTA | GA | 31078 | 2019-07-18 | 761 | D | 1 | 1 | P6KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of facility data and a policy titled, Labeling of Medication Containers, last revised (MONTH) 2007, the facility failed to ensure that expired medications and biological's, were not available for resident use in one (1) medication storage room and one (1) medication refrigerator, and failed to label one (1) opened multi-use vial of [MEDICATION NAME] Purified Protein Derivative (PPD) with the open date, ensuring disposal by the appropriate expiration date. Findings include: An observation was conducted on 7/16/19 at 3:11 p.m. in the medication storage room with Licensed Practical Nurse (LPN) CC where she confirmed the facility had one central storage room and one medication refrigerator. The room was locked, the refrigerator was locked. During this observation, 50 expired medications and 19 expired vaccines were found as follows: Located on a shelf with other stock medications were: [MEDICATION NAME] lock syringes (IV flushes) 5ml of 50u/5ml- 25 expired 2/28/19 [MEDICATION NAME] lock syringes (IV flushes) 5ml of 50u/5ml- 16 expired 5/31/19 [MEDICATION NAME] lock syringes (IV flushes) 5ml of 50u/5ml- 3 expired 4/30/19 [MEDICATION NAME] lock syringes (IV flushes) 5ml of 50u/5ml- 1 expired 3/31/19 [MEDICATION NAME] lock syringes (IV flushes) 5ml of 50u/5ml- 5 expired 1/19/19 Located in the refrigerator, Influenza Flu vaccines 0.5 ml Lot 7 prefilled syringes were found in an open box containing nine (9) syringes, expiration date of 5/31/19. Influenza Flu vaccines 0.5 ml Lot 0 prefilled syringes were found in an unopened box containing ten (10) syringes, expiration date of 5/31/19. Located in the refrigerator, a [MEDICATION NAME] Purified Protein Derivative (PPD) 10 ml vial 5Tu/0.1ml was found opened, no open date on the vial was found, unable to determine when it was opened for use. An interview was also conducted with LPN CC during the storage room observation. The LPN confirmed that all the nurses are… | 2020-09-01 |
| 2043 | 2043 | ROBERTA HEALTH AND REHAB | 115523 | 420 MYTLE DRIVE | ROBERTA | GA | 31078 | 2019-07-18 | 584 | E | 1 | 1 | P6KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of facility documentation, the facility failed to ensure that it was maintained in a safe, clean and comfortable environment on two (2) of four (4) halls. The facility census was 87 residents. Findings include: 1. An initial observation was conducted on 7/15/19 from 11:15 a.m. to 12:00 p.m. the observation conducted was in resident rooms and the hall-way on Hall-2 as follows: Two (2) of seven (7) ceiling light panels were not working on Hall-2. The hall-way appeared much darker than the other halls. room [ROOM NUMBER]A- over bed lights not working after two attempts room [ROOM NUMBER]B -over bed lights not working after two attempts room [ROOM NUMBER] -ceiling light for room working intermittently on then goes off room [ROOM NUMBER]A- over bed light not working short cord, multiple live ants crawling on wall just inside the door-jam to room [ROOM NUMBER] room [ROOM NUMBER]B- room air conditioner near 228B bed with an approximate 1 inch gap between air conditioner and will, outside is visible from the gap on right side and top of air conditioner, broken blinds room [ROOM NUMBER]B over bed light with short cord (4 inches) room [ROOM NUMBER]B over bed light with short cord (4 inches) room [ROOM NUMBER]A- live spider crawling across drywall above the door visible from inside the room, over bed light with short cord (4 inches) room [ROOM NUMBER]- live spider crawling in his web behind the door in the corner on the drywall, a whole approximately 2 inches, found in the corner between baseboard and door-jam to the bathroom room [ROOM NUMBER]A- over bed light with short cord (4 inches) room [ROOM NUMBER]A call light not working, bathroom shared (4 residents share) between rooms [ROOM NUMBERS]- an old appearing white toothbrush observed on sink behind hat and cold water knobs room [ROOM NUMBER]A- soiled privacy curtain, over bed light with short cord (4 inches) room [ROOM NUMBER]A- over bed light short cord … | 2020-09-01 |
| 3293 | 3293 | PRUITTHEALTH - DECATUR | 115647 | 3200 PANTHERSVILLE ROAD | DECATUR | GA | 30034 | 2019-12-12 | 698 | D | 1 | 1 | FSFG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of facility's policies titled [MEDICAL TREATMENT] Care Pre-and Post-[MEDICAL TREATMENT] and Post-[MEDICAL TREATMENT], the facility failed to maintain an effective communication system between the [MEDICAL TREATMENT] and the facility for one Resident (R) R#65 receiving [MEDICAL TREATMENT] services. The sample size was 52 residents. Findings include: A review conducted of the policy titled, [MEDICAL TREATMENT] Care Pre-and Post-[MEDICAL TREATMENT] reviewed last 5/2018, documents under the section titled, Documentation Tools [MEDICAL TREATMENT] Center Communication