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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 101 | 101 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2018-08-23 | 880 | D | 0 | 1 | 07R411 | Based on observation, record review and staff interview, the facility failed to perform hand hygiene after performing incontinence care for one resident (R) (R#25). The sample size was 34 residents. Findings include: On 8/20/18 at 4:13 p.m., Certified Nursing Assistant (CNA) BB was observed performing perineal care, including the rectal area and buttocks, for R#25 after she had been incontinent of a moderate amount of urine. After the perineal care was completed, the CNA did not remove their gloves, and placed the resident's pants back on, and pulled the bed sheet and quilts back over her. CNA BB was then observed to place the call pad over the resident's abdomen, and used the motorized controls to lower the bed height, then repositioned the pillow under R#25's head before removing their gloves. During interview with the Licensed Practical Nurse (LPN) Infection Control Nurse on 8/22/18 at 10:34 a.m., she stated that staff should remove their gloves and wash their hands immediately after the soiled linen is placed in a bag following perineal care, before they touched the resident or did any other care. Review of the facility's Perineal Care policy revised (MONTH) (YEAR) revealed: 8b. Wash perineal area, wiping from front to back. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. Review of the facility's Handwashing/Hand Hygiene policy revised (MONTH) (YEAR) revealed: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents. j. After contact with blood or bodily fluids. | 2020-09-01 |
| 102 | 102 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2017-09-21 | 431 | D | 1 | 1 | KNJV11 | > Based on the facility's Storage of Medications policy, observations, staff interviews, and review of manufacturer's instructions the facility failed to ensure medications were: 1) dated appropriately when opened in 1 of 2 medication storage rooms, and 2) removed expired medication and biologicals from use in 1 of 2 medication storage rooms. The facility census at the time of the survey was 122 residents. Findings include: 1. Review of the policy titled Storage of Medications last revised on (MONTH) 2007, revealed in number 4, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. a. Failure to Appropriately Date Medications Once Opened. An audit of the Subacute Care (SAC) medication room refrigerator was conducted on 9/20/17 at 11:45 a.m. in the presence of Registered Nurse (RN) Unit Manager (UM). The audit revealed two opened and used multiuse vials of Tuberculin Purified Protein Derivative (PPD) solution (lot number 4). The containers and used vials of PPD solution were not dated when opened. The manufacturer's instructions on the side of the medication container revealed the medication should be discarded 30 days after being opened. During an interview with RN UM on 9/20/17 at 12:16 p.m. RN UM acknowledged the two used vials of PPD solution were not dated when opened. RN UM stated the medication should be dated when opened and the medication was only good for 30 days after being opened. RN UM removed the two opened and undated multiuse vials of PPD solution from use. b. Expired Medication and Biologicals An audit of the Subacute Care medication room cupboards were conducted on 9/20/17 at 11:50 a.m. in the presence of RN UM. The audit revealed: 1. Gericare Vitamin B-6, Dietary Supplement 100 tablets, 100 milligram (mg) unopened with an expiration date of 5/17. 2. Major Geravim liquid (lot number 0710B) 16 ounces unopened with an expiration date of 8/17. 3. Magnesium-oxide 400 mg tablets (lot number 39) … | 2020-09-01 |
| 103 | 103 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2015-10-08 | 159 | E | 0 | 1 | 6PVM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident trust fund accounts, and interviews, the facility failed to ensure that acceptable accounting principles were maintained for seven (7) residents (#137, # 31, #24, #35, #97, #75, #74 ) from twenty-five (25) fund accounts managed by the facility. Findings Include: An Interview with the Administrator, Director of Nurses and PP was conducted on [DATE] at 5:15 pm while reviewing the twenty-five (25) resident fund accounts managed by the facility. Discrepancies were identified in the following accounts. 1. Patient liability for Resident #137 was $406.00 in (MONTH) (YEAR). Resident liability was charged in (MONTH) 201.5 at $390.00, (MONTH) (YEAR) $235.00 and (MONTH) (YEAR) at $425.00. On [DATE] the resident was billed again $375.00 for [DATE] to [DATE]. $375.00 for [DATE] to [DATE]. $375.00 for [DATE] to [DATE]. $375.00 for [DATE] to [DATE]. $375.00 [DATE] to 5 /,[DATE] and [DATE] to [DATE] for $375.00 after liability was previously paid in those months. PP is not aware of why different amounts of liability was charged or why resident was charged twice for the months of January, February, March, April, (MONTH) and (MONTH) of (YEAR). 2. Resident #31's Patient liability for Jan (YEAR) was $1098.00. On [DATE] this resident was charged twice in the amount of $6045.00 for [DATE] to [DATE] room charge and [DATE] to [DATE] room charge. There is no evidence of past due liability. PP believes there was a time when the resident was charged private pay. There is no supporting evidence that the resident or responsible party was made aware of past due amounts or adjustments to the account. 3. Resident #24's patient liability on (MONTH) (YEAR) was $650.00. The residents account was charged on [DATE] $620.00 and $680.00 on [DATE]. PP was not aware of why differences in liability was charged. 4. Patient liability for Resident #35 on (MONTH) (YEAR) was $702.00. Liability was charged on [DATE] for $500.00, [DATE] for $485.00 and [DATE] for… | 2020-09-01 |
| 104 | 104 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2015-10-08 | 221 | E | 0 | 1 | 6PVM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure residents were free from the use of side rails to prevent mobility without assessment and/or physician's order reflecting the medical condition requiring use of side rails for six (6) residents (#39, #52, #122, #144, # 101 and #213) from a sample of fifty (50) residents. Findings include: 1. Observations conducted on 10/5/15 at 4:30 p.m. revealed resident #39 in bed with four (4) one-half (1/2) side rails in the up position. Interview conducted on 10/5/15 at 2:31 p.m. with the Licensed Practical Nurse (LPN) QQ responsible for providing direct care for the resident revealed that bilateral full side rails are used every now and then for safety when the resident tried to climb out of bed. Review of medical record reveals Physicians orders dated 2/1/2015 for side rails 1/2 x 2 aid with bed mobility and define parameters of bed. An order on 8/26/2015 Side rails x 2 to aid in bed mobility and define parameters of the bed. The care plan dated 5/24/2014 indicated the resident has a risk of falls and an intervention in place to assure side rails up x 2. 2. Observation conducted on 10/5/2015 at 1:05 PM and 4:20 p.m. revealed resident # 52 in bed with four (4) one-half (1/2) side rails in the up position. Interview conducted on 10/5/2015 at 2:28 PM with QQ revealed four (4) one-half (1/2) side rails are used to prevent falls because the resident climbs out of bed. The resident is capable of getting in and out of bed and the full rails do prevent her from voluntarily getting out of bed. Review of medical record revealed a Physicians order dated 9/28/2015 with NO side rail orders. Review of the residents most recent care plan did not include a plan of care for restraints or use of side rails. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Minimum Status (BIMS) score of two (2). 3. Observations conducted on 10/5/15 at 1:40 PM and 10/6/15 at 2:… | 2020-09-01 |
| 105 | 105 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2015-10-08 | 278 | D | 0 | 1 | 6PVM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to accurately assess the dental status of two (2) residents (#24 and #63) and Antianxiety medication use for one (1) resident (#167) from a sample of fifty (50) residents. Findings include: 1. Record review for resident #24 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented in Section L- Dental/Oral Status that the resident had no dental conditions present. Observation conducted on 10/7/15 at 9:35 AM of the dental status for resident #24 revealed no natural upper or lower teeth, the resident was edentulous. Interview conducted on 10/7/15 at 10:24 AM with the LPN/MDS Coordinator OO confirmed the Annual assessment dated [DATE] did not accurately assess the dental status for this resident and it should have identified resident #24 as edentulous. 2. Record review for resident #63 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented in Section L- Dental/Oral Status that no dental conditions were present. Observation conducted on 10/7/15 at 9:30 AM of the dental status for resident #63 revealed no natural upper teeth, missing lower teeth and fragmented lower teeth. Interview conducted on 10/7/15 at 10:28 AM with the LPN/MDS Coordinator OO confirmed the Annual assessment dated [DATE] did not accurately assess the dental status for this resident and it should have identified missing and/or fragmented teeth. 3. Record review for resident #167 revealed a Quarterly MDS assessment dated [DATE] which documented in Section N- Medications that the resident received antianxiety medication zero out of seven (0/7) days prior to the assessment. A review of the physician's orders [REDACTED]. Further record review of the Medication Administration Record [REDACTED]. | 2020-09-01 |
| 106 | 106 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2015-10-08 | 279 | E | 0 | 1 | 6PVM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview,the facility failed to develop a dental care plan for two (2) residents (#44, #138) A urinary incontinence care plan for one resident (# 84) and a [MEDICAL CONDITION] medication care plan for two(2) residents(#167 and #200) from a sample of fifty (50) residents. Findings include: 1. Record review for resident #68 revealed Minimum Data Set (MDS) assessment dated [DATE] which documented in Section L- Oral/Dental status that the resident's natural teeth were chipped. Section V-Care Area Assessment (CAA) triggered Oral/Dental status with the decision to be care planned. Medical record review of resident #68 revealed no evidence a Dental care plan had been developed. Interview conducted on 10/06/2015 at 3:30 pm with the Care Plan Coordinator NN confirmed the annual MDS assessment dated [DATE] triggered Oral/Dental with the decision to be care planned. Further, she confirmed a dental care plan was never developed and that a care plan for dental should have been developed. 2. Record review for resident #138 revealed a MDS assessment dated [DATE] which documented in Section L- Oral/Dental status that the resident's teeth were broken or chipped. Section V-Care Area Assessment (CAA) triggered Oral/dental with the decision to be care planned. A record view of resident #138 care plans revealed no evidence a dental care plan had been developed. Interview conducted on 10/7/2015 at 10:00 am with the Care Plan Coordinator OO confirmed the annual MDS assessment dated [DATE] triggered Oral/Dental with the decision to be care planned. She revealed the resident never asked for a dental exam so she did not developed a plan of care for resident #138 dental needs. 3. Record review for resident #177 revealed an admission MDS dated [DATE] which documented Urinary incontinence with the decision to be care planned. A review of resident #177 care plans revealed no evidence of a plan of care for resident #177 was developed to address … | 2020-09-01 |
| 107 | 107 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2015-10-08 | 309 | D | 0 | 1 | 6PVM11 | Based on record review and interview, the facility failed to follow a physician's order to discontinue the use of antianxiety medication for one (1) resident (#167) from a sample of fifty (50) residents. Findings include: A review of the physician's orders for resident #167 revealed documentation on 8/24/15 via Physician Telephone Order Form to discontinue Klonopin 2 mg nightly. Further record review of the Medication Administration Record [REDACTED]. An interview conducted on 10/8/15 at 9:50 a.m. with the Director of Nursing (DON) confirmed the physician order on 8/24/15 to discontinue Klonopin 2 mg nightly and that the medication continued to be administered to the resident through 8/31/15. | 2020-09-01 |
| 108 | 108 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2015-10-08 | 323 | D | 0 | 1 | 6PVM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview the facility failed maintain a safe environment for one (1) resident (#73) with history of wandering, from a sample of fifty (50) residents. Findings include: Record review of Resident #73 revealed an admitted [DATE] and [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment of this resident indicated a Brief Interview Mental Status (BIMS) of five (5) indicating she is cognitive impaired and in Section [NAME] assessed as a wanderer. A Nurses Summary note dated 10/6/2015 documented that resident #73 wandered into the unlocked laundry room and in attempt to sit on a tricycle slid backward and fell . The fall was witnessed and resident did not received any injury. Interview with Director of Nurses (DON) conducted on 10/7/2015 at 12:20 p.m. revealed there has not been any further investigation of this incident since the resident was not injured. Observations conducted on 10/07/2015 12:30 p.m. ,10/8/2015 at 6:00 a.m. and 7:15 a.m. revealed that the laundry room door was open and unattended. In the laundry room two (2) bottles of bleach visible and easily accessible along with laundry equipment and hangers. Interview with laundry technician II on 10/8/15 at 10:30 a.m. revealed the door to the laundry room was always closed in the past but she was told that it was not necessary to keep it closed. An interview with JJ Housekeeping supervisor on 10/08/2015 at 11:00 a.m. indicated it is her expectation that the laundry room door be locked in order to prevent residents from entering the laundry room. She also indicated that she only been on the job for one (1) week and does not know if this is the practice of the facility. No policy exists that she is aware of. An interview with the Administrator on 10/08/2015 at 8:00 a.m. revealed that her expectation that the laundry room door be locked when unattended. The facility Environmental Services Department Safety policy states cleaning agents sha… | 2020-09-01 |
| 109 | 109 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2015-10-08 | 329 | D | 0 | 1 | 6PVM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor behavioral symptoms and side effects for one (1) resident (#167) that received and antipsychotic medication from a sample of fifty (5) residents. Findings include: A record review for resident #167 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented in Section E- Behaviors that the resident had exhibited behaviors of delusions, hallucinations, verbal symptoms directed at others, other behavioral symptoms not directed at others and wandering. A review of the physician's order [REDACTED]. A further record review of the Medication Administration Record [REDACTED]. There was no evidence of behavior monitoring or monitoring of medication side effects during the time frame in which the medication was administered. An interview conducted on 10/8/15 at 9:50 AM with the Director of Nursing (DON) CC revealed all antipsychotic medications are to be monitored for side effects and behaviors are to be monitored and documented in the MAR. She confirmed there is no evidence in the MAR from (MONTH) (YEAR) through (MONTH) (YEAR) of side effect of behavior monitoring had been conducted. | 2020-09-01 |
| 110 | 110 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2015-10-08 | 441 | F | 0 | 1 | 6PVM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to establish and maintain an infection control program to help prevent transmission of disease and infection, failed to practice consistent infection control principles to prevent cross contamination in the laundry facility and failed to label and store personal care equipment in a sanitary manner on four (4) of four (4) halls (Blue, Brown, Green and Mauve). Findings include: 1. A review of the Infection Control Log for (YEAR) revealed listings of identified infections and antibiotic therapy only. There was no evidence of tracking, trending, follow up or infection control related in-services for staff. An interview conducted on 10/8/15 11:30 AM with the Infection Control Nurse AA confirmed there is no evidence of any in-services provided to the staff related to infection control and all she does is documents antibiotics. An interview conducted on 10/8/15 at 12:15 PM with the Infection Control Partner EE revealed she works mainly at the hospital but partners with the facility. The Nursing Home partner AA is responsible for providing in-services to the Nursing Home Staff. She confirmed at this time there is no evidence of in-service sign in sheets related to infection control practices. Further, she said there used to be an Infection Control Book which contained all the infection data, in-services and infection control audits but she does not know what happened to it. 2. An observation conducted of the laundry facility conducted on 10/8/15 at 11:00 AM revealed one very small room with one (1) washer and one (1) dryer. There was no separate entrance of area for soiled clothing. The dirty bin for the incoming soiled clothing was just inside the doorway to the left right next to the clean hanging clothes. The table for separating and folding the clean clothes is approximately three (3) to four (4) away from the dirty linen barrel. (See photo) An interview conducted on 10… | 2020-09-01 |
| 111 | 111 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2015-10-08 | 500 | C | 0 | 1 | 6PVM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide documentation of a written agreement or contract with two (2) companies (North Georgia [MEDICAL TREATMENT] Center and DCI) providing [MEDICAL TREATMENT] services for two (2) of two (2) residents that received these services (A and #200). The sample size was fifty (50) residents. Findings include: Review of the Entrance Conference Worksheet revealed that two (2) residents received [MEDICAL TREATMENT] services at an outside certified [MEDICAL CONDITION] unit. An interview conducted 10/8/15 at 11:20 AM with the Administrator revealed she was not able to provide evidence of a contract or agreement with either company providing these services and confirmed two (2) residents are receiving [MEDICAL TREATMENT] treatment, one from each company. | 2020-09-01 |
| 112 | 112 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2018-09-20 | 578 | D | 1 | 1 | UFSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of medical records and staff interviews the facility failed to ensure an appropriate code status for one resident (R) (R#59). The sample size was 39 residents. Findings included: Review of the medical record revealed that R#59 was admitted with [DIAGNOSES REDACTED]. BIMS was 01 which indicated severe cognitive impairment. Review of history and physical revealed R#59 had mental [MEDICAL CONDITION], health care power of attorney (POA) revealed R#59 had the mind of an eight to nine years old. Further review revealed resident's care, and interaction with her, was difficult, and she refused care due to history of mental [MEDICAL CONDITION]. Preadmission Screening Resident Review (PASRR) level two revealed mental [MEDICAL CONDITION]. Review of the medical record revealed a form in the Advanced Directive (AD) section of the physical chart titled Five wishes. No other AD documentation was in the chart. Review of advanced directive checklist (ADC) revealed Do Not Resuscitate (DNR); Do Not Intubate (DNI). Review of the form Five Wishes revealed wishes for: 1. The person I want to make care decisions for me when I can't. 2. The kind of medical treatment I want or don't want. 3. How comfortable I want to be 4. How I want people to treat me 5. What I want my loved ones to know. The Five wishes form revealed Do Not Resuscitate (DNR) had been written on the first page, it had no name or date. On page six of the section titled What Life Support Treatment means to me, revealed it previously had I would want her to be resuscitated but not on life support. It had been scratched through and someone had written DNR but had no name or date. Review of Plan of Care initiated 11/18/16 revealed focus: Resident chooses to have death with dignity, advanced directive established. Individual wishes include DNR status. Review of a Social Services Progress note dated (MONTH) 26, (YEAR) revealed Advanced directive reviewed and she remains a DNR. Interview o… | 2020-09-01 |