Form. Maintain [MEDICAL TREATMENT] Communication Form in patient/residents' chart, vital sign sheet, nurses note. Under section titled Implementation, Pre-[MEDICAL TREATMENT]: verify physician orders, take and record patient/resident blood pressure and pulse, observe shunt access (AV shunt or Permacath) prior to patient/resident transport to [MEDICAL TREATMENT]. If access port is in the axilla or groin, reinforce pigtail with occlusive dressing to decrease opportunity for dislodging port. If access in the other area, tape pigtail as appropriate to secure it. Under section titled, Post-[MEDICAL TREATMENT] documents to verify Physician Orders. Upon return from [MEDICAL TREATMENT], take and record patient/resident blood pressure, pulse and observations of the dressing at the access site. Palpate for evidence of thrill and bruit before and after [MEDICAL TREATMENT], documenting both as appropriate and notifying Physician if they are absent. Record review revealed the resident was admitted on [DATE] from acute hospital with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documents the following sections: Cognitive-Brief Interview for Mental Status (BIMS) score of 11, minimal impairment; Functional- requires supervision for eating, bathing, and limited assistance for toileting, transfers, walking, dres… | 2020-09-01 |
| 2525 | 2525 | FULTON CENTER FOR REHABILITATION LLC | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2019-11-26 | 656 | D | 1 | 0 | VEQO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of the facility's policy titled Comprehensive Person-Centered Care Planning Policy and Procedure, the facility failed to implement the care plan interventions for the safe use of a Hoyer Lift during transfer activity for R#1 of three sampled residents. Findings include: A review was conducted of the facility's policy, titled Comprehensive Person-Centered Care Planning Policy and Procedure undated and the policy titled Safe Lifting and Movement of Residents. In Section II Comprehensive Care Plans: documentation reflects that the facility shall develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. A review was conducted of the facility's policy, titled Safe Lifting and Movement of Residents last revised (MONTH) 2013 revealed the Policy Interpretation and Implementation documents the following: No 3. Nursing staff, in conjunction with the rehabilitation staff shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include, resident's preferences for assistance, resident's mobility/degree of dependency, resident's size, weight bearing ability, cognitive status, whether resident is usually cooperative with staff and goals for rehabilitation, including restoring or maintaining functional abilities. Record review revealed the resident has a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 7/12/19 revealed the that the resident was assessed for extensive assistance with a two plus person physical assistance, for bed mobility and transfers. The resident is assessed for the Brief Interview for Mental Status (BIMS) of 12 indicating the resident… | 2020-09-01 |
| 2395 | 2395 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2017-11-09 | 315 | D | 1 | 1 | B1H711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and policy review it was determined the facility failed to provide appropriate incontinence care for one resident (R) sampled for incontinence care (R#158). The inappropriate incontinence care created the likelihood of the development of a urinary tract infection. There were 35 sampled residents. Findings include: Review of the policy titled Urinary Continence and Incontinence-Assessment and Management-Guidelines dated (MONTH) (YEAR) revealed in the policy statement that the nursing staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. Review of the undated policy titled Perineal Care revealed the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. For the female resident step 9 included: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. 1. Separate labia and wash area downward from front to back . 2. Continue to wash the perineum moving from inside outward .Do not reuse the same washcloth or water to clean the urethra or labia. 3. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. 4. Gently dry the perineum. c. Instruct or assist the resident to turn on her side with her top log slightly bent, if able. d. Rinse wash cloth and apply soap or skin cleansing agent. e. Wash the rectal area thoroughly . f. Rinse thoroughly using the same technique shown in e above. g. Dry area thoroughly. 11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Reposition the bed covers. Make the resident comfortable. 14. Place the call light within easy reach of the resident. 15. Clean wash basin and return to desi… | 2020-09-01 |
| 2397 | 2397 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2017-11-09 | 441 | D | 1 | 1 | B1H711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and policy review, it was determined the facility staff failed to remove gloves and wash hands after providing perineal care and before repositioning the resident and returning care items to storage areas for one resident (R)#158 from 35 sampled residents. This failure resulted in the potential for the transmission of harmful germs. Findings include: Review of the undated policy Isolation-Categories of Transmission-Based Precautions revealed that Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infections. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Further review of the policy revealed In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Review of the undated policy Perineal Care revealed step 7 of the procedure to Put on gloves. Further review of the policy indicated in step 12 to Remove gloves and discard into designated container, Wash and dry your hands thoroughly. Step 13 Reposition the bed covers. Make the resident comfortable. Step 14 Place the call light . Step 15 Clean wash basin and return to designated storage area. Step 16 Clean the bedside stand . Review of the Profile for R#158 revealed admission in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Observation of perineal care provided by Certified Nursing Assistant (CNA) NN on 11/8/17 at 10:48 a.m. to R#158 revealed the following: CNA NN provided perineal care and then failed to remove her gloves when she repositioned R#158 in her bed, replaced the care items to the storage drawer, rearranged the… | 2020-09-01 |
| 397 | 397 | HARBORVIEW SATILLA | 115265 | 1600 RIVERSIDE AVE | WAYCROSS | GA | 31501 | 2018-02-15 | 584 | E | 1 | 1 | LMHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review Facility B failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior by failing to repair drywall, leaky faucets, and broken floor tiles in 10 rooms out of 36 rooms on two out of two halls. The census for Facility B was 68 residents. Findings include: 1. Observation on 2/12/18 at 11:30 a.m. room [ROOM NUMBER] was observed revealed that there was bare T-shaped white spackle on beige-colored paint on the TV wall opposite the residents' beds. The baseboard near the bathroom was observed to be broken. There was peeling paint behind the heads of both beds. 2. Observation on 2/12/18 at 11:33 a.m. in room [ROOM NUMBER] revealed a leaky faucet was observed, and bare spackle on the window wall. 3. Observation On 2/12/18 at 11:36 a.m. inroom [ROOM NUMBER] evealed broken linoleum tile under the sink. 4. Observation on 2/12/18 at 11:38 a.m. room [ROOM NUMBER] revealed multiple patches of peeling paint on the air-conditioning unit below the window. 5. Observation on 2/12/18 at 11:40 a.m. of room [ROOM NUMBER] revealed multiple patches of peeling paint on the air-conditioning unit. 6. Observation on 2/12/18 at 11:45 a.m. of room [ROOM NUMBER] revealed broken ceramic tile on the sink, a leaky faucet, and broken linoleum tile under the sink. 7. Observation on 2/12/18 at 11:49 a.m. room [ROOM NUMBER] revealed gouged drywall on the doorway wall and on the TV wall of the room, opposite residents' beds. 8. Observation on 2/15/18 at 12:40 p.m. room [ROOM NUMBER] revealed cracked caulk on the sink. 9. Observatgion on 2/15/18 at 12:42 p.m. room [ROOM NUMBER] revealed a leaky faucet and a large spot of bare spackle near the sink. 10. Observation on 2/15/18 15 12:45 p.m. of the 100-hall shower room was noted to have a badly rust-colored sink and a leaky faucet. On 2/15/18 at 12:50 p.m. an interview and tour was made of the facility with the Director of Maintenance (D… | 2020-09-01 |
| 3266 | 3266 | PARKSIDE POST ACUTE AND REHABILITATION | 115643 | 3000 LENORA CHURCH DRIVE | SNELLVILLE | GA | 30078 | 2018-05-20 | 656 | D | 1 | 0 | 9RIX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review the facility failed to implement a comprehensive care plan for one Resident ( R#5) of three residents reviewed . This failure resulted in the resident being hospitalized with a blood pressure-related diagnosis. Findings include: Resident (R) #5 was admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 4/14/18, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Further review revealed R#5 required extensive assistance to total dependence for all activities of daily living (ADL) except eating, for which she required limited assistance. She was noted to be always incontinent of bowel and bladder. Review of a Medical progress note, dated 4/8/18, revealed R#5 was admitted to the Intensive Care Unit (ICU) on 4/6/18. The note further revealed the Medical Doctor's (MD) [DIAGNOSES REDACTED]. Review of the Blood Pressure Summary in the facility electronic medical record (EMR), revealed no record of vital signs between 9/18/17 and 4/6/18. A review of R#5's paper chart revealed no information on vital signs, except on 1/10/18, 2/27/18, and 4/12/18, all written in the psychiatric progress notes . No other vital signs information was found on the paper chart. On 5/2/18 at 11:40 a.m. the Director of Nursing (DON) was interviewed in the classroom. She stated no vital signs had been taken between 9/18/17 and 4/6/18 because they did not have a doctor's order to do so and the resident was stable. Review of the care plan, page 8 of 24, initiated 7/8/2011, revised on 1/18/2018, with a target date of 5/6/2018, revealed a goal that R#5 would maintain normal vital signs and a decrease of signs or symptoms [MEDICAL CONDITION] the review date. Side effects such as orthostatic [MEDICAL CONDITION] (low blood pressure) were to be monitored. Refer to F658 | 2020-09-01 |