| 113 | 113 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2018-09-20 | 656 | D | 1 | 1 | UFSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, policy review and staff interview the facility failed to develop a person centered care plan for one dependent resident (R) #53 related to grooming: nail care. The sample size was 39. Findings include: Review of the facility policy titled Comprehensive Care Plan, revised (MONTH) (YEAR), indicated the facility will develop a comprehensive person-centered care (plan that identifies each residents medical, nursing, mental and psychosocial needs with seven days after completion of the comprehensive assessment. The care plan is developed with the resident or the resident's representative and reflects the resident's goals, wishes and preferences. The plan includes measurable objectives and timetables agreed to by t he resident to meet such objectives. The purpose is to provide effective and person-centered care for each resident. The minimum requirements of the comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A review of the clinical record for R#53 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section G revealed that the resident was assessed for extensive assist for bed mobility, transfers, locomotion on/off the unit, dressing, toilet use and personal hygiene. Observation on 9/18/18 at 12:56 p.m., 9/19/18 at 12:18 p.m., 9/19/18 at 3:20 p.m. and 9/20/18 at 9:00 a.m., revealed that the resident's fingernails, on both hands, have dark brown material underneath and are untrimmed. Review of updated care plan for the resident, dated 8/1/18, revealed no evidence that R#53 had a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Inter… | 2020-09-01 |
| 114 | 114 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2018-09-20 | 677 | D | 1 | 1 | UFSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for one dependent resident (R) R#53 related to nail care. The sample size was 39. Findings include: A review of the clinical record for R#53 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section G revealed that the resident was assessed for extensive assist for bed mobility, transfers, locomotion on/off the unit, dressing, toilet use and personal hygiene. Review of updated care plan for R#53, dated 8/1/18, did not have evidence of a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Observation on 9/18/18 at 12:56 p.m., 9/19/18 at 12:18 p.m., 9/19/18 at 3:20 p.m. and 9/20/18 at 9:00 a.m., revealed that fingernails on both hands have dark brown material underneath and are untrimmed. Interview on 9/20/18 at 9:30 a.m., with Certified Nursing Assistant (CNA) DD stated that ADL care consists of getting residents up, bathing/showering, feeding, dressing, grooming, including hair, oral care, brushing teeth/dentures, and shaving and making bed. She stated that nail care is done on Sundays during the day shift. She stated that nailcare can be done at any time when it is needed, but primarily nails are trimmed and cleaned on Sundays. Interview on 9/20/18 at 10:16 a.m., with Director of Nursing (DON) verified that R#53 nails had dark brown material underneath them and they were untrimmed. She stated that it is her expectation that the CNA staff observe the residents nails when they are providing care. If nails need to be cleaned and/or trimmed, she expects the CNA staff to take care of it, not pass it on to the next staff member. She further stated that anyone can do… | 2020-09-01 |
| 115 | 115 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2018-09-20 | 758 | D | 1 | 1 | UFSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interviews and review of Resident # 36's medical record, the facility failed to ensure that an anti-anxiety medication was not administered past 14 days, as needed (PRN) without a rationale and without an end date, for one resident (R#36). The sample size was 39 residents. Findings include: Review of R#36's medical clinical record revealed [DIAGNOSES REDACTED]. R#33 had a Brief Interview of Mental Status (BIMS) of 03 indicating severe cognitive impairment. Minimum Data Set (MDS) and Plan of Care (P[NAME]) revealed she had behavior problems. R#36 exhibited behaviors toward staff, hitting during care, shouting, kicking at staff, being verbally abusive to staff, pulling at tablecloth in dining room and pulling at other resident's food. Review of Physician order [REDACTED]. Review further revealed the initial order date was 7/14/17. Review of the clinical record revealed the consultant pharmacist made recommendations to the physician in April, May, July, and (MONTH) (YEAR): [MEDICATION NAME] had been ordered as needed (PRN) and had been ordered longer than 14 days without a rationale or stop date. Recommendation on 4/19/18: [MEDICATION NAME] 1 mg Q4h PRN, need rationale in medical record and indicate duration. Physician response to recommendation dated 7/13/18 was Will investigate. It was signed and dated on 8/20/18 but he did not make any change in the order and did not include a rationale or stop date. Response to the consultant pharmacist recommendation to physician dated 8/24/18, the physician response was Nurses report she still needs it. He signed and dated 9/4/18 but made no change to order and did not include a rationale or stop date for the medication. Review of the MAR for July, August, and (MONTH) (YEAR) revealed R#36 had been on [MEDICATION NAME] ([MEDICATION NAME]) PRN since (MONTH) 14, (YEAR). Further review revealed R#33 received [MEDICATION NAME] eight times in July, 12 times in August, and five time… | 2020-09-01 |
| 116 | 116 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 159 | D | 0 | 1 | 8OVO11 | Based on record review and staff interview, the facility failed to ensure four of four sampled residents' (R) (#17, #31, #76, #87) trust fund accounts remained under the $2,000 limit to maintain eligibility for Medicaid services. The facility handled a total of 65 resident accounts. Findings include: During interview with the Business Office Manager (BOM) on 10/26/17 at 8:51 a.m., she stated that if a Medicaid resident's trust account approached the eligibility limit, the facility sent out what she called a $200 letter to the family at the first of each month. Review of an example of this letter entitled Resident Fund Balance Notification revealed that the recipient was notified that their current resident fund balance was within $200 or exceeding what was allowable under Medical Assistance, and to contact the Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. During continued interview, she stated that she kept no documentation of when or who she sent these letters out to, nor any additional attempts to reach the responsible party (RP) if they did not respond to the letter. The BOM further stated that she was not afraid that the residents may lose their Medicaid eligibility if their balances were consistently over the $2,000 limit. During continued interview, she stated that if the RP did not respond to the $200 letter, that in weekly staff meetings they discussed ways to spend the residents' money down. Review of the following Medicaid residents' quarterly trust fund Resident Statement Landscape reports for one year revealed the following: 1. R #17: The account balance exceeded $2,000 since 11/1/16, with a balance of $2,570.65 as of 10/3/17. On 10/26/17 at 8:51 a.m., the BOM stated that the daughter had bought some clothing for the resident, but did not spend the account down enough to bring it below $2,000. 2. R #31: The account balance exceeded $2,000 from 5/3/17 through 7/13/17, and funds placed in a burial account on 7/25/17 to lower the balance. However, on… | 2020-09-01 |
| 117 | 117 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 226 | D | 0 | 1 | 8OVO11 | The facility failed to obtain a criminal background check prior to hire for one of nine employees and failed to obtain reference checks for two of nine employees. Findings include: During an interview with Administrator on 10/26/17 at 10:30 p.m., stated she is the person responsible for checking references for new employees. She does not know how she missed an employee without references returned. She further stated that the therapy staff were contracted employees prior to changing ownership. All the personnel files are kept with the contract company, and therefore not in the employee file on site. She further stated that Corporate Office employed the Director of Nursing, and she was not accustomed to checking behind the Corporate Office hires. 1. Review of employee files on 10/26/17 revealed that Director of Nursing (DON) began employment with the facility on 4/3/17 without the return of reference checks. 2. Review of employee files on 10/26/17 revealed that Certified Nursing Assistant (CNA) FF began employment with the facility on 9/25/17 without the return of reference checks. 3. Review of employee files on 10/26/17 revealed that Physical Therapy Assistant (PTA) GG began employment with the facility on 6/5/17 without return of criminal background check until 8/8/17. | 2020-09-01 |
| 118 | 118 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 247 | D | 0 | 1 | 8OVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to notify two residents (R) W and X that they would be receiving a new roommate. The sample size was 46 residents. Findings include: During interview with R W on 10/23/17 at 3:39 p.m., she stated that she had gotten a new roommate the previous week, but staff didn't tell her she would be getting a new roommate. Further interview, revealed that she had been out of her room, and when she returned to her room the new roommate was there. Review of R W's Brief Interview for Mental Status (BIMS) on her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a score of 14 (a score of 13-15 indicates a resident is cognitively intact). Review of her electronic interdisciplinary Progress Notes for three months revealed there was no mention that she was notified she would be getting a new roommate. During interview with R X on 10/24/17 at 10:04 a.m., revealed that she recently got a new roommate, but was not notified by staff. During further interview, she stated they just brought the new roommate in the room and there was no introduction, and felt that it was not a very nice thing to do. Review of R X's Quarterly MDS dated [DATE] revealed a BIMS score of 13. Review of her electronic interdisciplinary Progress Notes for three months revealed there was no mention that she was notified she would be getting a new roommate. Observation at this time revealed that residents W and X were both in the same four-bed room. During interview with the Administrator on 10/24/17 at 5:47 p.m., she stated that if there was a room-to-room transfer of an existing resident, the Social Services Director (SSD) notified the families and existing residents in the room, and documented this in the electronic medical record. During interview with the SSD on 10/25/17 at 3:23 p.m., she stated that when a resident was being moved to a different room, she would tell the resident(s) in that room to s… | 2020-09-01 |
| 119 | 119 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 253 | E | 0 | 1 | 8OVO11 | Based on observation and staff interview, the facility failed to ensure a clean and comfortable environment in 18 rooms on three of three nursing units as evidenced by patched but unpainted walls; cracked or broken flooring; dusty vent; stained walls and privacy curtain; improperly disposed incontinent briefs resulting in odors; and dirty light fixture. The facility census was 85 residents, and the sample size was 46. Findings include: During observations in resident rooms and bathrooms on Unit 2, the following environmental concerns were noted: Room 29 on 10/23/17 at 1:54 and 2:12 p.m.: The privacy curtain was unable to be pulled all the way across the A-bed as it was jammed in the ceiling track. There were several vertical scrapes on the wall behind and to the left side of the head of the A-bed that had been patched at one time, but not painted. Observation in the bathroom revealed that the vinyl flooring had been installed so that it came up approximately four inches on all four walls, and the flooring to the left of the commode had split where the wall met the floor, approximately two-thirds of the length of this wall. There was a long, thin, red streak below a wall vent located near the ceiling above the closet, and this vent had a moderate amount of dust on it. The laminate on one corner of D-bed's over bed table was missing, exposing the rough particle board underneath. [RM #] on 10/23/17 at 2:47 p.m.: There was an approximate two-inch vertical and a small circular brown stain on the privacy curtain for the B-bed. One corner of a floor tile close to the sink was broken off. A plastic bag was observed in the bathroom with what appeared to be a soiled incontinent brief tied to the grab bar next to the commode. There was an unpleasant odor in the bathroom, and one sock and a pair of pants were observed directly on the floor. Further observations in this bathroom on 10/24/17 at 10:33 a.m. revealed that the clothing was off the floor, but there was still a plastic bag with soiled incontinent briefs in it tied t… | 2020-09-01 |
| 120 | 120 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 278 | D | 0 | 1 | 8OVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the Resident Assessment Instrument Manual. The facility failed to properly assess and code the Minimal Data Set (MDS) for two (2) resident (R) #20 and R#82 for dental status, and one (1) resident R#75 for preadmission screening and resident review (PASARR) level two was not properly coded on assessment per Resident Assessment Instrument (RAI) guidelines. The resident sample was 46. Findings include: 1. Review of annual Minimum Data Set ((MDS) dated [DATE], for resident (R) #20, section C- cognitive patterns resident has a BIMS score of 2, the resident was unable to complete the interview. Further review of section L- oral/dental status revealed the resident's dental status is coded as the resident does not exhibit any obvious or likely cavity or broken natural teeth. Review of section V- Care Area Assistance (CAA) the resident's care area for dental status did not trigger for dental care. On 10/24/2017 at 2:17 p.m. the resident was observed sitting in his Brodie chair while in his room watching television, alert and pleasant when spoken to, the resident is noted to have missing or broken teeth. On 10/26/2017 8:48 a.m. the resident was observed sitting in his Brodie chair eating breakfast while in his room, the resident is very, pleasant responds when spoken too. No issues noted while eating, the resident is noted to have missing or broken teeth. Interview on 10/26/2017 at 6:13 p.m. with MDS Coordinator AA revealed the Point Click Care automated system automatically transfers information from the kiosk system into the MDS. The MDS coordinator AA stated if there is an issue or concern with the resident; the MDS coordinators will go into the MDS system and modify incorrect coding's, and enter a note in the progress notes. The MDS Coordinator confirmed at this time, that they are only doing paper reviews. During the interview, MDS coordinator BB, confirmed a correction should have been made to … | 2020-09-01 |
| 121 | 121 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 279 | D | 0 | 1 | 8OVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of Resident Assessment Instrument (RAI) guidelines. Facility failed to provide a [MEDICAL CONDITION] care plan for one resident (R# 40) out of 46 sampled residents. Findings include: Record review of R #40 revealed resident takes [MEDICATION NAME] 0.25mg every morning and [MEDICATION NAME] 0.5 mg at bedtime for a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) with assessment reference date 08/15/17 showed a care area assessment summary (CAAS) which triggered for [MEDICAL CONDITION] drug use and will be addressed in care plan. Further record review for R#40 revealed there was no care plan for [MEDICAL CONDITION] medication use. Interview 10/26/2017 6:46 p.m. with MDS staff Licensed Practical Nurse AA confirmed the resident was not care planned for [MEDICAL CONDITION] medications, although the resident should have been care planned. Interview 10/26/2017 7:05 p.m. with Director of Nursing (DON) she stated that she expects the MDS Coordinator to follow the RAI guidelines. | 2020-09-01 |
| 122 | 122 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 280 | D | 0 | 1 | 8OVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to ensure one resident (R) W was notified of her care plan meeting dates, times, and location so that she could attend. The sample size was 46 residents. Findings include: During interview with R W on 10/23/17 at 3:26 p.m., she stated that she had been invited to attend her care plan meetings in the past and told the staff that she would like to go, but that nobody ever came to get her on the day of the meeting, and she didn't know where to go. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status score of 14, indicating that she was cognitively intact. During interview with the Social Services Director (SSD) on 10/25/17 at 3:23 p.m., she stated that she either called the families to set up a care plan meeting, or mailed the invitation if she was not able to reach them. She further stated that residents were invited to attend the care plan meeting if they were able to. During further interview, the SSD stated that if the family attended the meeting, they would walk to the resident's room together to see if they wanted to attend, and if the family did not come she would go to the resident's room by herself and verbally ask the resident if they wanted to attend. The SSD stated that she started working at the facility in April, and did not recall R W ever attending her care plan meetings. She stated that documentation of invitation to the meeting would be in a Care Plan Note in the interdisciplinary Progress Notes in the computer. The SSD reviewed R W's interdisciplinary Progress Notes from (MONTH) (YEAR) to the present date, and did not see a Care Plan Note, and stated it could possibly be documented in the paper chart. During interview with Licensed Practical Nurse MDS staff AA on 10/26/17 at 2:05 p.m., she stated that the SSD started scheduling and inviting residents and families to the care plan meetings … | 2020-09-01 |
| 123 | 123 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 281 | D | 0 | 1 | 8OVO11 | Based on observation, staff interview, record review, review of the State of Georgia Rule 410-10-01 Standards of practice for Registered Professional Nurses and Rule 410-10-02 Standards of Practice for Licensed Practical Nurses and review of policy and procedure of Medication Administration-Preparation and general guidelines dated 05/2012,the facility failed to maintain professional nursing standards of quality and nursing standards of practice as evidence by performing finger stick blood sugars on two of two residents Findings include: 2. During observation on 10/25/17 at 5:32 p.m., Registered Nurse (RN) CC was noted to perform Finger Stick Blood Sugar (FSBS) check during routine afternoon med pass. The EvencareG3 Glucometer was lying on top of the medication cart when surveyor approached RN. Registered Nurse gathered the supplies, including glucometer, lancet, alcohol swabs and cotton balls. She failed to cleanse the glucometer before entering the residents room. Upon entering the residents room, she proceeded to lay all the supplies needed for the FSBS on the residents bed, without using a protective barrier. Registered nurse did not wash her hands before performing FSBS, nor did she wear any gloves during the procedure. Post procedure, RN gathered up the used supplies, including the lancet, and discarded them in the red trash bin on the med cart. She placed the glucometer on top of the medication cart, without cleansing the meter. She did not wash her hands after performing the procedure. Surveyor asked if she had any other FSBS to check at this time and she replied No. She proceeded down unit one hallway to administer medications to residents. Interview on 10/26/17 at 4:38 p.m., with DON, stated it is her expectation that staff clean the glucometer before and after each use for three minutes wetness, wearing gloves, disposing of sharps in sharps containers. She further stated that the nurses are to use a barrier between clean and dirty fields. She states that there has not been any inservice trainings for th… | 2020-09-01 |