| 3036 | 3036 | EASTMAN HEALTHCARE & REHAB | 115622 | 556 CHESTER HIGHWAY | EASTMAN | GA | 31023 | 2019-07-24 | 584 | E | 1 | 0 | EMU611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review the facility failed to maintain a clean comfortable environment within a temperature range of 71 degrees Fahrenheit (F) - 81 degrees F on three of five halls. Record review and interviews revealed the air-conditioning (AC) system in the facility had broken down multiple times in the past. Interview with the facility Heating, Ventilation, and Air-conditioning (HVAC) consultant revealed the facility HVAC system was inadequate and likely to continue to be unreliable. Observation with the Medical Director (MD) and Administrator interview revealed cluttered and unclean shower rooms, a black substance on a large AC vent, and a large area of a black substance above Resident (R)#11's bed. Findings include: An unannounced brief tour of each resident care hall on 7/17/19 at 2:25 p.m. revealed a medium-sized facility with five short resident-care halls. The facility was warm, dank, and humid throughout. Three residents complained during the tour it was too hot in the building and they were not comfortable. The surveyor broke out into a sweat during this tour. On 7/17/19 from 2:34 p.m. - 2:48 p.m. each resident care area was toured with the Maintenance Director. The Maintenance Director stated he had worked for the facility for six weeks. The Maintenance Director used an infrared thermometer to measure temperatures. The Maintenance Director stated this type of thermometer cannot measure air temperatures, only solid objects. The Maintenance Director was observed to be sweaty. He wore a towel around his neck. The Maintenance Director stated the towel was to absorb the sweat. The following temperatures were measured by the Maintenance Director while under observation by the surveyor: 1. In the lobby, the wall near the front door, the wall temperature was 84 degrees F. 2. In the lobby, the wall near the nursing station was 86 degrees F. 3. The temperature of the AC vent in the ceiling above nursing station… | 2020-09-01 |
| 3038 | 3038 | EASTMAN HEALTHCARE & REHAB | 115622 | 556 CHESTER HIGHWAY | EASTMAN | GA | 31023 | 2019-07-24 | 925 | F | 1 | 0 | EMU611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review the facility failed to maintain an effective pest control program causing a flying insect infestation observed throughout the facility, on multiple occasions for five of five survey days. A series of observations further revealed at least one dumpster behind the facility kitchen was uncovered during the five-day survey, providing harborage for multiple flying insects the entire time. Observation also revealed the screen door to the facility kitchen was left open during a four-day period. Multiple observations further revealed flying insects to land on residents and to crawl on them. Several flying insect observations were confirmed by the Medical Director (MD) and the Administrator. Interview with the facility Pest Control Consultant (PCC) revealed the facility was not implementing his recommendations beyond spraying of insecticides, rendering the facility pest control program only partly effective. Findings include: Interview with R#3 on 7/17/19 at 2:47 p.m. revealed her to by lying in bed covered with a white sheet. A common housefly was observed on her sheet. Interview with the Administrator on the 100-hall on 7/17/19 at 3:15 p.m. revealed he was measuring temperatures with an infrared thermometer. He stated he agreed there was a flying insect flying around his head. On 7/17/19 at 11:00 p.m. R#8 was interviewed in the hall outside room [ROOM NUMBER]. He was seated in a wheelchair. There was a flying insect flying around his head. On 7/17/19 at 11:15 p.m. a through-and-through gouge about the size of a pack of cigarettes was noted in the drywall near the floor to the left of the door to room [ROOM NUMBER]. On 7/17/19 at 11:17 p.m. the Administrator and the surveyor directly observed resident room [ROOM NUMBER]. The Administrator stated he agreed there was a flying insect in the room. Interview with the Director of Nursing (DON) on 7/19/19 at 12:30 p.m. revealed she stated she did not beli… | 2020-09-01 |