| 124 | 124 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 282 | D | 0 | 1 | 8OVO11 | Based on observation, record review, and staff interview, the facility failed to follow the care plan related to providing assistance as required for incontinent care for one resident (R) #101. The sample size was 46 residents. Findings include: Review of R #101's potential/actual elimination deficit related to bladder and bowel incontinence care plan, initiated on 3/28/17, revealed an intervention to provide assistance as required for toileting and incontinent care. Review of her ADL (activity of daily living) self-care performance deficit related to activity intolerance, confusion, fatigue, and limited mobility care plan initiated on 3/28/17 revealed an intervention that the resident was totally dependent on one to two staff for toilet use and incontinent care. Review of her risk for skin breakdown related to incontinence and poor self mobility care plan initiated on 3/28/17 revealed an intervention to provide incontinence care after each incontinence episode, or per established toileting plan. Observation on 10/23/17 at 2:09 p.m. revealed that R #101 was sitting in a wheelchair in her room, and a urine odor was noted. Further observation at this time revealed that her pants were wet in the perineal area. Observation on 10/26/17 at 3:00 p.m. revealed that R #101 was sitting in a wheelchair in the hall across from the nurse's station, and a urine odor was noted. Observation of incontinent care at 3:05 p.m., on the same day, revealed that her incontinent brief contained a moderate to large amount of urine and stool. Interview with Resident Care Specialist (RCS) II at this time revealed she last changed the resident around 11:00 a.m. that day. Cross-refer to F 315 | 2020-09-01 |
| 125 | 125 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 309 | E | 0 | 1 | 8OVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, Hospice contract and staff interview, the facility failed to integrate Hospice services and care planning according to the Hospice agreement for one Resident (R#95) of 46 sampled residents. Findings include: 1. Review of the clinical record for R 95, revealed current [DIAGNOSES REDACTED]. Further review revealed that R 95 was admitted for Hospice Respite on [DATE]. Review of care plan for R 95 revealed that resident chooses to have death with dignity, advanced directive established. Individual wishes include Hospice services and CPR, initiated on [DATE]. Interview on [DATE] at 4:51 p.m., with Director of Nursing (DON), revealed that each Hospice resident has a specific notebook for communications with Hospice provider and the facility staff. The notebook has the physician orders, service order for visit frequency's, Interdisciplinary Team (IDT) meeting notes and visit notes from each discipline. The Hospice notebook, nor any supporting documents for R 95, could be located within the facility. The DON could not locate the Hospice notebook on either unit. DON stated that it is her expectation is that Hosp(ice staff are to report to the floor nurses after each visit. Review of the Hospice agreement between the facility and the Hospice provider dated [DATE], indicated that the Hospice will be responsible for coordinating patient care, assessments and evaluations, discharge planning and bereavement. Further review revealed that the Hospice shall designate a member of the IDT to coordinate the implementation of the Plan of Care. The Hospice shall provide to the facility at the time of admission, copies of the Hospice Plan of Care, the Hospice election form and advance directive, names and contact information for Hospice personnel involved in the care of the patient, medication information and Hospice and attending physician orders [REDACTED]. Review of facility's Clinical Practice Standard for Hospice Care, re… | 2020-09-01 |
| 126 | 126 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 315 | D | 0 | 1 | 8OVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide incontinence care in a timely manner on two observations for one resident (R) #101. The sample size was 46 residents. Findings include: Review of R #101's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment). Further review of this MDS revealed that she needed extensive assistance for toilet use, was not on a toileting program, and was always incontinent of bowel and bladder. Review of R #101's potential/actual elimination deficit related to bladder and bowel incontinence care plan, initiated on 3/28/17, revealed an intervention to provide assistance as required for toileting and incontinent care. Review of her ADL (activity of daily living) self-care performance deficit related to activity intolerance, confusion, fatigue, and limited mobility care plan initiated on 3/28/17 revealed an intervention that the resident was totally dependent on one to two staff for toilet use and incontinent care. Review of her risk for skin breakdown related to incontinence and poor self mobility care plan initiated on 3/28/17 revealed an intervention to provide incontinence care after each incontinence episode, or per established toileting plan. Review of a Bowel and Bladder Evaluation dated 9/6/17 revealed that R #101 was incontinent of both bowel and bladder, and was not able to participate in a bowel and bladder program as she did not have cognitive skills for toileting retraining. Further review of this evaluation revealed that the resident would be kept clean and dry to prevent skin breakdown and UTIs (urinary tract infections). Observation on 10/23/17 at 2:09 p.m. revealed that R #101 was sitting in a wheelchair in her room, and a urine odor was noted. Further observation at this time revealed that her pants were wet in the perineal area. Dur… | 2020-09-01 |
| 127 | 127 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 323 | D | 0 | 1 | 8OVO11 | Based on observation, record review and staff interview the facility failed to maintain safe water temperatures below 120 degrees Fahrenheit in three resident rooms on one of three units. The census was 85. Findings include: Observation during the initial tour on 10/23/17 beginning at 11:04 a.m., the following unsafe hot water temperatures were obtained using the surveyor's digital thermometer: At 11:09 a.m., the hot water temperature in room 30 was 121 degrees Farenheit (F). At 11:17 a.m., the hot water temperature in room 34 was 122 degrees Farenheit (F). At 11:21 a.m., the hot water temperature in room 35 was 122 degrees Farenheit (F). On 10/23/17 at 12:30 p.m., the following unsafe water temperatures were confirmed by the Maintenance Supervisor, using the facility digital thermometer. [RM #] water temperature was 120.8 degrees F. Room 32 was 120.8 and Room 34 was 104.7. Interview on 10/23/17 at 12:30 p.m., with Maintenance Supervisor, stated that he checks the water temps every day. He has a scheduled list of which rooms to check each daily. He states that there are not specific times of day they check them, but he tries to do them early in the day. He starts on the beginning of the hall and ends on the opposite side of hall. He denies having any recordings of elevated water temps over 110 degrees Farenheit. He stated that if high temps are noticed, he would adjust the hot water control and retest the temps in 30 minutes. Interview on 10/23/2017 12:50 p.m., with Director of Nursing (DON), stated that she had not been informed by staff of hot water temps being hotter than normal temps. There have not been any complaints from residents about the water being too hot or too cold. She denies that there have been any burns reported. On 10/23/17 at 1:30 p.m., temperatures rechecked with Maintenance Supervisor. [RM #] water temperature was 119 degrees F and room 32 water temperature was 114.8. On 10/24/2017 at 9:59 a.m., Maintenance Supervisor and Administrator stated that they have shut off the hot water on Station … | 2020-09-01 |
| 128 | 128 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 371 | F | 0 | 1 | 8OVO11 | Based on observation, interview, and review of facility policies and procedures, the facility failed to ensure the meat slicer was properly cleaned and sanitized to remove leftover dried food particles. This deficient practice has the potential to effect all residents who consume an oral diet. The resident Census was 85 resident with 77 residents who received an oral diet. Findings include: During a second tour of the kitchen with the Dietary Manager (DM) on 10/25/17 at 10:59 a.m. revealed a deli style meat slicer covered with a plastic bag indicating the equipment had been properly cleaned and sanitized after previous use. The DM removed the plastic covering at 11:00 a.m. to reveal the deli style meat slicer has dried food particles on the base of the meat slicer, and under the slicing blade. The DM confirmed the observation of dried up food particles on the base of the deli style meat slicer and under the slicing blade; the DM at this time stated that staff are to disassemble the meat slicer after each use, and clean away any food particles that have been left on the slicing blades and base. Review of Health Services Group Policy Statement titled Equipment revised (MONTH) 2014 revealed; It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order. | 2020-09-01 |
| 129 | 129 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 372 | F | 0 | 1 | 8OVO11 | Based on observations and staff interviews the facility failed to assure that garbage and refuse was properly disposed, and contained to prevent possible rodent infestation around two of two dumpsters. Findings include: During a brief initial tour of the kitchen and dumpster area on 10/23/17 at 11:15 a.m. with the Dietary Manager (DM), revealed the outside dumpster area where two (2) dumpsters were sitting side by side behind the facility in partially gated area. Observation of the ground area around both dumpsters revealed scattered needle cap coverings, food debris, and previously used gloves. Continued observation revealed that debris was located on the asphalt driveway near the back of both of the dumpsters. Observation of the trash dumpster area on 10/24/17 at 5:45 p.m. debris remains behind both dumpsters, continued observation on 10/25/17 at 1:05 p.m., and further observation of the trash dumpster area on 10/25/17 at 6:00 p.m. revealed the area remains dirty with debris. Interview with the Maintinence Supervisor (MS) on 10/26/17 at 2:59 p.m. revealed the maintinence department is responsible for cleaning around the dumpster area, and it should be checked daily. The MS confirms that the area has not been checked according to schedule in the past few days. The MS revealed he was notified on 10/25/17 that the area behind the trash dumpsters was dirty and needed cleaning. Review of facility policy titled Physical Plant Exterior Maintenance release/revision date: (MONTH) 2007 revealed the facility's procedure is to clean the building's exterior and grounds of all trash, rubbish, debris, unused equipment/furniture, in addition to periodic cleaning of problem areas. Interview with Dietary Manager (DM) on 10/26/17 at 1:30 p.m. confirmed that there was debris behind both of the dumpsters, and was not cleaned until 10/25/17 by the housekeeping and maintinence departments. He also confirmed he is not aware of cleaning schedule times. | 2020-09-01 |
| 130 | 130 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2017-10-26 | 441 | E | 0 | 1 | 8OVO11 | Based on observation, record review, and staff interview, the facility failed to practice acceptable infection control practices to prevent possible cross-contamination as evidenced by not cleaning a glucometer (a device used to check blood sugars) before and after use; properly dispose of lancets used to obtain blood; provide a clean barrier between clean and contaminated objects or surfaces; perform hand hygiene when indicated; and wear gloves when contact with blood was possible. There was a total of eleven observations made of glucometer use and cleaning with concerns by one of seven nurses observed. The facility census was 85 residents, and the sample size was 46. Findings include: During interview with the Director of Nursing (DON) on 10/26/17 at 4:40 p.m., she stated her expectation was that staff clean the glucometer before and after use according to the manufacturer's instructions, and for the glucometer to maintain contact with the Clorox wipe for three minutes. She stated during further interview that the lancet used to obtain the fingerstick blood sugar (FSBS) should be disposed of in the sharps container, and that staff should wear gloves when doing the FSBS. During continued interview she stated that some sort of barrier should be used to place the glucometer on, such as a paper towel. During interview with the DON on 10/26/17 at 9:42 p.m., she stated that since she started working at the facility in (MONTH) no inservices had been done on how to clean the glucometer, and she could find no inservices on glucometer cleaning for the past year. She further stated that they were inservicing staff today on how to properly clean a glucometer, and return demonstrations were done by each nurse. During continued interview, the DON stated that Registered Nurse (RN) CC had been sent home for the day, and would not be allowed to independently work on a med cart until further training was provided. Review of the facility's Glucometer Decontamination Resident Care Policy revised 9/2015 revealed: The glucometer sha… | 2020-09-01 |
| 131 | 131 | AZALEA HEALTH AND REHABILITATION CENTER | 115044 | 1600 ANTHONY ROAD | AUGUSTA | GA | 30907 | 2016-12-08 | 309 | D | 0 | 1 | ML9M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review it was determined the facility failed to follow physician orders [REDACTED].#147. R#147 was admitted to the facility on [DATE] at 6:13 p.m., and did not receive all prescribed medications the first night of the resident's stay at the facility. The facility's failure to ensure the resident received the necessary care and services to attain or maintain her highest practicable level of physical, mental and psychosocial well-being was due to staff's failure to obtain and administer physician ordered medications in a timely manner. Findings include: Review of facility policy titled Emergency Pharmacy Service and Emergency Kits with revision date [DATE] revealed the emergency pharmacy is available on 24 hour basis. Telephone/fax numbers are posted at each nursing station. Ordered medication are obtained either from the emergency box, from the provider pharmacy or back-up pharmacy. Record review for R#147 revealed the resident was admitted to the facility from an acute care hospital on Friday evening 01/8/16 at 6:13 p.m. The resident's admission [DIAGNOSES REDACTED]. On 1/9/16 at 3:30 p.m. the resident was transferred to another facility with medications. Admission Physician orders [REDACTED]. Sodium inject 100 mg subcutaneous every 12 hours related to presence of pacemaker, Atorvastatin Calcium 20 mg at bedtime for [MEDICAL CONDITION], , Artificial Tears one drop three times per day for dry eye syndrome, [MEDICATION NAME] HCL 25 mg at bedtime for depression, and Refresh pm ointment one application at bedtime for dry eye syndrome. Review of the Medication Administration Record [REDACTED] [MEDICATION NAME] sodium inject 100 mg subcutaneous every 12 hours related to presence of pacemaker [MEDICATION NAME] 32.4 mg for [MEDICAL CONDITION] [MEDICATION NAME] HCL 25 mg for depression Atorvastatin calcium 20 mg for [MEDICAL CONDITION] Refresh pm ointment one application at bedtime for… | 2020-09-01 |
| 132 | 132 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2018-07-12 | 641 | D | 0 | 1 | 1ZSP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility data, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the respiratory status of one Resident (R) (R A). This failure to accurately assess the resident, resulted in a comprehensive care plan that did not reflect the respiratory status of R [NAME] The resident sample size was 24. Findings Include: A resident record review was conducted and reflected R A was readmitted from an acute hospital with a [DIAGNOSES REDACTED]. A review was conducted of the MDS annual assessment, dated 2/14/18 and the quarterly assessment, dated 5/15/18. The annual assessment reflected the following: hearing/vision= hearing impaired, unclear speech, impaired vision; mood=08 depression; behavior=00; the cognitive assessment reflects a Brief Interview for Mental Status (BIMS) was conducted with a cognitive score of 15 indicating no impairment; bowel and bladder= always incontinent of both; functional= 2 person assist with transfers and mobility needed, non-ambulatory/[MEDICAL CONDITION]; health conditions= shortness of breath (SOB)= none, tobacco use= yes; dental= cavities/broken natural teeth, inflamed gums; medications= antidepressant and opioids; skin= (Section M) application of a non-surgical dressing other than to feet; special treatments and programs= Respiratory Treatments (Section O-0100) indicates at letter Z none of the above while a resident. A review of the MDS with an Assessment Reference Date (ARD) of 5/15/18, reflected that in Section O-Special Treatments, Procedures and Programs O- -D-2 that Respiratory Therapy: number of days used was 0 days during the seven (7) day look back period. Review of the Physician orders [REDACTED]. Review of the facility form titled Treatment Record for the months of 5/18 and 6/18 reflected a documentation of treatment orders for: skin assessments (initially ordered 3/10/15) conducted every week by the treatment nurses; and a treatment… | 2020-09-01 |
| 133 | 133 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2018-07-12 | 686 | D | 0 | 1 | 1ZSP11 | Based on observations, interviews and record reviews, the facility failed to identify a pressure ulcer and failed to obtain a Physician's order for treatment for one Resident (R) (R#55) . The sample size was 24 residents. Findings Include: Observation on 7/10/18 at 2:24 p.m. with Certified Nursing Assistant (CNA) (CC), revealed thtat CNA CC was changing R#55 and a Opti- foam gentle silicone face foam and Broder dressing was observed on the right hip without a nurse's signature. CNA CC called the Unit Manager, Registered Nurse BB, Licensed Practical Nurse AA, Director of Nursing and Administrator the dressing was removed by RN BB wound nurse exudate and dry black blood and odor were observed. Measurements of the wound are 1.5 centimeters (cm) x 1.5 cm. No depth. Interview on 7/10/18 at 2:30 p.m. with R#55 revealed that staff put the dressing on her right hip one month ago. Interview on 7/10/18 at 3:00 p.m. with Certified Nursing Assistant CC related to R#55 right hip stage 4, pressure ulcer wound; CNA CC revealed the dressing was observed one week ago with no date, or signature. Interview on 7/10/18 at 3:10 p.m. with Wound Nurse BB, and Treatment Nurse AA in relation to the right pressure ulcer, both wound nurses revealed that they were unaware of the wound; and Wound Nurse BB said she completed a skin assessment for the resident on 7/6/18 and that there was not a pressure ulcer at that time the residents skin was intact. Interview on 7/10/18 at 3:20 p.m. An interview with Unit Manager, MDS Nurse, DON and Administrator revealed that they were all unaware of this pressure ulcer, however, they observed the old dressing not dated, without a nurse's signature and they observed exudate with dry black blood and odor. Interview on 7/11/18 at 10:40 a.m. with Medical Director reveraled that he was unaware of the pressure ulcer until the Unit Manager called him yesterday, 7/10/18, to obtain a treatment order. The Medical Director revealed that the resident previously had a Stage IV pressure ulcer on her right hip that had r… | 2020-09-01 |
| 134 | 134 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2018-07-12 | 693 | D | 0 | 1 | 1ZSP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that one of one resident (R) (R27) who receives nutrition via a [DEVICE] ([DEVICE] a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) has a Physician order related to the amount of the bolus ( administration of a limited volume of enteral formula over brief periods of time) of [MEDICATION NAME] the resident should receive. The sample size was 24 residents. Findings include: Record review revealed that R#27 was admitted to the facility with [DIAGNOSES REDACTED]. Record review Minimum Data Set (MDS) annual assessment dated [DATE]. Section K-Swallowing/Nutritional Status: KO100. Swallowing Disorder signs and symptoms of possible swallowing disorders K- none. K0510 nutritional approach feeding tube. K0710 [NAME] Percent intake by artificial route 51% by artificial route during the entire seven days. B. Average fluid intake per day by IV or tube feeding 501 cc/day or more. Review of the care plan dated 5/10/18 identified the resident has a [DEVICE] for her tube feeding. At risk for complications. Has history of aspiration pneumonia. Requires meds crushed and given in tube. Goal resident will receive tube feeding as ordered without complications over the next 90 days. approaches include but not limited to: give tube feeding as ordered. Observation on 07/10/18 at 7:55 p.m. of the bolus feeding for R27 by Registered Nurse (RN) EE revealed that RN EE flushed the [DEVICE] with 175 cc of water and administered a bolus of [MEDICATION NAME] 1.5 250 milliliters (ml) by gravity. Review of the Physician orders for (MONTH) 1, (YEAR) through (MONTH) 1, (YEAR), revealed an order for [REDACTED]. Further review revealed that the Physician Orders did not contain the amount of [MEDICATION NAME] that the resident was to receive via bolus every four hours. Review of the Physician order dated (MONTH) 17, (YEAR) r… | 2020-09-01 |
| 135 | 135 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2019-10-31 | 625 | D | 0 | 1 | OMYR11 | Based on record review, staff interview and review of the facility policy titled Bed Holds the facility failed to ensure that two of four residents (R) (R#220, R#62) were provided a bed hold notice at the time of transfer to a hospital. Findings include: 1. Review of the medical record for R#220 revealed resident was transferred from the facility to the hospital on the following dates: 7/4/19, 7/8/19, 8/12/19, 9/11/19, 10/16/19. Review of the hospitalization s since (MONTH) 2019 did not reveal that a bed hold notice was provided to R#220. During interview on 10/31/19 at 3:39 p.m. with the Admissions Director who revealed that the bed hold policy is discussed upon admission but, nursing is responsible for sending out bed hold notices when residents transfer to the hospital. During interview on 10/31/19 at 3:43 p.m. with Unit Manager Licensed Practical Nurse (LPN) HH who reported that a packet is sent to the hospital with residents upon transfer. This packet included the face sheet, Physicians Order for Life-Sustaining Treatment (POLST), advance directives, transfer sheet, immunizations, current physicians' orders, last progress note, and the most current labs. Unit Manager further reported that bed hold notices are not a part of the packet that is sent to the hospital. Unit Manager LPN HH further reported that Admissions or someone in the financial department would be responsible for the bed hold notification. During interview on 10/31/19 at 4:00 p.m. with the Administrator, it was reported that Admissions and Reimbursements are responsible for notifying residents of bed hold upon transfer. Reimbursements would only do so as a secondary resource. It was further reported that bed hold notices should be sent with the other hospital documents at the time of transfer. The Administrator confirmed the Medicaid Status for R#220 for each date that resident was transferred to the hospital. During interview on 10/31/19 at 6:32 p.m. with the Administrator it was reported that bed hold notification was provided but there is n… | 2020-09-01 |
| 136 | 136 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2019-10-31 | 641 | B | 0 | 1 | OMYR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for hospice for three resident's (R) R#75, R#43, and R#114 of 16 hospice residents. Findings include: 1. Record review revealed that R#75 was admitted to the facility on [DATE] on Hospice. Review of the Quarterly MDS assessment dated [DATE] for Section O: Special treatments and Programs revealed that Hospice was not triggered for R#75. Record review of the facility care plan for R#75 with an onset date of 3/29/19 with a problem area of hospice due to [MEDICAL CONDITIONS] and nutritional marasmus. Approaches: Coordinate care with hospice team, coordinate care with hospice to assure the resident has little pain as possible, provide resident and family with grief and spiritual counseling if desired, hospice to visit as ordered/indicated. Review of the hospice care plan from the hospice company dated 9/19/19 revealed R#75 had a current care plan with hospice. 2. Review of the medical record revealed that R#43 was admitted to the facility on [DATE] and was a hospice resident. Review of the Annual MDS dated [DATE] and the Quarterly MDS assessment dated [DATE] revealed that on Section O, the resident was not triggered for receiving hospice. Review of the facility care plan dated with a problem onset of 6/22/19 revealed R#43 was on hospice due to a terminal [DIAGNOSES REDACTED]. 3. Record review revealed that R#114 resident is a hospice resident. Review of the Re-Admission MDS assessment dated [DATE] revealed R#114 was readmitted to the facility and continued on hospice although hospice did not trigger on the re-admission MDS assessment. Review of the facility care plan with a problem onset of 10/18/19 revealed the resident was admitted to the facility on hospice. Coordination of care for the facility and hospice were in place on the care plan. An interview on 10/31/19 at 5:23 p.m. with Registered Nurse (RN/MDS) DD stated there is… | 2020-09-01 |
| 137 | 137 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2020-01-24 | 812 | E | 1 | 1 | 1R0411 | > Based on observations, record review and staff interviews, the facility failed to ensure that all items on the kitchen tray line, specially ground pork, were held at the appropriate temperature to prevent food born illness which effected 20 residents who received ground meats. Findings include: Review of policies entitled, Food Preparation and Distribution, updated February 2019 revealed that a temperature monitoring log will be maintained throughout meal service hot foods will be held at greater or equal to 135 degrees Farenheit (F), cold foods will be held at less or equal to 41 degrees F, while frequently monitoring temperatures during meal service, if any temperature is determined to be out of ranger, corrective action will take place (hot items will be pulled from the tray line and re-heated until an internal temperature of 165 degree F for 15 seconds is reached; cold items will be pulled from the tray line and placed into an ice bath, cooler, freezer, or blast chiller until 41 degrees or lower is reached; and items will be re-checked and proper temperature verified before beginning to serve. Observation and interview of the main kitchen tray line temperature taken by Food Service Aide (FSA) AA with the facilities calibrated thermometer on 1/23/20 between 6:24 p.m. through 6:39 p.m., revealed that the ground pork had a temperature of 130 degrees F. Interview with FSA AA at this time revealed that he was unsure how many ground pork have been served so far. An interview with Dietary Manager on 1/24/20 at 12:51 p.m. revealed the facility has in-services monthly, and she expects that staff identify when temps are not correct and pull food and not serve any food at a temperature that is too low or too high. | 2020-09-01 |
| 138 | 138 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 558 | D | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to accommodate one resident's (R) environment (R#21) to enable him to easily access the bathroom, hallway, and closet. The sample size was 34 residents. Findings include: During interview with R#21 on 8/6/18 at 1:46 p.m., he stated that he was in the B-bed (by the window), and it was hard for him to get to the bathroom because of the way the beds in the room were arranged. He stated during further interview that he had scraped his knuckles before on the wall on one side and the footboard of the A-bed on the other side when he tried to go from his bed toward the hallway. R#21 stated during continued interview that he also could not get into his closet, if his roommate was up in his wheelchair between the A-bed and the closets. R#21 further stated that the beds in his room had been arranged this way since his current roommate was admitted to his room. Review of R#21's roommate's Minimum Data Set (MDS) revealed that he was admitted on [DATE]. Review of R#21's Quarterly MDS dated [DATE] revealed that he had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment. Further review of this MDS revealed that R#21 was independent for locomotion in his room. Observation in R#21's room on 8/7/18 at 8:40 a.m. revealed that measurements taken with the surveyor's tape measure from the bed rail on the hallway side of the A-bed to the closets was 30 inches, and measurement from the footboard of the A-bed to the wall across from this bed was 32 inches. Continued observation revealed that the wall across from the A-bed had two continuous black scrapes, nine inches apart, from below the television set attached to the wall to the top of the nightlight, that extended all the way toward the hallway to the end of this wall. Observation on 8/7/18 at 9:38 a.m. revealed that the measurement taken with the surveyor's tape measure from the widest points of… | 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 |
| 140 | 140 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 656 | D | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and staff interviews, the facility failed to follow the care plan related to activities of daily living (ADLs), and activities for one resident (R#82), and failed to follow the care plan related to activities for one resident (R#74). The sample size was 34 residents. Finding include: Review of resident (R) #74's Annual Minimum Data Set ((MDS) dated [DATE] revealed staff assessment for activity preferences included listening to music, keeping up with the news, and participating in religious activities or practices. Review of R#74's psychosocial care plan with a revised date of 7/31/18 revealed behavior of being withdrawn and talking less, and she indicated activities that she enjoys are fresh air, religious services and her family. Review of the interventions to this care plan revealed to involve resident in activities or provide 1:1 (one-on-one) daily, and in room visits for social stimulation if resident cannot attend activities. Observation of R#74 on 8/6/18 at 11:36 a.m.; 8/7/18 at 9:52 a.m., 11:37 a.m., and 2:51 p.m.; 8/8/18 at 8:20 a.m., 11:57 a.m., and 2:09 p.m.; and on 8/9/18 at 8:00 a.m.; 9:10 a.m.; and 10:27 a.m. revealed that R#74 was in the bed with her television off. During interview with Certified Nursing Assistant (CNA) AA on 8/9/18 at 9:16 a.m., she stated that she had never seen R#74 with a radio or CD (compact disc) in her room, and that the resident's television worked. During interview with the Activity Director on 8/9/18 at 1:02 p.m., she stated that R#74 enjoyed television programs like game shows, and liked getting her hair brushed. She stated during further interview that she did not remember the last time that R#74's television was on. During interview with the Activity Assistant on 8/9/18 at 1:52 p.m., she stated that she did not know why R#74's television had not been on, could not remember the last time it was on, and that the resident liked to watch television. Review of R#… | 2020-09-01 |
| 141 | 141 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 657 | D | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to update the care plan for one resident (R) (R#54) to reflect exacerbations of [MEDICAL CONDITIONS] and new orders for nebulizer treatments. The sample was 34 residents. Findings include: Record review for R#54 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which assessed R#54 with shortness of breath (SOB) or trouble breathing on exertion. Review of the Chest x-ray dated 4/15/18 revealed an order for [REDACTED]. Review of the Physician order [REDACTED]. Review of the care plans in the Electronic Medical Record (EMR) for R#54 revealed no care related to [DIAGNOSES REDACTED]. Review of the paper clinical record for R#54 revealed Care Plan dated 7/5/17, through period 8/31/18 that identified the resident is at risk for shortness of breath, impaired breathing patterns secondary to [MEDICAL CONDITION]. An update on 4/14/18 added congestion and wheezing. Interventions included: *Provide reassurance and support to prevent anxiety during episodes of SOB *Provide rest periods as needed * In room visits for social stimulations if resident cannot attend activities * Observe for shortness of breath, noisy breathing, irregular breathing, increased coughing, temperature, cyanosis, early morning headache, unable to talk, [MEDICAL CONDITION], with follow up as indicated * Notify MD as needed. An update on 4/14/18 documented: [MEDICATION NAME] x 1, (4/15/18) CXR x 2 views. The care plan did not update for the order on 4/19/18 for [MEDICATION NAME] BID x 14 days. Further the care plan did not update in (MONTH) (YEAR) to reflect the order for [MEDICATION NAME] nebulizer treatments QID or exacerbations of [MEDICAL CONDITION]. Interview on 8/9/18 at 11:00 a.m. with the Director of Nursing (DON) revealed they are currently switching to the Electronic Medical Record (LG) which started in (MONTH) (YEAR). She stated that part of the care plans for R#54 had been entered into the EM… | 2020-09-01 |
| 142 | 142 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 677 | D | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interviews, and record review, the facility failed to provide activities of daily living care, (ADL) related to finger nail care for one dependent Resident (R) # 82. The sample size was 34. Findings include: Record review revealed that R#82 had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R# 82 required extensive assistance from one to two staff members for most of his ADL care. Documentation specified that the resident required extensive one-person physical assistance from staff for his personal hygiene. Review of R#82's care plan related to activities of daily living (ADLs) updated on 5/16/18 revealed that the resident was totally dependent on staff for ADLs. Nursing were to assist R#82 with ADL care as needed. Observation on 8/7/18 at 11:10 a.m., revealed R#82 with long, jagged, dirty finger nails on the right hand with a dark substance observed under the nails and around the cuticles. The resident's left hand was unseen due to it being located underneath a bed sheets. R#82 was observed on 8/8/18 at 9:56 a.m., 11:12 a.m., and at 1:33 p.m. His fingernails on his right hand remained long, jagged, and dirty with a dark substance underneath and around the cuticle area. An interview on 8/8/18 at 1:52 p.m. with Certified Nursing Assistant (CNA) AA who gave R#82 a shower on 8/8/18. She stated that she washed the resident with soap and water, trims the resident's beard at their request, and she also trims the resident's fingernails. The CNA looked at R#82s fingernails on both of his hands and verified that R#82s fingernails were jagged and dirty with a bark substance underneath the cuticle areas. She stated that she filed the resident's nails today but did not clean underneath or trim his nails. She did not state why she did not trim or clean underneath R#82s fingernails. An interview with Registered Nurse (RN) OO on 8/8/18 at 2:09 p.m., verified the R#82s… | 2020-09-01 |
| 143 | 143 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 679 | D | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and record reviews, the facility failed to provide an ongoing program of activities for three residents (R) (R #82, R#15, and R#74). The sample size was 34 residents. Findings include: 1. Review of R#82 care plan included one developed on 11/23/16 for psychosocial well-being with Interventions that included involving the resident in 1:1 activities or visits daily and in room visits for social stimulation if resident cannot attend activities. Observation on 8/7/18 at 11:00 a.m., the resident is observed in bed. He has not attended any scheduled activities in the facility. On 8/8/18 at 11:12 a.m., R#82 was observed lying in bed with the room lights on, awake with his eyes open looking at the ceiling. The resident does not have a television or radio on. R#82 observed lying in bed with his eyes open on 8/8/18 at 3:33 p.m. He is looking up at the ceiling. No visitors or 1:1 activities being performed. Record review revealed an Activity Quarterly assessment dated [DATE], that revealed that R#82 participates in two activities each week. The types of activities that the resident participates in are social/sensory activities. For participation level, the Assessment identified that R#82 requires assistance to attend activities. Per the Assessment, information for completion of the Activity Assessment was gathered from care plans, family interview, patient observation, and progress notes. An interview with the Activity Director (AD) on 8/9/18 at 1:33 p.m. revealed that she performs an activity assessment on residents when they are first admitted to the facility and then each quarter. If residents are not able to communicate, she contacts their family and/or friends for information. If the resident has a change in condition, she finds out this information in the morning meeting. She stated that occasionally staff will bring R#82 out of his room for group activities. She stated that she performs 1:1 activities with the… | 2020-09-01 |
| 144 | 144 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 684 | D | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, review of the policy titled Medication Orders and staff interviews, the facility failed to transcribe the physician orders for nebulizer treatment in the Electronic Medical Record (EMR) and failed to administer nebulizer treatments per physician orders for one resident (R) (R#54). The sample was 34 residents. Findings include: Review of the facility policy titled Medication Orders reviewed and updated (MONTH) (YEAR) documented in section #3- Documentation of the Medication Order: [NAME] Each medication order is documented in the patient's medical record with the date, time, signature, and title of the person receiving the order. B. The following steps are initiated to complete documentation: 1) Clarify the order with the prescriber, if necessary. 2) Fax, call and/or submit electronically, the medication order to the provider pharmacy. 3) When necessary, transcribe newly prescribed medications immediately on the MAR indicated [REDACTED]. Enter the new order on the MAR. In an electronic record, the above steps are completed by the defined process. 4) After completion, document each medication order noted on the physician's order form with date, time, signature (fill name) and title. Section #4- Specific Procedures for the Four Types of Medication Orders. New Orders signed by the prescriber (handwritten or e-prescribed). 1) The nurse clarifies the order if necessary with the prescriber. 2) Notes the order and enters it on the Physician Order Sheet if not written there by prescriber or enters into the electronic health record. 3) Transcribes the order immediately to the MAR indicated [REDACTED]. R#54 was admitted with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted, the resident was rarely or never understood. Section J- Health Conditions assessed R#54 with shortness of breath (SOB) or trouble bre… | 2020-09-01 |
| 145 | 145 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 761 | F | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to ensure that medications were stored at the proper temperature in two of two medication room refrigerators, and failed to ensure that needles used to deliver intramuscular injections were discarded after the manufacturer's expiration date in one of two medication rooms. The facility census was 95, and the sample size was 34 residents. Findings include: During observation in the Station 1 med room on 8/9/18 at 11:00 a.m., one box of 25-gauge 1-inch needles, and one box of 21-gauge 1-inch needles were observed with a manufacturer's expiration date of 12-2017 printed on the box. This was verified during interview with Licensed Practical Nurse (LPN) CC at this time, who stated that Central Supply staff stocked and checked the supplies in the medication rooms. During observation in the medication cart 2 with LPN BB on 8/9/18 at 11:10 a.m., she stated that there was a total of nine 25-gauge needles in the cart with an expiration date of 12-2017, but was not aware of any residents on her hall that received injections with this type of needle. During observation in medication cart 1 with Registered Nurse (RN) EE on 8/9/18 at 11:20 a.m. revealed that there was seven 25-gauge and six 21-gauge needles with an expiration date on the packaging of 12-2017. During interview with RN EE at this time, she stated that the night shift nurses gave vitamin B-12 injections to four residents, and that the nurses would use these needles for the injections. During interview with Central Supply staff DD on 8/9/18 at 11:29 a.m., she stated that she had not ordered any needles since the facility was bought by a different company in 2014, and had not checked the needle boxes for expiration dates. During observations in the Station 1 medication room on 8/9/18 at 2:20 p.m., the medication refrigerator temperature was 30 degrees (Fahrenheit) as measured by the facility's thermometer inside the … | 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 |