| 1973 | 1973 | PRUITTHEALTH - WEST ATLANTA | 115512 | 2645 WHITING STREET N.W. | ATLANTA | GA | 30318 | 2018-10-01 | 584 | E | 1 | 0 | UBSP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, homelike environment by not repairing concerns including broken plaster, peeling paint, stained walls and ceilings, unanchored commodes, broken or missing floor tiles, and broken or missing baseboards in eight resident rooms out of 51 rooms in two of two resident halls. Findings include: On 9/28/18 at 9:25 a.m. room [ROOM NUMBER] was directly observed. There was bare rough spackle, unpainted, in the bathroom. There was missing floor tile near the closet. There was broken plaster near the closet. On 9/28/18 at 9:28 a.m. room [ROOM NUMBER] was directly observed. There was broken baseboard near the A-bed. The paint was peeling throughout the room. The cover of the pass-through-air-conditioner (PTAC) beneath the window was on the floor, exposing the bare air conditioning mechanics, which was covered with dust and grime. There was an unbagged fracture-type bedpan on the floor of the bathroom, turned upside down. On 9/28/18 at 9:31 a.m. the entire ceiling of the large 200-hall was observed. Multiple ceiling tiles had brown or black liquid stains on them throughout the length and breadth of the hall. On 9/28/18 at 9:40 a.m. room [ROOM NUMBER] was directly observed. There was broken plaster all around the door frame, exposing the metal corner protector. On 9/28/18 at 9:42 a.m. room [ROOM NUMBER] was directly observed. There was a very large area of rough, unpainted spackle on the popcorn-type ceiling above the A-bed. There was a broken baseboard under the PTAC at the B-bed, exposing bare cinder-block-type masonry. On 9/28/18 at 9:45 a.m. the wall near the high ceiling above the entrance to room [ROOM NUMBER] was noted to have a very large area of peeling paint and bare plaster. On 9/28/18 at 9:45 a.m. licensed practical nurse (LPN) BB was interviewed at her medication cart. She stated she had worked for the facility for three months. She st… | 2020-09-01 |
| 2292 | 2292 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2018-05-25 | 656 | D | 1 | 0 | 12O611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility did not implement a comprehensive care plan for one resident of three sampled by failing to administer ordered medications 18 times on 5/10/2018 and 5/11/2018. Findings include: Review of the Face Sheet revealed Resident (R) #1 was admitted to the facility on [DATE] at 5:19 p.m. His [DIAGNOSES REDACTED]. Review of R#1's minimum data set (MDS) data revealed a brief interview for mental status (BIMS) score of 12, or largely intact cognition. He required extensive assistance with activities of daily living (ADLs). Review of R#1's Physicians Orders, dated 5/10/18, revealed the following medications were among those ordered: Fluconazole 100 milligrams (mg) by mouth (antifungal) for three days at 9:00 a.m. [MEDICATION NAME] (depression) 50 mg by mouth daily at 9:00 a.m. [MEDICATION NAME] handi-haler (breathing support), inhale into lungs daily at 9:00 a.m. [MEDICATION NAME] (supplement) 1000 mg by mouth daily at 9:00 p.m. [MEDICATION NAME] (pain management) 10 mg/.5 ml oral solution, give 12 mgs by mouth every six hours for four days. [MEDICATION NAME] 100 mg capsule, give 200 mg by mouth twice a day (arthritis) [MEDICATION NAME] (pain management) 300 mg capsule, give two capsules by mouth three times a day. [MEDICATION NAME] (breathing support) inhaler, inhale two puffs into lungs two times daily at 9:00 a.m. and 5:00 p.m. [MEDICATION NAME] ([MEDICATION NAME]) 750 mg tablet one table by mouth daily at 9:00 a.m. for three days (antibiotic) Fludrocortisone 0.1 mg tablet by mouth daily at 9:00 a.m. (steroid [MEDICAL CONDITION]) [MEDICATION NAME] 10 mg tablet by mouth at 9:00 a.m. daily (HTN) [MEDICATION NAME] 10 mg tablet by mouth daily at 9:00 a.m. (allergies [REDACTED].>[MEDICATION NAME] 20 mg capsule by mouth daily at 9:00 a.m. for gastro-[MEDICAL CONDITION] reflux disease (GERD) Sennosides 25 mg by mouth daily at 9:00 a.m. for constipation (Senna) Review of R#1's Baseline Care Pla… | 2020-09-01 |