| 147 | 147 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 883 | D | 0 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and review of the facility policy titled Immunizations: Pneumococcal Vaccination (PPV) of Residents, the facility failed to offer the pneumonia vaccine to two residents (R) R#15 and R#40 of five residents reviewed for the pneumonia vaccine. The sample size was 34 residents. Findings include: Review of the clinical record for R#15 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no indication that the pneumonia vaccine was offered or administered to the resident. Review of the clinical record for R#40 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no indication that the pneumonia vaccine was offered or administered to the resident. Review of the facility policy titled Immunizations: Pneumococcal Vaccination (PPV) of Residents reviewed and updated (MONTH) (YEAR), procedural guidelines state that all residents of our facility should receive the Pneumococcal vaccine if they are [AGE] years of age or older or younger than [AGE] years with underlying conditions that are associated with increase susceptibility to infection or increase risk for serious disease and its complications. Each residents Pneumococcal immunization status will be determined upon admission or soon afterwards, and will be documented in the resident's medical record. All residents with undocumented or unknown Pneumococcal vaccination status will be offered the vaccine. Informed consent in the form of a discussion regarding risk and benefits of vaccination will occur prior to vaccination. Interview on 8/8/18 at 11:35 a.m. with Infection Control nurse, stated she only works 16 hours per week. She stated that for the influenza/Pneumonia vaccinations, she gets consents for each residents. She was sending letters to the family and the family was to contact the facility for refusal. She stated that she was unable to find any documentation… | 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 |
| 149 | 149 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-02-05 | 725 | F | 1 | 0 | 6UET11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, review of the monthly schedule (needs list), daily assignments, grievances, staff and resident interviews the facility failed to provide adequate staffing to provide care for two out of two residents interviewed R A and R B. The facility census was 76. Findings include: Interview on 2/4/19 at 10:50 a.m. with resident (R) 'A' who stated that the longest she has had to wait for someone to change her brief has been 30 - 45 minutes. Further stated that she hasn't noticed it being on any particular shift or at a certain time of day. RR: Review of Quarterly MDS dated [DATE] revealed resident with BIMS of 13. Interview on 2/4/19 at 10:55 a.m. with the East Hall Unit Supervisor HH who stated that if they have a nurse to call in that they have an on-call schedule for the nurses. Further stated that she is on call this week and that she split a shift last night with another nurse to cover the shift. Further stated if a Certified Nursing Assistant (CNA) calls in they will ask someone from the previous shift to stay over or ask if someone from the on-coming shift can come in early. Stated that they have used CNA's from the hospital when the hospital census is low. HH further stated that they do use agency CNA's and currently have a contract nurse working nights for them. Interview on 2/4/29 at 12:30 with CNA BB stated that they work short staffed at times, but they ask her to work overtime a good bit, because they can't find anyone else to work. She further stated that they post a schedule with vacant positions on it, and staff are encouraged to sign up to work extra shifts, and she tries to work two to three extra shifts a week, because she needs the money. Interview on 2/4/19 at 2:00 p.m. with CNA EE stated that she works agency, but works three to four 12 hour shifts per week at this facility. Interview: 12/4/19 at 2:14 p.m. R 'B' stated that she has had to wait as long as 30 minutes for staff to answer call light to get help … | 2020-09-01 |
| 150 | 150 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-02-05 | 727 | F | 1 | 0 | 6UET11 | > Based on observation, record review, review of facility daily nurse staff posting and staff interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight (8) consecutive hours a day, for seven (7) days a week for three (3) days (1/2/19, 1/26/19 and 2/4/19) of a 30 day review. The census was 76. Findings include: Observation during initial tour on 2/4/19 at 10:22 a.m. revealed no Registered Nurse (RN) on duty, other than the Director of Nursing. Review of past 30 days of Daily Nurse Staffing posts, revealed there was no RN on duty for the minimum eight (8) consecutive hours per day on 1/2/19, 1/26/19 and 2/4/19. Review of the Daily Nurse Staffing posted for 1/2/19, revealed no RN worked in the building for eight (8) consecutive hours for that date. Review of the Daily Nurse Staffing posted for 1/26/19, revealed no RN worked in the building for eight (8) consecutive hours for that date. Patient per day (PPD) for 1/26/19 was below the State requirement. Review of the Daily Nurse Staffing posted for 2/4/19, revealed no RN worked in the building for eight (8) consecutive hours for that date. Interview on 2/5/19 at 1:30 p.m. with Director of Nursing (DON) stated that she looks at the Daily Nurse Staffing posting and hasn't noticed any days that an RN was not on duty, for eight consecutive hours. She stated that she does not make any revisions to the Daily Nurse Staffing posting once the unit clerk has it posted. She verified that on 1/2/19 and 1/26/19 there was not a RN coverage for eight (8) consecutive hours and on 2/4/19, there was not a RN for eight (8) consecutive hours. She further stated that the RN Supervisor was called in to cover the floor for staff call-outs on 2/19. | 2020-09-01 |
| 151 | 151 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2018-04-18 | 609 | D | 1 | 0 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, staff interviews and family interview the facility failed to report and investigate an injury of unknown origin related to a burned area on the upper left chest of Resident #1 (R#1). The sample was four (4) residents. The facility census was seventy-seven (77). Findings include: Record review for R#1 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. During an observation conducted on 4/18/18 at 10:25 a.m. of R#1 an area of burned, discolored skin was noted on her left upper chest. She was sitting in the dining room for activities and her shirt was positioned slightly away from her left upper chest. The area was one inch long and three quarters inch wide with 2 small pink superficial open areas. The area was clean, dry, without drainage or redness. R#1 did not show any signs of discomfort. R#1 was confused and did not express herself clearly and could not explain anything about this burned area. Review of Nurse's Notes dated 4/14/18, time 20:35, revealed as follows: Resident noted to have an old burn mark in the shape of a curling iron on her left collar bone area. At least 3 days old it is beginning to peel off in areas. Resident is unable to say how it happened and expresses no c/o pain or (sic) from it. Resident's responsible party present and aware. Nurses notes revealed the Physician was notified of findings on 4/15/18 at 7:31. An Incident Report dated 4/15/28, time 8:14 revealed the same Nursing documentation as the above Nurse's Note. During an interview conducted on 4/18/18 at 1:30 p.m. Certified Nursing Assistant (CNA) CC revealed she had showered R#1 on 4/12/18 and she had no burn, blister or mark on her left upper chest. On 4/16/18 when she gave R#1 a shower she had recorded on the shower skin inspection sheet that R#1 had a blister on her upper left chest. Review of Body Audit Form, completed by the night shift working the night of 4/13/18 and … | 2020-09-01 |
| 152 | 152 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2018-04-18 | 610 | D | 1 | 0 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, staff interviews and family interview the facility failed to investigate an injury of unknown origin related to a burned area on the upper left chest of Resident #1 (R#1). The sample was four (4) residents. The facility census was seventy-seven (77). Findings include: Review of Abuse Prohibition Policy and Procedure effective date 12/20/17- Investigation of injuries of unknown source. Interviews will also be conducted when a resident has an injury from an unknown source. Signed statements will be gathered from : Staff who cared for resident just prior to and just after injury; Other reliable residents in the vicinity nearby area; Family or visitors who may have noticed anything. Once an injury of unknown source has been identified, staff will observe resident and watch behavior to see if the source of injury can be identified based on the resident's behavior (i.e. how they move their arms, walk, push a wheelchair, behave, etc.) The chart will be reviewed for any pertinent information that could help the investigation. If the abuse resulted in an injury, the facility will report to appropriate agencies no later than 2 hours after the allegation is made. Record review for R#1 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. During an observation conducted on 4/18/18 at 10:25 a.m. of R#1 an area of burned, discolored skin was noted on her left upper chest. She was sitting in the dining room for activities and her shirt was positioned slightly away from her left upper chest. The area was one inch long and three quarters inch wide with 2 small pink superficial open areas. The area was clean, dry, without drainage or redness. R#1 did not show any signs of discomfort. R#1 was confused and did not express herself clearly and could not explain anything about this burned area. Review of Nurse's Notes dated 4/14/18, time 20:35, revealed as follows: Resident noted t… | 2020-09-01 |
| 153 | 153 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2018-05-02 | 584 | E | 0 | 1 | 04GG11 | Based on observations and staff interviews, the facility failed to ensure a clean, comfortable, homelike environment during meal service in one of two dining rooms (West Wing Dining Room). Specifically, the facility failed to clean up food, debris and utensils from the floor after first dining. This failure resulted in an unclean dining experience for residents that were scheduled for meal service during second dining. Findings include: Observation of the West Wing Dining Room on 4/30/18 at 12:24 p.m. revealed the first meal for lunch was served at 12:24 p.m. There were two tables on the left of the dining room with seated residents, a small half circular table to the back right with seated residents and one long table on the right side of the dining room with seated residents. There was one small table closer to the kitchen that was not occupied. At 1:08 p.m. a staff member began collecting clothing protectors left on the tables by residents that had finished their lunch. At 1:12 p.m. the Dietary Aide brought a large garbage bin and a cart with dish bins to the dining room. The staff began collecting plates, utensils and cups from the tables. The staff washed the tables with sanitizer wipes. Residents were noted outside the hall waiting for the second dining service. Observed on the left end of the long table was a large piece of dinner roll, food crumbs and pieces hash brown casserole under the table on the floor and the chair on the end had food crumbs on it. The back-left table towards the aisle side had a packet of saltine crackers and pieces if mixed vegetables (green beans and carrots) on the floor under the table. At 1:17 p.m. a resident with a walker came to sit on the left end of the long table. The resident was observed sweeping the crumbs off the chair with her clothing protector before she sat down. The resident then looked down at the floor and held her feet to the side so she would not put her feet on the dinner roll and hash brown casserole on the floor. The resident had to ask the staff to remove… | 2020-09-01 |
| 154 | 154 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2018-05-02 | 600 | D | 0 | 1 | 04GG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family, and staff interviews, review of the facility's Abuse Prohibition Policy and Procedure revised, 12/17, The facility failed to ensure that an allegation of verbal/mental abuse was reported to the State Agency (SA) and that a thorough investigation related to the allegation of verbal/mental abuse was done for one resident (R#74). Findings Include: Review of the Abuse Prohibition Policy and Procedure revealed that Abuse is also defined as any intentional or grossly negligent act or series of acts or intentional or grossly negligent omission to act which causes injury to a resident, including, but not limited to, assault or battery, failure to provide treatment or care, or sexual harassment of the resident. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend d, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident such as telling a resident that she will never be able to see her family again. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation. Investigation: Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, the following investigation and reporting procedures will be followed: 1. The description of the alleged complaint. 2. Information gathering. 3. Document the description of the injury. 4. Interviews will be conducted of all pertinent parties. 5. Past performances and/or previous incidents. 6. Describe actions taken by facility to protect resident. 7. All investigation information will be kept on file in a secured location. Record review for R#74 revealed the resident … | 2020-09-01 |
| 155 | 155 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2018-05-02 | 761 | D | 0 | 1 | 04GG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to discard expired medication in one of four medication carts. The sample size is 24. Findings include: During medication pass on [DATE] at 8:45 a. m., with Licensed Practical Nurse (LPN) BB, revealed an opened multiple-dose vial of [MEDICATION NAME] R insulin with opened date of [DATE]. A label on the vial read discard after 28 days. Expired [DATE]. Review of the facility policy titled, Pharmacy Services and Procedure policy, revised (YEAR), indicated that the facility should ensure that medications and biological's have an expiration date on the label and have not been retained longer than recommended by the manufacturer or supplier. The policy further states facility should record the date opened on the medication container, if the medication has a shortened expiration date. Review of the policy titled, Recommend Minimum Medication Storage Parameters, revised (YEAR), indicated multiple-dose vials for injection, are to be dated when opened, and discard unused portions after 28 days or in accordance with manufacturer's recommendations. Interview on [DATE] at 8:45 a.m. LPN BB stated the policy for opened injectable medications is 28 days. She verified the opened bottle of [MEDICATION NAME] R insulin of [DATE] had an open date and pharmacy sticker indicated to discard after 28 days from opening date which is [DATE]. Interview on [DATE] at 9:15 a.m., Director of Nursing stated the policy for open injectable medications have a duration time, [MEDICATION NAME] 28 days. She verified the open bottle of [MEDICATION NAME] R insulin had [DATE] open date and the pharmacy sticker indicated to discard after 28 days from opening date which is [DATE]. Interview on [DATE] at 11:00 a.m., Pharmacy Consultant stated the policy for open injectable medications have a duration time, [MEDICATION NAME] 28 days. He verified the medication was refilled and sent to facility on [DATE], the open bott… | 2020-09-01 |
| 156 | 156 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2018-05-02 | 835 | D | 0 | 1 | 04GG11 | Based on record review, resident, family, and staff interviews, review of the facility's Abuse Prohibition Policy and Procedure revised, 12/17, The Adminstrator failed to ensure an allegations of verbal/mental abuse was reported to the State Agency (SA) and that a thorough investigation related to the allegation of verbal/mental abuse was done for one resident (R#74) Finding include: During interview with R#74 on 4/30/18 at 12:00 p.m., in the resident's room, revealed that she had a nurse talk in an inappropriate manner to her. Resident stated her daughter would be there soon and ask that I speak with her because the stroke she had affects her ability to talk clearly. On 4/30/18 at 12:30 p.m. R #74's daughter requested the surveyor to speak with her with her Mom present. Upon entering the room R #74's roommate was not in the room and at the daughter request the door was shut to allow a private conversation. Daughter states that on Monday of the previous week her Mom was having a lot of pain and had refused her shower. She states a nurse told R #74 that if she didn't take a shower she would pick her up and throw her in the shower and this upset R #74 and she told the nurse she was not taking a shower because she was in a lot of pain and having a bad day. Daughter then stated that the nurse said, If you don't take a shower you will not get any more pain medication. Daughter states she called in a complaint to the Ombudsman who said she would get back with her but states she hasn't heard from her yet. Also states that she complained to the head nurse. During the interview R #74 would shake her head in agreeance to everything her daughter was telling me. R #74 stated that the nurse was joking but it was not funny. On 5/2/18 2:45 at p.m.during interview with the Administrator and DON revealed that the Administrator did not report the Allegation because the Ombudsman was involved already. Administrator was given a copy of the regulation regarding reporting allegations of abuse to the State Agency within 2 hours if ther… | 2020-09-01 |
| 157 | 157 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2017-05-18 | 257 | E | 1 | 1 | KH1211 | > Based on observation, record review, review of the policy titled The Resident Environment, resident and staff interviews, the facility failed to ensure comfortable temperatures on one of two units (West Unit). The resident census on the West Unit was 46. The facility census was 83 residents. Findings include: Review of the facility policy titled The Resident Environment effective 5/2017 and expiring 5/2020 documented that Habersham Home long term and short stay resident accommodations meet all state rules/regulations to include: there is adequate temperature control. During tour of the facility on 5/15/17 that began at 10:08 a.m. on the West Unit it was noted to be extremely cold in the hallways. Some residents were noted to be wearing a [NAME]ets, sweaters and blanket across the lap. R A was walking through the hall and she was visibly shivering with her arms folded across her chest. Her lips were quivering. The resident was wearing a long sleeve shirt and when asked, she stated that she was cold. A CNA was alerted that R A was cold and she brought a [NAME]et to put on the resident. A West Unit dining observation, during the lunch meal on 5/15/17 at 12:30 p.m. revealed it was extremely cold. In addition to the cold temperature, there were four overhead fans blowing. There was no visible temperature gauge or thermometer in the dining room. Some residents were noted with their arms folded across their chest. Some residents were placing their arms underneath their clothing protector as if to keep them warm. While asking a random resident in the dining room if they were cold at 12:45 p.m., a family member of R B yelled out and stated It's always cold in here! We tell them but they don't do anything about it! At 12:56 p.m., another family member of a resident R C stated the residents are always cold in the dining room. She stated that her mother has a long sleeve shirt on and a sweater and she is still complaining of being cold. The family member stated that she is in the dining room at lunch almost every day and s… | 2020-09-01 |
| 158 | 158 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2017-05-18 | 280 | D | 1 | 1 | KH1211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to update the care plan to reflect the presence of an unstageable pressure ulcer, and failed to update the care plan related to pain assessment and management during wound care for one resident (R) #24. The sample size was 37 residents. Findings include: 1. Review of R #24's clinical record revealed that he was readmitted to the facility after a hospitalization on [DATE] with a Stage 3 pressure ulcer. Review of his 30-day Minimum Data Set ((MDS) dated [DATE] noted that he had one Stage 2 and one unstageable pressure ulcer. Review of Physician's Progress Notes dated 5/9/17 noted the resident continued to decline, and his Stage 3 sacral decubitus was not getting better. During observation of wound care done by the Director of Nursing (DON) on 5/17/17 at 9:07 a.m., the resident was noted to have a large sacral wound with grayish-black eschar in the wound bed. Review of R #24's care plans revealed a potential for pressure ulcer development last revised on 12/23/16, with no mention of the actual pressure ulcer. Review of a recurrent impairment to skin integrity of the right upper inner thigh care plan developed on 3/22/16 noted that the resident had blisters to the toes which resolved on 7/18/16, and was updated to reflect moisture [MEDICAL CONDITION] of the buttocks and coccyx on 7/9/16, 9/26/16, and 1/9/17. Further review of this care plan revealed that it did not include the actual pressure ulcer to the sacrum that the resident was readmitted with on 4/5/17. During interview with MDS Coordinator JJ on 5/18/17 at 3:49 p.m., she stated that at the time that R #24 came back from the hospital on [DATE], the wound nurse updated any care plans related to wounds, and did Section M (Skin Conditions) on the MDS. She further stated that for the past week the wound care nurse was assigned to the med cart, and that she (the MDS nurse) was responsible for doing the pressure ulcer… | 2020-09-01 |
| 159 | 159 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2017-05-18 | 282 | D | 1 | 1 | KH1211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to follow the care plan related to following facility policies and protocols for the prevention of skin breakdown for one resident (R) #24. The sample size was 37 residents. Findings include: Review of R #24's 30-day Minimum Data Set ((MDS) dated [DATE] revealed that he had one Stage 3 and one unstageable pressure ulcer. Review of the Weekly Pressure Assessment Tool dated 5/4/17 revealed that the resident had an unstageable pressure ulcer to the sacrum. Review of R #24's potential for pressure ulcer development care plan last revised on 12/23/16 revealed an intervention to follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of the facility's Documentation of Treatments policy revised (MONTH) of 2009 noted: In order to assure proper monitoring and documentation of the condition of each resident's skin integrity, weekly assessments will be performed by a licensed nurse. Review of the facility's Resident Monitoring policy effective (MONTH) of 2008 noted: Licensed Nurses are to complete a weekly Skin Assessment form on every resident. Review of R #24's Body Audit Form skin assessments revealed that there were none found in the clinical record after 4/17/17. During interview with the Director of Nursing on 5/17/17 at 9:25 a.m., she stated that the wound care nurse did weekly skin assessments on all of the residents. During interview with Registered Nurse (RN) II on 5/18/17 at 1:35 p.m., she stated that she was the usual wound care nurse. During interview with RN II on 5/18/17 at 3:05 p.m., she stated that she could find no other weekly skin assessments after 4/17/17 for R #24. During further interview, she stated that she was responsible for completing the weekly skin assessments, but had not been able to do them lately because she was working as a medication nurse. Cross-refer to F 314. | 2020-09-01 |
| 160 | 160 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2017-05-18 | 309 | D | 1 | 1 | KH1211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to evaluate one resident (R) #24 for pain during wound care. The sample size was 37 residents. Findings include: Review of R #24's clinical record revealed that he was admitted with [DIAGNOSES REDACTED]. Review of his 30-day Minimum Data Set ((MDS) dated [DATE] revealed that he had severe cognitive impairment, and had one Stage 3 and one unstageable pressure ulcer. Further review of this MDS revealed that he was not on a scheduled pain regimen, and had non-verbal sounds of pain or possible pain in the last five days for one to two days of the assessment period. Review of the risk for pain related to varied ability to make needs known care plan revealed interventions to monitor resident complaints of pain or signs and symptoms of non- verbal pain. Review of all of R #24's care plans revealed that no interventions included assessing for pain nor providing pain management during wound care. Review of a Pain assessment dated [DATE] revealed that R #24 received PRN (as needed) pain medications over the past five days, and was not on a scheduled pain medication regimen. Review of the Weekly Pressure Assessment Tool dated 5/4/17 revealed that R #24 had an unstageable sacral pressure ulcer measuring 4.6 cm (centimeters) long by 3.5 cm wide by 1.2 cm deep. Review of R #24's physician Telephone Orders dated 4/30/17 revealed an order for [REDACTED]. During observation of wound care by the Director of Nursing (DON) on 5/17/17 at 9:07 a.m., she was heard to tell R #24 that the treatment was going to be a little uncomfortable, and that she would be as gentle as I can. When the DON removed the old sacral dressing, a large, deep wound with a dry wound bed that contained grayish-black eschar was observed. When the DON cleaned the wound with wound cleanser that had been sprayed on gauze, R #24 was heard to say awwww in an uncomfortable tone. During further observation, the resident … | 2020-09-01 |
| 161 | 161 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2017-05-18 | 314 | D | 1 | 1 | KH1211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to use the correct wound care product as ordered, and failed to consistently do weekly skin assessments for one resident (R) #24, who was high risk for skin breakdown and currently had an unstageable pressure ulcer. The sample size was 37 residents. Findings include: 1. Review of R #24's clinical record revealed that he was admitted to the facility with [DIAGNOSES REDACTED]. Review of labs dated 4/7/17 revealed that he had an [MEDICATION NAME] level of 2.3 (normal 3.5-5.0). Review of a Braden Scale done on 5/15/17 revealed that he was assessed as high risk for skin breakdown. Review of a physician's orders [REDACTED]. Review of a Weekly Pressure Assessment Tool dated 4/5/17 revealed that the resident was readmitted to the facility that day with a Stage 3 sacral pressure ulcer. Review of his 30-Day Minimum Data Set ((MDS) dated [DATE] noted that he had severe cognitive impairment, was a pressure ulcer risk, and had one Stage 3 and one unstageable pressure ulcer. Review of physician's orders [REDACTED]. Review of Physician's Progress Notes dated 5/9/17 noted the resident continued to decline, and his Stage 3 sacral decubitus was not getting better. During observation of wound care to R #24's sacral wound performed by the Director of Nursing (DON) on 5/17/17 at 9:07 a.m., grayish-black eschar was noted in the wound bed, and the wound bed was dry. The DON was observed to clean the wound with wound cleanser, packed the wound bed with [MEDICATION NAME] Ag Extra, and covered the wound with a [MEDICATION NAME] dressing. During interview with the DON at this time, she stated that the [MEDICATION NAME] was used to help get rid of the slough, and to absorb moisture in the wound. Review of Weekly Pressure Assessment Tools dated 4/12/17 and 4/18/17 revealed that the wound had no drainage. Review of a Weekly Pressure Assessment Tool dated 5/4/17 revealed that the sacral pressure… | 2020-09-01 |
| 162 | 162 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2017-05-18 | 322 | D | 1 | 1 | KH1211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to check for placement and residual prior to giving water flushes, medications, and enteral formula through a gastrostomy tube (GT) for one resident (R) #37. The sample size was 37 residents. Findings include: During a medication pass observation on 5/17/17 beginning at 12:54 p.m., Licensed Practical Nurse (LPN) KK was observed to prepare the medications for R #37 for administration via her GT. During further observation, the nurse connected the GT to a 60-mL (milliliter) syringe, and gave 80 mL of water flush, followed by the crushed medications dissolved in water, followed by a can of enteral formula, and followed with an additional 80 mL of water flush. The nurse was not observed to check the resident's GT for placement and/or residual enteral formula prior to the above observation. Review of R #37's physician's orders [REDACTED]. During interview with LPN KK on 5/17/17 at 1:25 p.m., she stated that she had forgotten to bring her stethoscope into R #37's room when she gave her medications, and verified that she did not check for placement of the GT or residual first. Review of the facility's Med Administration Enteral Feeding Tube policy revised (MONTH) of 2014 noted to check for correct placement of tube by injecting air and listening with stethoscope to abdomen or placing end of tube in glass of water and observing for air bubbles or aspiration of stomach contents. Review of the facility's Guidelines for Enteral Feeding policy last revised (MONTH) (YEAR) noted that open feeding systems bolus and/or gravity had the highest risk of side effects like abdominal distension, aspiration, reflux, diarrhea, vomiting and generation of high residual volumes. | 2020-09-01 |
| 163 | 163 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2017-05-18 | 323 | E | 1 | 1 | KH1211 | > Based on observation, record review and staff interview, the facility failed to keep potentially harmful chemicals in a secured area on two of four halls on two of two units (East and West units). There were 18 residents on the West unit and 17 residents on the East unit that were independently mobile and had severe cognitive impairment. The facility census in both buildings was 83 residents. Findings include: During initial tour of the facility in the East unit building on 5/15/17 at 9:45 a.m., the following observation was made in the unlocked Storage room across from room 123: On a shelf just inside the door were three 3-liter jugs with screw-on tops, low enough to be accessible by a resident in a wheelchair, with labeling that included: Cen-Kleen IV One-Step Disinfectant-Cleaner-Fungicide-Mildew Stat-Virucide. Danger. This observation was verified during interview with Licensed Practical Nurse (LPN) Supervisor LL on 5/15/17 at 9:53 a.m., who stated they normally kept chemicals locked up, and that these chemicals were used to clean the whirlpool tub. Observation at this time revealed that there were seven residents in the hall where this Storage closet was located, and LPN LL stated that six of them were independently mobile. During initial tour of the facility in the West unit building on 5/15/17 beginning at 10:11 a.m., an unlocked Custodian Closet was observed across from room 410. Further observation revealed the following chemicals inside that had TwistNFill caps unless noted otherwise: 1. One 1-gallon jug of DMQ Damp Mop Neutral Disinfectant Cleaner that had a measuring cup on the top and a screw-on lid on the floor in this closet. The jug was approximately 1/3 full, and the labeling included Danger. 2. Two 2-liter jugs of Heavy Duty Multi-Surface Cleaner Concentrate on a shelf; one jug was full and one jug was approximately 1/3 full. 3. Three 2-liter jugs of Non-Acid Disinfectant Bathroom Cleaner Concentrate on a shelf. One jug was approximately 1/2 full, and two jugs were full. The jug labeling inclu… | 2020-09-01 |
| 164 | 164 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-06-27 | 550 | D | 1 | 1 | 3SRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, record review, and review of the policies Urinary Catheter Policy, (Insertion, Maintenance, Irrigation) and Resident's Federal and State Rights the facility failed to place a privacy bag over the indwelling Foley catheter of 3 out of 8 residents (R) (R#3, R#8, and R#127) on 1 of 2 units. Findings include: 1. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#3 revealed in section (C) a Basic Interview for Mental Status (BIMS) score of 11/15 indicating intact cognitive responses, (E) Behaviors - None. (G) Functional Status - 2+ person physical assist. (H) Bowel and Bladder - Indwelling Foley Catheter, and always incontinent of bowel. (I) Active Diagnosis (including but not limited to) - [MEDICAL CONDITION] bladder. (N) Medications - Antianxiety, antidepressant, diuretic, and opioid 7/7 days a week. Review of the medical record for R#3 revealed an order dated (MONTH) 2, 2019 for an 18 French Catheter with 20cc Balloon. Change monthly and as needed related to malfunction. During an observation on 6/24/19 at 1:30 p.m. of R#3 in her room revealed her catheter bag to be hanging, uncovered, on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 9:12 a.m. of R#3 in her room revealed her catheter bag to be hanging, with the upper portion of the bag covered, revealing the mid and lower portion of the bag. The catheter bag was noted to be on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 11:10 a.m. of R#3 during activities revealed her to be sitting in her wheelchair with the catheter bag hanging below the back of the chair and it was noted to be uncovered. During an interview on 6/26/19 at 9:16 a.m. with Licensed Practical Nurse (LPN)/Unit Supervisor BB she stated if a resident has a catheter, and is in the bed, she would expect the catheter bag to be covered completely and preferably hang… | 2020-09-01 |
| 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 |
| 166 | 166 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-06-27 | 656 | D | 1 | 1 | 3SRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and record review, the facility failed to follow the person-centered comprehensive care plan related to privacy bags for 3 out of 8 residents (R) (R#3, R#8, and R#127) with indwelling Foley catheters on 1 of 2 units. Findings include: 1. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#3 revealed in section (C) a Basic Interview for Mental Status (BIMS) score of 11/15 indicates intact cognitive responses. (E) Behaviors - None. (G) Functional Status - 2+ person physical assist. (H) Bowel and Bladder - Indwelling Foley Catheter, and always incontinent of bowel. (I) Active Diagnosis (including but not limited to) - [MEDICAL CONDITION] bladder. (N) Medications - Antianxiety, antidepressant, diuretic, and opioid 7/7 days a week. Review of the care plan with an initiated date of 1/19/18 and revision date of 1/2/19 revealed R#3 has an indwelling Foley catheter. Interventions include: Position catheter bag and tubing below the level of the bladder with a privacy cover over the bag. Review of the medical record for R#3 revealed an order dated (MONTH) 2, 2019 for an 18 French Catheter with 20cc Balloon. Change monthly and as needed related to malfunction. During an observation on 6/24/19 at 1:30 p.m. of R#3 in her room revealed her catheter bag to be hanging, uncovered, on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 9:12 a.m. of R#3 in her room revealed her catheter bag to be hanging, with the upper portion of the bag covered, revealing the mid and lower portion of the bag. The catheter bag was noted to be on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 11:10 a.m. of R#3 during activities revealed her to be sitting in her wheelchair with the catheter bag hanging below the back of the chair and it was noted to be uncovered. During an interview on 6/26/19 at 9:16 a.m. with Licens… | 2020-09-01 |
| 167 | 167 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-06-27 | 695 | D | 1 | 1 | 3SRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, staff interviews and review of the policy titled Oxygen Policy, the facility failed to ensure Oxygen concentrator filter was clean for one resident (R) (R#126). The sample size was 39. Findings include: Review of the facility policy titled Oxygen Policy revealed the policy states the facility shall provide oxygen therapy as ordered by the physician. Oxygen concentrator will be used for continuous therapy, with oxygen tanks available for emergency or temporary use. Concentrator filters are to be cleaned weekly in warm, soapy water, rinse and dried. Filters will be changed as needed. Review of the clinical record for R#126 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no data available on Minimum Data Set (MDS) due to new admission status with entry tracking MDS dated [DATE]. Review of R#126 care plan initiated on 6/21/19 revealed resident has oxygen therapy related to shortness of breath. Interventions to care include oxygen settings at two Liters via nasal cannula continuous to keep sats above 90%. Observation on 6/24/19 at 1:25 p.m. revealed oxygen in use via concentrator at bedside. Concentrator has external filter on right side that is covered with thick gray layer of dust. Observation on 6/25/19 at 8:25 a.m. revealed oxygen in use via concentrator. External filter remains with thick gray layer of dust. Observation on 6/26/19 at 12:51 p.m. revealed oxygen in use via concentrator. External filter continues to have thick gray layer of dust. Observation on 6/27/19 at 8:09 a.m. revealed oxygen continues to be used, delivered by concentrator. External filter remains with thick gray layer of dust. Physician's order dated (MONTH) 27, 2019 revealed an order for [REDACTED]. Interview on 6/27/19 at 8:19 a.m. with Licensed Practical Nurse (LPN) LL stated the night shift is responsible for changing oxygen tubing, nebulizer masks and humidification bottles. She stated sh… | 2020-09-01 |
| 168 | 168 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-06-27 | 812 | E | 1 | 1 | 3SRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, observation, and review of policy titled Storage of Food and Supplies the facility failed to label and date opened food items in two of the walk-in coolers, walk-in freezer; and dry food storage area; failed to ensure cleanliness of food preparation stations; failed to ensure cleanliness and proper storage of ice machine scoop. The deficiency practice had the potential to affect 27 of 29 residents receiving an oral diet. The facility census was 76. Findings include: An initial tour of the kitchen was conducted on [DATE] from 11:08 a.m. to 11:50 a.m. with Dietary Service Director (DSD) CC, he confirmed that he wasn't a Certified Dietary Manager (CDM) at this time and his serv -safe is currently expired and was taking [DATE] off from work to renew his certification. He reported the serv-safe certified personnel Registered Dietitian (RD), and himself (currently expired). The DSD confirmed they had 20 food service staff that included the staff for the Bistro, Suite One Cafe and the two skilled nursing facility (SNF) called the Healthcare Kitchen. He explained the main kitchen provides meals to the hospital and the two skilled nursing facility. The Suite One Cafe serve staff, guest and any residents in the (SNF) and hospital that desire to go there on the second floor, which is a part of the Healthcare Kitchen services. During this initial observation and interview, DSD EE acknowledged that several food items were insecurely wrapped and unlabeled located in both walk-in refrigerators and deep freezer. The DSD EE confirmed that there should labels on each container containing the flour, sugar, breadcrumbs, with scooper removed from contents. He stated that due to the high turnover of staff, it's hard to keep track and remind them of the potential hazards. Continued observations on [DATE] of the Healthcare Kitchen with DSD EE present included: Walk-in refrigerators revealed the following unlabeled and no dated food items … | 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 |