| 2293 | 2293 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2018-05-25 | 684 | D | 1 | 0 | 12O611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility did not maintain high quality of care by not following physician's orders for one resident out of three sampled by failing to administer ordered medications 18 times on 5/10/2018 and 5/11/2018. Findings include: Review of the Face Sheet revealed Resident (R) #1 was admitted to the facility on [DATE] at 5:19 p.m. His [DIAGNOSES REDACTED]. Review of R#1's minimum data set (MDS) data revealed a brief interview for mental status (BIMS) score of 12, or largely intact cognition. He required extensive assistance with activities of daily living (ADLs). Review of R#1's physician's orders, dated 5/10/2018, revealed the following medications were among those ordered: Fluconazole 100 mg by mouth (antifungal) for three days at 9:00 a.m. [MEDICATION NAME] (depression) 50 mg by mouth daily at 9:00 a.m. [MEDICATION NAME] handi-haler (breathing support), inhale into lungs daily at 9:00 a.m. [MEDICATION NAME] (supplement) 1000 mg by mouth daily at 9:00 p.m. [MEDICATION NAME] (pain management) 10 mg/.5 ml oral solution, give 12 mgs by mouth every six hours for four days. [MEDICATION NAME] 100 mg capsule, give 200 mg by mouth twice a day (arthritis) [MEDICATION NAME] (pain management) 300 mg capsule, give two capsules by mouth three times a day. [MEDICATION NAME] (breathing support) inhaler, inhale two puffs into lungs two times daily at 9:00 a.m. and 5:00 p.m. [MEDICATION NAME] ([MEDICATION NAME]) 750 mg table one table by mouth daily at 9:00 a.m. for three days (antibiotic) Fludrocortisone 0.1 mg tablet by mouth daily at 9:00 a.m. (steroid [MEDICAL CONDITION]) [MEDICATION NAME] 10 mg tablet by mouth at 9:00 a.m. daily (HTN) [MEDICATION NAME] 10 mg tablet by mouth daily at 9:00 a.m. (allergies [REDACTED].>[MEDICATION NAME] 20 mg capsule by mouth daily at 9:00 a.m. for gastro-[MEDICAL CONDITION] reflux disease (GERD) Sennosides 25 mg by mouth daily at 9:00 a.m. for constipation (Senna) On 5/23/20… | 2020-09-01 |
| 1178 | 1178 | SOUTHLAND HEALTHCARE AND REHAB CENTER | 115376 | 606 SIMMONS ST | DUBLIN | GA | 31040 | 2017-12-20 | 689 | D | 1 | 0 | 29K711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to apply anti-skid strips on the bathroom floor to prevent falls for one resident (A) of 36 sampled residents. Findings include: Record review revealed that resident (R) A had [DIAGNOSES REDACTED]. Review of the care plan revealed that there was a care plan in place for the resident being at risk for falls with an intervention, dated 6/24/17, for anti-skid strips to be applied on the floor by the toilet. The anti-skid strips were implemented after the resident sustained [REDACTED]. During an interview on 12/18/17 at 5:40 p.m., R A was aware that he needed assistance from staff to toilet, but stated he would attempt to use the bathroom by himself, without calling for assistance first. During an observation on 12/18/17 at 5:40 p.m., there were no anti-skid strips on the floor in the bathroom, as care planned for a fall intervention. During an interview on 12/18/17 at 6:00 p.m., the Director of Nursing (DON) stated that the anti-skid strips must have been removed when the floor was deep cleaned. A review of the (MONTH) (YEAR) calendar for stipping and waxing floors documented that R A's room was cleaned on 12/4/17. During an interview on 12/19/17 at 4:15 p.m., the DON confirmed that the anti-skid strips were removed on 12/4/17 and not replaced until after surveyor inquiry on 12/18/17. Anti-skid strips were observed in place, on the bathroom floor, in front of the toilet, on 12/19/17 at 12:40 p.m. | 2020-09-01 |
| 4442 | 4442 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2016-10-05 | 463 | D | 1 | 0 | ELW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to assure that call lights were functional for 1 of 52 sampled residents (R17). In addition, one public bathroom that had the potential to be used by residents was not equipped with a functional call light. The census was 229. Findings include: 1. Review of the annual Minimum Data Set (MDS) for R17, with an Assessment Reference Date (ARD) of 7/14/16, indicated the resident was alert and oriented, based on a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive deficits or memory problems. Per a Social Service Annual Update Note note, dated 7/28/16, the resident is alert, able to communicate her needs, and can understand others. The resident's current care plan, with a target date (target date is the verbiage used by the facility) of 10/16 indicated the resident requires assist with ADL (Activities of Daily Living) care secondary to impaired mobility and had [DIAGNOSES REDACTED]. Per the resident's care plan, staff was to assist with bathing, eating, personal hygiene, toilet use, transfers, and bed mobility as needed. The resident was also at risk for fall related injuries and approaches to prevent falls included staff assisting the resident with transfers as needed and encourage resident to call for assistance for all needs, especially when reaching for objects on the floor. Observation on 9/26/16 at 9:07 a.m. revealed the resident was in her room. The resident stated, My call light's not working. They never answer it. She then pushed the call light button to verify her statement. No sound was heard in either the resident's room or outside the room when she activated her call light. During an interview with Certified Nursing Assistant (CNA) 173 on 9/27/16 at 9:12 a.m., the CNA stated the call lights trigger an electronic paging system. She pointed to a board hanging in the hallway which listed the room number for any rooms in which the … | 2019-10-01 |