| 170 | 170 | NHC HEALTHCARE ROSSVILLE | 115104 | 1425 MCFARLAND AVE | ROSSVILLE | GA | 30741 | 2018-04-19 | 758 | D | 0 | 1 | IBN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to discontinue orders for as needed (PRN) antianxiety medications for two residents (#80 and #239) after 14 days, failed to indicate the need to extend the order beyond that period, and failed to document the reason for the extension or the period during which the extended order should be in effect. The sample size was 21. Findings include: Review of the undated policy titled, Medication Utilization and Prescribing - Clinical Protocol, the physician and staff of the facility are to review the rationale for prescribed medications that lack a clear indication for use or are being used intermittently on a PRN basis, and the physician will provide/document a rationale when the dose, duration, or frequency of a prescribed medication exceeds the accepted practice or manufacturer's recommendation. 1. Review of the clinical records for Resident (R)#80 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) assessment of 1/8/18 revealed active [DIAGNOSES REDACTED]. The assessment also documented that the resident was receiving antianxiety medications 7 of 7 days. Review of the current order sheets for R#80 revealed an order for [REDACTED]. Review of the medication administration records (MARs) for R#80 revealed no administration of PRN [MEDICATION NAME] in February, (MONTH) or (MONTH) of (YEAR) 2. Review of the clinical record revealed R#239 was admitted on [DATE] with current and has current [DIAGNOSES REDACTED]. Review of R#239's quarterly MDS assessment of 2/8/18 revealed active [DIAGNOSES REDACTED]. The assessment also documented that the resident had was receiving antianxiety medications. Review of the current physician order [REDACTED]. Review of MARs revealed that PRN [MEDICATION NAME] 1 mg was last administered to R#239 on 3/2/18. Interview on 4/19/18 at 9:32 a.m. with the Assistant Director of Nursing (ADON) re… | 2020-09-01 |
| 171 | 171 | NHC HEALTHCARE ROSSVILLE | 115104 | 1425 MCFARLAND AVE | ROSSVILLE | GA | 30741 | 2018-04-19 | 761 | D | 0 | 1 | IBN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to follow the policy titled Storage of Medications and Biological ' s . The facility failed to ensure proper disposal of expired medication in one of three medication carts. Sampled size is 21. Findings Include: On 4/17/18 12:00 p.m. three medication carts were observed, with one expired medication in one cart: On 4/17/18 at 12:00 p.m. during an observation with Licensed Practical Nurse (LPN) EE found expired medication in cart number one of the three carts on the North Wing. One Humalog 100 Units milliliters of Kwik insulin [MEDICATION NAME] pen injection opened 3/16/18, expired 4/13/18. A record review of the facility ' s Storage of Biological Medications and Medication Administration policy with an issue date of (MONTH) 1st, 2007 and a review/revision date of (MONTH) 1st, 2010/ (MONTH) 1st, 2013, revealed the facility will ensure medications and biological's are stored, labeled, and disposed of properly by expiration date. An interview on 4/17/18 at 12:00 p.m. with the Licensed Practical Nurse (LPN) EE revealed staff are expected to date and label all medications when opened and check for expired medications in the medication carts on a daily basis before the administration of medication to all residents. An interview on 4/17/18 at 12:10 p.m. with the Director of Nursing (DON) revealed staff are in-serviced on medication storage, medication administration, and medication expiration date. An interview on 4/18/18 at 10:15 a.m. with the Pharmacy Consultant revealed staff are in-serviced on medication storage, medication administration, and medication expiration date on monthly basis. | 2020-09-01 |
| 172 | 172 | NHC HEALTHCARE ROSSVILLE | 115104 | 1425 MCFARLAND AVE | ROSSVILLE | GA | 30741 | 2019-06-27 | 585 | D | 0 | 1 | 7CZH11 | Based on record review, resident and staff interview, and review of the policy, Services Recovery/Grievance Procedure, the facility failed to document and promptly respond to a grievance filed by one resident (#48) from a sample of 30 residents. Findings include: During an interview on 6/24/19 at 2:14 p.m., R#48 revealed that the Certified Nursing Assistant (CNA) who assisted her with her shower on 6/17/19 had ignored her instructions on how to assist her from moving from a seated to a standing position. The resident said she did not believe the CNA was abusive, but by failing to follow her instructions about the best way to assist her, the CNA had inadvertently left a bruise on her right forearm. The resident said she had immediately called for the Director of Nursing (DON) to come to her room at which time she lodged a complaint about the CN[NAME] The DON told her she wrote it up, but no member of the facility staff had since communicated to her what was the outcome of her grievance/complaint. A review of the quarterly Minimum Data Set (MDS) assessment of 5/2/19 revealed that Resident (R) #48 had a Brief Interview for Mental Status (BIMS) score of 14. A score of 13-15 indicates that an individual is cognitively intact. Review of the undated policy, Services Recover/Grievance Procedure, revealed that staff are expected to address resident and family concerns as soon as they become aware of them. The center social worker was identified as center ombudsman responsible for following up in a timely manner, and documenting the summary, investigation, corrective action, resolution, and follow up of each concern reported. During an interview on 6/26/19 at 10:41 a.m. with the Admission Director (AD), it was revealed that residents are informed of the grievance process upon entrance and a copy of the process is provided in their admission packet. The AD also said that the Social worker (out on leave) was the facility's grievance officer), but that residents were informed that any member of staff was available to take the… | 2020-09-01 |
| 173 | 173 | EFFINGHAM CARE & REHABILITATION CENTER | 115106 | 459 HIGHWAY 119 SOUTH | SPRINGFIELD | GA | 31329 | 2018-08-16 | 656 | G | 0 | 1 | P8CL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow the plan of care for Resident (R)#60 who had an intervention for staff to keep her bed in the lowest position. This failure to keep her bed in the lowest position resulted in harm for R#60 when she rolled off her high bed onto the floor and sustained a [MEDICAL CONDITION]. Additionally, the facility failed to follow the plan of care for one resident (R)(R#60) who had interventions for Certified Nursing Assistants (CNA) to check the skin during am/pm care and for Licensed nurses to monitor her skin weekly. The sample size was 26 residents. Findings include: 1. Review of a Nurses' Note dated 3/21/18 at 4:36 a.m. revealed that at approximately 12:00 a.m., R#60 was found kneeling on the floor with her torso on the bed. She told staff at that time that she did not know how she got on the floor but, that she must have rolled off the bed. The resident sustained [REDACTED]. Review of the revised care plan for R#60 dated 3/21/18 revealed that the resident was at risk for falls due to her history of falls prior to admission, impaired balance, dementia with forgetfulness and confusion with a new intervention to keep the bed in the lowest position. Review of the Nurses' Note dated 6/1/18 at 6:44 a.m. revealed that R#60 was found on the floor between the bed and her recliner. Review of the Nurses' Note dated 6/1/18 at 1:13 p.m. revealed that R#60 complained of pain. The physician was notified and ordered an x-ray and subsequent CT scan which showed that the resident had an acute subcapital left femoral neck (hip) fracture. Interview with the Director of Nursing (DON) on 8/15/18 at 12:32 p.m. revealed that during her investigation of the 6/1/18 fall, Certified Nursing Assistant (CNA) AA told her that she had left R#60 in the bed after providing care to check on a resident in another room. Continued interview revealed that CNA AA had left the resident's bed in a high position at that … | 2020-09-01 |
| 174 | 174 | EFFINGHAM CARE & REHABILITATION CENTER | 115106 | 459 HIGHWAY 119 SOUTH | SPRINGFIELD | GA | 31329 | 2018-08-16 | 686 | D | 0 | 1 | P8CL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Skin Care and staff interview, the facility failed to identify a pressure sore timely for one (1) resident (R) (R#60) of 26 sampled residents. Findings include: R#60 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Date Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating that she was cognitively impaired. Continued review revealed that the resident required total assistance of staff for bed mobility and eating, was non-ambulatory, had a fall with major injury and was at risk for pressure sores. Review of the resident's care plan dated 3/7/17 revealed that R#60 was at risk for pressure sores due to her decreased activity, chairfast status most of the time and admission with pressure sores with an intervention for Certified Nursing Assistants (CNAs) to monitor her skin with am/pm care and report any reddened, irritated or open areas. There was also an intervention for nursing to monitor her skin weekly. review of the resident's medical record revealed [REDACTED]. Continued review revealed that staff placed interventions to prevent pressure sores and/or promote healing that included the initiation of soft heel boots, a pressure relieving mattress, Multivitamins, Vitamin C, Zinc and supplements. Review of the Quarterly Braden scale dated 7/11/18 revealed that the resident had a score of 12 indicating that she was at high risk for pressure sore development due to her very limited sensory perception responding only to painful stimuli; often moist skin; bedfast status; very limited mobility; and potential problem with friction/shearing. Although R#60 had a care plan intervention since 3/2/17 for nursing staff to provide weekly skin checks, review of the facility Skin Forms revealed that Licensed Nursing staff failed to check the resident's skin weekly in 7/2018. Review of the last Skin Form… | 2020-09-01 |
| 175 | 175 | EFFINGHAM CARE & REHABILITATION CENTER | 115106 | 459 HIGHWAY 119 SOUTH | SPRINGFIELD | GA | 31329 | 2018-08-16 | 689 | G | 0 | 1 | P8CL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's Falls Assessment and Prevention Policy and staff interview, the facility failed to ensure that Certified Nursing Staff lowered the bed to a low position for one (1) resident (R) (R#60) of three (3) residents reviewed for falls from a sample of 26 residents. This failure to lower the bed to a low position resulted in harm for R#60 when she rolled off the high bed onto the floor and sustained a left [MEDICAL CONDITION]. Findings include: Review of the facility's Falls Assessment and Prevention Policy revealed that residents at risk for falls will have interventions to minimize the occurrence of falls that include making sure that bed is at the safest and most functional height possible for each resident. Resident #60 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 9 indicating that she had some cognitive impairment. Continued review revealed that she was non-ambulatory, required extensive assistance of two staff for bed mobility and had one fall with injury since her prior MDS on 1/18/18. Review of the resident's care plan dated 3/2/17 revealed that the resident was at risk for falls due to her history of falls prior to admission, impaired balance, dementia with forgetfulness and confusion. The care plan had appropriate interventions to prevent falls. Review of the Nurses' Note dated 11/11/17 at 3:29 p.m. revealed that at 2:00 p.m. R#60 was found on the floor in front of her wheelchair. She stated at that time that she was attempting to get up to go to the bathroom and fell face first onto the floor. The resident sustained [REDACTED]. The physician was notified and R#60 was sent to the emergency room (ER). An x-ray of her right arm showed that she had a right radial head (elbow) fracture. Review of the resident's care plan revealed that staff revise… | 2020-09-01 |
| 176 | 176 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2018-04-17 | 550 | D | 1 | 0 | TFUK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, family interview and staff interview, the facility failed to ensure that dignity was maintained for one (1) resident (R) (R#A) from a sample of six (6) residents. The facility census was one hundred thirty-two. Cross refer to F 565 Findings include: An interview conducted on 4/11/18 at 2:01 p.m. with a family member of R#A revealed she had requested several times for her aunt to be dressed properly when in or out of the bed, during the day and night. The family member revealed she has found her aunt in bed, both at night and during the day for naps, with no pants or pajama bottoms on and has requested the Administrator, the Director of Nurses (DON), Social Service Director, Nurses and CNA's do something about this. Continued interview on 4/17/18 at 3:20 p.m. revealed she and the other family members do not want R#4 in bed or out without pants or pajamas bottoms on. Their aunt, when she was younger and alert, was modest and concerned about her appearance and would not go anywhere without the proper clothing and now that she is [AGE] years old gets cold easily. She would be embarrassed if she had to go to the hospital and knew she was only wearing a shirt and a brief, and she would be cold as well. The family would be very upset by this. Observations for R#A on 4/11/18 at 1:30 p.m. revealed she was in a wheelchair in the dining room wearing a T shirt, a pink over shirt, and matching pink pants. She was wearing non- skid footwear and had no signs of incontinence. On 4/11/18 at 4:45 p.m. an interview with Licensed Practical Nurse EE revealed the day shift Certified Nursing Assistants (CNA's) had put R#A to bed for an afternoon nap at 2:00 p.m. On 4/11/18 at 4:45 p.m. R#A was observed in bed wearing the same T shirt and pink over shirt she was wearing for earlier observations. The matching pink pants were folded twice and were on a chair in the corner of the room out of reach of the bed. The wheel chair was … | 2020-09-01 |
| 177 | 177 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2018-04-17 | 565 | D | 1 | 0 | TFUK11 | > Based on observation, record review and staff and family interview, the facility failed to resolve grievances filed for one resident (R), (R#4) from a sample of six residents. The facility census was one hundred thirty-two. Cross refer to F 355 Findings include: A family interview for R#A on 4/11/18 at 2:01 p.m. revealed she has discussed with the facility the family's wishes for R#A to wear proper clothing at all times. The family member revealed she had found R#A with out pants on when in bed, clothed only in a brief and shirt, or brief and pajama top at night, more than once. The family member revealed she has explained to the facility that the resident should wear pants when in bed during the day for naps and wear pajama bottoms at night when in bed. She revealed she brings home the resident's laundry and knows she has not been properly dressed when she finds 2 pajama tops and one or no pajama bottoms. She was unable to give dates and times when she has found the resident in bed with no pants on but it has happened more than once and she has found this recently. The family member confirmed she had expressed the family's wishes to the Administrator by email, at care plan meetings, in grievances and individually to Certified Nursing Assistants and Nurses over the last year, with improvement sometimes for a brief period, possibly a week then she will find her aunt without pants or pajama bottoms on in bed again. She revealed she has also repeatedly asked for lotion or oil to be applied to her aunt's skin every day and when laundering the clothing she is aware that this is not being done because the clothing sometimes has an excessive amount of dry skin on the inside. She revealed she intermittently also finds the residents pants and pajama bottoms soaked with an excessive amount of urine, like she had not received incontinence care at regular intervals and has included this in discussions, emails, and grievances without results. Record review of Care Plan Conference Summary, dated 6/20/17 revealed the family m… | 2020-09-01 |
| 178 | 178 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2018-04-17 | 584 | E | 1 | 0 | TFUK11 | > Based on observations, family interview and staff interview the facility failed to provide a clean, comfortable, homelike environment in two of three resident shower rooms. There were one hundred two (102) residents (R) potentially affected by the lack of shower room sanitation in the third and fourth floor showers. The facility census was one hundred thirty-two (132). Findings include: An observation of the third floor shower room was conducted on 4/11/18 at 5:45 pm. There were pieces of a brown substance on the floor, the room smelled of BM and there were 4 wet gloves and 3 wet towels on the floor. An interview on 4/11/18 at 3:20 p.m. was conducted with a family member of R#[NAME] The family member revealed she finds the showers dirty with trash on floor, wet towels and brown smears of bowel movement (BM) on the floor and smelling like BM whenever she has ever looked at them. An interview with the Unit Manager of the third floor on 4/11/18 at 5:50 p.m. revealed the housekeeper is expected to clean shower before they go home, and the Certified Nursing Assistants (CNA's) are expected to pick up the trash, wet linens and clean up any smears or stains of body substances before showering the next resident. An interview was conducted with R#D on 4/17/18 at 10:10 a.m. R#D revealed she has not made a formal complaint but she and others on her floor do not get to the shower room much because for the last 2 months the residents have been told intermittently that the shower drain was plugged and given bed baths instead. R#D revealed when she has had a shower the room was not clean and sanitary, with trash and dirty linen on floor first thing in the AM, so she knows it was probably from the day before and sometimes there are stains and smears on the floor. R#D revealed when she has been in the shower recently the drain was not plugged. An observation of the fourth floor shower room on 4/17/18 at 10:15 a.m. revealed pink and brown stains and standing water on a white plastic sheet suspended under the shower bed, and a red… | 2020-09-01 |
| 179 | 179 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2018-04-17 | 606 | E | 1 | 0 | TFUK11 | > Based on record review, review of facility policy and Administrator interview the facility failed to ensure Georgia Crime Information Center background checks were completed on seven (7) of eighteen (18) employees hired during the month of October, (YEAR). The facility census was one hundred thirty-two (132) residents. Findings include: During a record review of employee files for the dietary department a failure to provide a Georgia Crime Information Center (GCIC) background check was identified related to the Dietary Manager, hired on 10/19/17. The Dietary Manager had federal and county background screening. A review of facility policy titled Georgia Credentialing Checklist dated 12/27/17 revealed a Georgia Statewide Consent was required to be scanned and uploaded for each employee. An interview with the Administrator on 4/17/18 at 2:50 pm revealed a computer glitch with the outside vendor had caused the GCIC for the Dietary Manager's back ground screening to be missed. At this time all background check records for any new hires during the month of (MONTH) were requested. A review background checks for the eighteen employees hired by the facility during the month of (MONTH) (YEAR), revealed incomplete background checks, missing the GCIC screening, for seven of the eighteen employees. The seven incomplete files included county and federal back ground screening. Review of Grievances, Entity Reported Incidents and Resident Council Minutes for 10/1/2017 through 4/17/18 revealed the names of the seven employees without GCIC screening had not been mentioned. An interview on 4/17/18 at 4:30 p.m. with the Administrator revealed eighteen staff were hired in October. The company that is used to provide background checks had a computer glitch in October. The absence of a background GCIC had been discovered by the facility for the Dietary Manager and the background check company had been instructed to check for others. No one at the facility followed up on this and seven staff of the eighteen hired in (MONTH) did not hav… | 2020-09-01 |