| 4437 | 4437 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2016-10-05 | 282 | E | 1 | 0 | ELW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to assure that services were provided in accordance with the plan of care for 5 of 52 sampled residents (R2, R4, R20, R21, and R25). Care plan approaches were not followed for areas such as assistance with activities of daily living (ADLs) which included eating, bathing and dressing, as well as pressure ulcer prevention, accident prevention, and monitoring of clinical conditions. The census was 229. Findings include: 1. Review of the face sheet for R25 indicated the resident had [DIAGNOSES REDACTED]. Review of the resident's current care plan, with a target date of 11/2016, indicated the resident had a problem of Self-care deficit: requires assistance with ADLs r/t (related to) impaired mobility. Dx (diagnosis): [MEDICAL CONDITION], rt (right) sided weakness. To meet the goal of having all ADL needs met, the care plan directed the staff to provide assistance with all ADLS as needed. Review of the Daily Care Guide (an abbreviated form of the care plan used by direct care staff) for R25, provided the following information: a. Per the Daily Care Guide, R25 required one-person physical assistance with eating. Staff was to cut food/meats into small bites, food in bowls, assist PRN (as needed). Encourage self-feeding and assist her to finish meal .To dining room for meals. Observation on 9/26/16 at 8:45 a.m. revealed R25 was in her bed, attempting to feed herself breakfast which included cereal in milk, eggs, and sausage in gravy. There was no staff in the resident's room from 8:45 a.m. to 9:15 a.m., except at 8:53 a.m., when Certified Nursing Assistant (CNA) 179 responded to the room's call light (which had been activated to check response times.) After CNA179 learned that the call light was just a test, she exited the room and R25 continued to attempt to eat her breakfast without staff assistance or supervision. During the half hour's observation, R25 slowly took her spoon … | 2019-10-01 |
| 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 |
| 4578 | 4578 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2017-09-10 | 329 | D | 1 | 1 | IOYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure that a Gradual Dose Reduction and a physician order [REDACTED].#37) out of 19 sampled residents. Finding include: Record review for R # 28 revealed that a Gradual Dose Reduction was recommended on 6/12/17, for [MEDICATION NAME] 7.5 milligrams (mg) to be decreased to [MEDICATION NAME] 5 mg. Further record review revealed that the physician agreed to these recommendations on 7/15/17. Review of a phone order written and signed by the physician on 7/15/17 revealed that the order was written to decrease [MEDICATION NAME] 7.5 mg to [MEDICATION NAME] 5 mg. Further record review revealed that there was not any evidence that the new order for [MEDICATION NAME] 5mg was included on the (MONTH) (YEAR) Medication Administration Records (MARs) and it was not on the (MONTH) (YEAR) MAR. Review of the MARs revealed that R#28 continued to be administered [MEDICATION NAME] 7.5 mg. Observation with the Director of Nursing on 9/11/17 at 1:45 p.m. revealed that the medication in medication cart for R#28 was [MEDICATION NAME] 7.5 mg. Interview with Director of Nursing on 9/11/17 at 1:30 p.m. revealed that it is her expectation for all orders to be reconciled monthly by the Licensed Practical Nurse of each unit. Joy QP999 Most Recent MDS Assessment: 02 - Quarterly review assessment (A0310A) / 99 - None of the above (A0310B) on 06/29/2017 MDS)(I4800,I4200) Active [DIAGNOSES REDACTED]. Note: this [DIAGNOSES REDACTED]. I4800 Non-Alzheimer's Dementia - 1 (Checked (Yes)) I4200 Alzheimer's - 1 (Checked (Yes)) MDS)(I4400, I5200, I5400, J1400) Active [DIAGNOSES REDACTED]. Note: Any of these [DIAGNOSES REDACTED]. I4400 [MEDICAL CONDITION] - 0 (Not checked (No)) I5200 [MEDICAL CONDITION] - 0 (Not checked (No)) I5400 [MEDICAL CONDITION]/[MEDICAL CONDITION] - 0 (Not checked (No)) J1400 terminal prognosis - 0 (Not checked (No)) MDS)(I5250, I5350, I5900, I6000) Active [DIAGNOSES REDACTED]. Depress… | 2019-09-01 |
| 2979 | 2979 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2019-07-03 | 805 | D | 1 | 0 | KWBX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure that a diet was served as ordered for one of three residents (R#2) reviewed for diets. Findings include: Resident (R) #2 had [DIAGNOSES REDACTED]. The resident had been receiving hospice services since 4/8/16. There was a care plan in place since 11/30/15 for the potential for an alteration in nutrition with an intervention for dietary staff to serve the diet as ordered. R#2 had a physician's orders [REDACTED]. However, during an observation on 6/11/19 at 1:00 p.m., R #2 was observed to have been served a regular consistency diet for lunch. The lunch tray contained fried chicken, carrots, mashed potatoes, banana pudding, iced tea and water. The fried chicken was not a mechanical soft consistency. During an interview on 6/11/19 at 2:39 p.m., the Dietary Manager incorrectly stated that the resident was on a regular diet. She indicated that the resident was changed from a pureed diet to a regular consistency diet. After reviewing the 6/5/19 physician's orders [REDACTED]. However, there was no evidence that the mechanically soft diet had been discontinued until after surveyor inquiry. During an interview on 7/2/19 at 9:30 a.m., the Director of Health Services (DHS) stated that the resident did not have any swallowing problems but was placed on the pureed diet in (MONTH) 2019 due to a decline at that time. | 2020-09-01 |
| 627 | 627 | WINDERMERE HEALTH AND REHABILITATION CENTER | 115291 | 3618 J DEWEY GRAY CIRCLE | AUGUSTA | GA | 30909 | 2018-04-30 | 694 | D | 1 | 0 | UHMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure that the enteral nutrition being administered to one resident (R) #2, had been labeled by the administering staff member. The sample size was three. Finding include: Observation of resident (R)#2 on 4/30/18 at 5:40 p.m. revealed the resident in his bed, supine, and sleeping. The resident was receiving enteral nutrition through a gastrostomy tube ([DEVICE]). Continued observation revealed an intravenous (IV) pole located to the left of the resident's bed with an unidentified brown liquid being administered to the resident from a Kangaroo bag using an enteral feeding pump. Observation of the Kangaroo bag revealed there was no label or other type of identification on the bag. Observation and interview on 4/30/18 at 5:43 p.m. revealed that the resident's enteral feeding set was observed by Licensed Practical Nurse (LPN) EE and Registered Nurse (RN) FF who both agreed that the Kangaroo bag was not labeled and that a label stating the contents, the rate, the date and the name of the nurse who starts the feeding set should have been placed on the Kangaroo bag. RN FF discontinued the feeding and removed and discarded the feeding set. Review of the facility policy Enteral Nutrition, revised 2/2017, revealed the documentation requirements for enteral feeding on page four of the policy, under 'Documentation', item 2. the policy states that key documentation elements include type, amount and rate of feeding formula. Under item 3. it states to add Additional documentation required by Lippincott's Nursing Procedures (as required). Interview with the Administrator and the Director of Nursing (DON) on 4/30/18 at 6:45 p.m. who confirm that enteral feeding sets must be labeled by the nurse who starts the feeding with their name, the date the feeding was started, and the type, amount and rate of feeding formula. | 2020-09-01 |
| 4577 | 4577 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2017-09-10 | 246 | D | 1 | 1 | IOYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure the call light remained in reach for one resident (R) (#37) out of 19 sampled residents. Findings include: During an interview on 9/8/17 at 11:41 a.m., R#37 revealed that his call light is left out of reach. Observation at this time revealed resident sitting in the wheelchair with ice water on bedside table next to him. The call light was laying by the bed and not in reach of the resident. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented R#37 had a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact and an active [DIAGNOSES REDACTED]. Review of the Care Plan for R#37 initiated on 8/18/17 revealed that he requires staff assistance for Activities of Daily Living (ADL's) related to a [DIAGNOSES REDACTED]. An interview on 9/8/17 at 12:00 p.m. with Licensed Practical Nurse (LPN) Unit Manager AA as she was coming down the hall revealed that R#37 is unable to drink his water independently and must call for assistance. LPN AA entered resident room at this time. Observation on 09/09/17 at 8:48 a.m. revealed R#37 lying in bed. Call light noted to be on the night stand which was out of reach. Observation on 09/09/17 at 1:24 p.m. revealed R#37 sitting up in the chair. Call light noted to be on the night stand which was out of the resident's reach. Interview on 09/09/17 at 2:35 p.m., with Certified Nursing Assistance (CNA) BB revealed that R#37 requires total assistance with ADL's. CNA confirmed that he is able to use the call light. During an interview on 09/09/17 at 3:04 p.m. the Director of Nursing (DON) revealed that she expects the call light to be in reach at all times for any resident capable of using it. She stated that residents with a weakness on one side should have the call light placed near the opposite side. | 2019-09-01 |
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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 );