| 180 | 180 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2017-05-14 | 252 | D | 1 | 0 | S6LJ11 | > Based on observations and interviews, it was determined that the facility failed to provide a resident environment that was free from offensive odors in two of three floors. This failure resulted in no actual harm with the potential for minimal harm. Findings include: Observations conducted during the initial tour on 5/11/2017 between 3:15 p.m. and 4:30 p.m. on all three resident floors revealed strong urine odors around rooms 301 through 304 and fecal and urine odors around rooms 427 through 430. Observations conducted of resident rooms and bathrooms on 5/12/2017 between 9:30 a.m. and 12:30 p.m. revealed the following: In the bathroom of room 318 the toilet was found to be off center on the floor and old chaulk subssstance was not around the base but in an area where the toilet base originally was located. Chaulk had been applied to the toilet base where it currently sits in an off center position and the old chaulk had never been removed. There were yellow stains around the base and a strong urine odor. In room 328 soiled bed pads were noted in the trash can with a distinct urine odor coming from them. In the bathroom of room 418 odors were noted with a brown substance around the edges of the toilet. In the bathroom of room 417 a brown smelly substance was noted around the toilet seat. A brown residue was observed in the sink in the room. In the bathroom of room 430 a brown substance was noted around the toilet seat with a distinct odor of feces. Interview with family member of R#1 on 5/13/2017 at 11:30a.m. revealed that the bathroom of R#1 is smelly and rarely cleaned and there are odors all over the facility. She stated that she was very unhappy with the lack of cleaning in the room of R#1. Interview with R#3 on 5/13/2017 at 10:45a.m. revealed the staff don't clean the bathrooms the way they should or empty the trash cans as often as they should. Interview with R#4 on 5/14/2017 at 9:05 a.m. revealed that the staff don't clean the bathrooms very well and leave smelly items in the bathrooms and trash cans. Ob… | 2020-09-01 |
| 181 | 181 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2017-05-14 | 253 | E | 1 | 0 | S6LJ11 | > Based on general observations of the facility and interviews, it was determined that the facility had failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on two (2) of three (3) floors. Findings include: Observations conducted of resident rooms and bathrooms on 5/12/2017 between 9:30 a.m. and 12:30 p.m. revealed the following: In the bathroom of room 318 the toilet was found to be off center on the floor and old chaulk subssstance was not around the base but in an area where the toilet base originally was located. Chaulk had been applied to the toilet base where it currently sits in an off center position and the old chaulk had never been removed. There were yellow stains around the base and a strong urine odor. In the bathroom of room 321 an uncovered bed pan was noted on the floor. In the bathroom of room 322 a urine specimen collection pan was noted on the floor uncovered with a brown substance around the edges. In the bathroom of room 325 an uncovered urinal was noted on the toilet tank. The toilet was noted to be running with a broken handle noted. In the bathroom of room 324 an uncovered urinal was noted on the toilet tank. In room 328 soiled bed pads were noted in the trash can with a distinct urine odor coming from them. In the bathroom of room 418 odors were noted with a brown substance around the edges of the toilet. In the bathroom of room 417 a brown smelly substance was noted around the toilet seat. A brown residue was observed in the sink in the room. In the bathroom of room 422 an uncovered specimen collection device was noted on the floor. In the bathroom of room 421 a bedpan was noted on the floor next to the toilet with dirty tissue in it. In the bathroom of room 426 a bedpan was noted on the floor with a urinal in it and both were uncovered. Another uncovered urinal with a small amount of urine was noted on the other side of the toilet on the floor. Yet another urinal was noted uncovered on the toilet tank with a small am… | 2020-09-01 |
| 182 | 182 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2017-05-14 | 441 | D | 1 | 0 | S6LJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations the facility failed to store bed pans and urinals in a sanitary manner on two (2) of three (3) floors. The facility census was one hundred thirty six (136) residents. Findings include: Observations conducted of resident rooms and bathrooms on 5/12/2017 between 9:30 a.m. and 12:30 p.m. revealed the following: In the bathroom of room [ROOM NUMBER] the toilet was found to be off center on the floor and old chaulk subssstance was not around the base but in an area where the toilet base originally was located. Chaulk had been applied to the toilet base where it currently sits in an off center position and the old chaulk had never been removed. There were yellow stains around the base and a strong urine odor. In the bathroom of room [ROOM NUMBER] an uncovered bed pan was noted on the floor. In the bathroom of room [ROOM NUMBER] a urine specimen collection pan was noted on the floor uncovered with a brown substance around the edges. In the bathroom of room [ROOM NUMBER] an uncovered urinal was noted on the toilet tank. In the bathroom of room [ROOM NUMBER] an uncovered urinal was noted on the toilet tank. In the bathroom of room [ROOM NUMBER] an uncovered specimen collection device was noted on the floor. In the bathroom of room [ROOM NUMBER] a bedpan was noted on the floor next to the toilet with dirty tissue in it. In the bathroom of room [ROOM NUMBER] a bedpan was noted on the floor with a urinal in it and both were uncovered. Another uncovered urinal with a small amount of urine was noted on the other side of the toilet on the floor. Yet another urinal was noted uncovered on the toilet tank with a small amount of what appeared to be urine in the bottom. In the bathroom of room [ROOM NUMBER] an uncovered urinal was noted on the toilet tank with what appeared to be a small amount of urine in the bottom. Observation on 5/14/2017 at 9:00 a.m. revealed house keeping staff actively cleaning rooms and bathrooms that were reporte… | 2020-09-01 |
| 183 | 183 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2018-05-17 | 641 | D | 0 | 1 | PJ0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, it was determined the facility failed to ensure Minimum Data Sheets (MDS) assessments correctly identified a resident with a urinary tract infection [MEDICAL CONDITION] for one resident (R) #80 of 32 sampled residents whose MDSs were reviewed. Findings include: Medical record review revealed R#80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], documented the resident's cognition was moderately impaired, required extensive assistance with bed mobility, transferring between surfaces, dressing, eating and toilet use. The assessment also documented the resident was frequently incontinent of bowel and bladder. The MDS also assessed the resident had a UTI within the past 30 days. The resident's laboratory reports and medication administration records were reviewed and did not contain documentation that the resident was diagnosed and /or treated for [REDACTED]. Review of R#80's care plan, dated 4/25/18, documented: Problem: Resident has a potential for complications associated with incontinence of bowel and/or bladder. Approach: Monitor need for / schedule appropriate diagnostic procedures. Monitor and report any changes in bladder status to nurse such as low urine output, foul smelling urine, discolored urine, pain, bladder distention, frequency, urgency and fever. Report changes in bladder status to physician . On 5/14/18 at 8:30 a.m., during the initial tour the resident was observed sitting in her wheelchair at the nurses' station. On 5/14/18 at 3:20 p.m., the resident was observed sitting in her wheelchair at the nurses' station On 5/14/18 at 3:40 p.m., the resident was observed being toileted by the staff. The staff reported the resident would tell them when she need to go to the rest room. The resident's brief was dry at that time. On 5/15/18 at 12:10 p.m., the MDS Nurse #JJ was interviewed in th… | 2020-09-01 |
| 184 | 184 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2018-05-17 | 679 | D | 0 | 1 | PJ0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review interview and review of facility policy, the facility failed to provide activities to meet personal preferences for one Resident (R) #354. The sample size at the time of the survey process was 32. The findings include: R #354 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R #354's most recent Minimum Data Set (MDS), an admission assessment with an Assessment Reference Date of 5/9/18, documented R #354 as being cognitively severely impaired to make decisions regarding activities of daily living. In Section F, Preferences for Customary Routine and Activities, R #354 is coded as responding that activities such as having books, newspapers and magazines to read; listening to music; being around animals; doing things with groups of people; going outside for fresh air and participating in religious services were very important to him. A review of R #354's facility document titled Initial Quality of Life Lifestyle Review dated 5/8/18 and completed by the Activities Director, EE, documented the following activities enjoyed by R #354: Animals Art Children Crafts/[NAME]working Current Events/Politics Exercise Fishing/Hunting/Camping Games/Cards Happy Hour Inspirational/Religious Services Meditation Music Puzzles Reading Scrapbooking Shopping/Outings/Traveling Social Events Sports Tv News Theatre/Dance Writing Yoga R #354 was observed on the following dates and times: 5/14/18 at 9:15 a.m. - R #354 was observed seated in his wheelchair in his room. No reading materials observed in his room. No music playing and the TV was not on. There were no activities observed to be in progress at this time. 5/15/18 at 10:00 a.m. - R #354 was observed seated in his wheelchair in his room. The Resident was observed to be playing with his gastric tube and there was no music and the TV was not on. There were no activities observed to be in progress at this time. 5/16/18 at 12:30 p.m. - R #354 was observed … | 2020-09-01 |
| 185 | 185 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-07-10 | 609 | D | 1 | 0 | UF4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to ensure an injury of unknown origin was reported to the State Agency in a timely manner for one residents (R) (#14) of seven residents reviewed for reporting requirements. Findings include: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIM's) score of 0 which indicates severe cognitive impairment. Section G0400 Functional Limitations in Range of Motion indicated no impairment of the upper extremities. The resident requires extensive assistance with bed mobility and transfers. Review of the Electronic Medical Record (EMR) dated 5/13/19 revealed the resident complained of pain in the right arm/shoulder x-ray revealed a right clavicle fracture with severe [MEDICAL CONDITION] changes and bony demineralization and [MEDICAL CONDITION]. The document titled SHC Medial Partners dated 5/13/19 by the Nurse Practitioner (NP) noted: Chief Complaint/History of Present Illness; shoulder pain, patient noted with acute onset right shoulder pain today. Unable to lift or move arm without pain. X-ray done showing overlapping acute distal clavicular fracture. Family notified, and request ER (emergency room ) transfer. Mechanism of injury- unknown. Plan: X-ray reviewed: Bony demineralization. Slightly angulated, slightly overlapping acute distal clavicular fracture. Severe [MEDICAL CONDITION] changes at the glenohumeral joint. Will transfer to ER for further evaluation. No reported hx (history) of recent fall or trauma to right arm. Follow up as needed upon return to the facility. Review of a mobile radiology report dated 5/13/19 at 3:04 p.m. revealed bony demineralization. Slightly angulated, slightly overlapping acute distal clavicular fracture. Severe [MEDICAL CONDITION] changes at the glenohumeral joint. Review of the SNF/NF to Hosp… | 2020-09-01 |
| 186 | 186 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-07-10 | 656 | J | 1 | 0 | UF4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of facility policy titled Comprehensive Care Plans and staff interviews, the facility failed to develop a person-centered comprehensive care plan with interventions that specified the need for monitoring for a resident with side rails, assessment of the need for side rails, alternatives to side rails that had been attempted, education of the family member requesting the side rails, and the increased risk of using an air mattress with side rails for one resident (R) (#23) of three residents reviewed for the use of side rails with air mattresses. On 7/8/19 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Social Service Director were informed of the Immediate Jeopardy (IJ) on 7/8/19 at 12:45 p.m. The noncompliance related to the IJ identified to have existed on 4/1/19 when R#23 was found with her head and neck entrapped between a side rail and air mattress. The IJ is outlined as follows: 1. R#23 had an order for [REDACTED]. The manufacture's recommendation per the facility was not to use side rails with an air mattress. The side rails were not removed until 4/8/19 after the family agreed to have them removed. The resident remained in the facility with side rails in place after sustaining another fall on 5/28/19. The air mattress was removed instead of removing the side rails. 2. Record review revealed that on 2/3/19, R#24's leg was caught in the side rail. X-rays were completed at the time of the incident and revealed no injuries. The Physician discontinued the side rails as an enabler on 4/11/19. An assessment was completed on 4/16/19 and revealed the residents side rails were not indicated and gave no reason for use. However, R#24 was observed to still have half side rails in use and an air mattress in place on 6/25/19 and 6/27/19. The IJ was… | 2020-09-01 |
| 187 | 187 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-07-10 | 700 | J | 1 | 0 | UF4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, facility and hospital clinical record review, review of the facility policy titled Bed Safety, and review of the Food and Drug Administration (FDA) guidelines titled Recommendations for Health Care Providers about Bed Rails, the facility failed to provide an environment free from the risk of entrapment within the side rail or between the side rail and air mattress for two residents (R) (#23 and #24) of three residents reviewed for the use of side rails with air mattresses. On 7/8/19 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Social Service Director were informed of the Immediate Jeopardy (IJ) on 7/8/19 at 12:45 p.m. The noncompliance related to the IJ identified to have existed on 4/1/19 when R#23 was found with her head and neck entrapped between a side rail and air mattress. The IJ is outlined as follows: 1. R#23 had an order for [REDACTED]. The manufacture's recommendation per the facility was not to use side rails with an air mattress. The side rails were not removed until 4/8/19 after the family agreed to have them removed. The resident remained in the facility with side rails in place after sustaining another fall on 5/28/19. The air mattress was removed instead of removing the side rails. 2. Record review revealed that on 2/3/19, R#24's leg was caught in the side rail. X-rays were completed at the time of the incident and revealed no injuries. The Physician discontinued the side rails as an enabler on 4/11/19. An assessment was completed on 4/16/19 and revealed the residents side rails were not indicated and gave no reason for use. However, R#24 was observed to still have half side rails in use and an air mattress in place on 6/25/19 and 6/27/19. The IJ was related to the facility's noncompliance with the program requir… | 2020-09-01 |
| 188 | 188 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-07-10 | 842 | D | 1 | 0 | UF4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility policy titled Neurological Evaluation/Monitoring, and staff interviews, the facility failed to document neurological assessments related to an unwitnessed fall for two residents (R) (#27 and #31) of four residents reviewed for falls. Findings include: Review of the facility policy titled Neurological Evaluation/Monitoring revised 11/12/18 revealed neuro (neurological) checks will be performed using the Neurological Evaluation Flow Sheet for a full 72 hours and placed in the medical record. The neuro checks will be performed every 15 minutes x 4 check, every 30 minutes x 4 check and every 1-hour time x 4 followed by 72 hours q (every) shift assessment and documentation. 1. Review of the face sheet revealed R#27 was admitted to the facility on [DATE] for rehabilitation following a stroke. Her admitting [DIAGNOSES REDACTED]. Review of the SBAR (Situation Background Assessment and Response) Communication Form dated 6/25/19 at 12:05 a.m. revealed R#27 had a fall on 6/24/19 at 5:00 p.m. when attempting to transfer unassisted. The resident was experiencing slurred speech and left facial drooping. The resident was sent to the emergency room (ER) for evaluation. There was no documented evidence of post fall neurological assessments. Review of the hospital records dated 6/25/19 revealed resident arrived at the ER with clear speech. Resident stated she requested pain medication along with her night time medications and she thinks that is why she had slurred speech. CT and X-ray reports of left side of body were negative. Physician requested MRI for further evaluation, but resident refused. 2. Review of the clinical record revealed R#31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed R#31 had an unwitnessed fall without injury on 6/23/19 at 7:35 p.m. There was no evidence of documentation of post fall neurological assessments. Interview with … | 2020-09-01 |
| 189 | 189 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2017-07-20 | 371 | F | 0 | 1 | XEII11 | Based on observation, staff interviews, and review of facility policy, it was determined the facility failed to ensure one of three resident refrigerators was maintained at a temperature of 41 degrees Fahrenheit (F) or below. In addition, the facility failed to ensure that resident food and drink items were labeled with a resident's name and dated on two of three resident nourishment refrigerators. There was a total of 113 residents receiving oral feedings. The census was 132 residents on the first day of the survey. Findings include: A review of the policy titled Record of Refrigeration Temperatures revised 7/1/14 revealed the following under the sub-section titled PR[NAME]EDURE: 4: The refrigerator must be clean and temperatures must be 41 degrees F or less. 5. Temperatures greater than these areas are to be reported to the Dietary Manager (DM) immediately. 8. Nursing unit refrigerators and freezers and any other refrigerator/freezers having resident food stored in it must be clean, have Use By Dates on food product. 1. On 7/19/17 at 9:38 a.m. an observation was conducted of the fourth-floor resident nourishment refrigerator. The Unit Manager, Registered Nurse (RN) AA was present. There were two thermometers in the refrigerator and both read 50 degrees F. RN AA confirmed the temperatures of 50 degrees F. On 7/19/17 at 9:54 a.m. an observation was conducted of the third-floor resident nourishment refrigerator with the Unit Manager Licensed Practical Nurse (LPN) BB present. There was a sign on the outside of the refrigerator door that read: Pantry Refrigerators are for resident food only. Please be sure that any items placed inside of fridge are labeled with a name, room number, and a date. (Any unlabeled items will be discarded.) The observation revealed the following - An opened 32-ounce container of thickened liquids. There was no date to indicate when the item was opened. LPN BB confirmed that the container contained thickened liquids for residents, and that it was not dated. - A Kentucky Fried Chicken box da… | 2020-09-01 |
| 190 | 190 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-08-01 | 636 | D | 0 | 1 | FRPF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) comprehensive assessment for one resident (R) (#2) of 44 sampled residents. Findings include: Resident was admitted to the facility on [DATE]. Record review for R#6 revealed an MDS Annual assessment dated [DATE] and a Quarterly assessment dated [DATE]. No other comprehensive assessments were documented for R#6. The Annual Assessment was scheduled on 5/30/19 but was not completed. Review of an alphabetical resident census revealed R#6 was currently a resident in the facility. During an interview on 8/1/19 at 1:45 p.m. MDS Coordinator Licensed Practical Nurse JJ revealed that she left in (MONTH) of (YEAR) and assessments were current. She stated when she returned in (MONTH) of 2019, the assessments were behind. An assessment was initiated on 8/1/19 and was in progress. | 2020-09-01 |
| 191 | 191 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-08-01 | 640 | B | 0 | 1 | FRPF11 | Based on record review and staff interview, the facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was transmitted within 14 days of discharge to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for four of seven discharged residents (R) reviewed (#1, #3, #4, and #6). Findings include: 1. Review of the discharge record revealed R#1 was discharged from the facility on 3/22/19. Review of R#1's MDS list revealed there was an Admission assessment completed on 2/15/19, and the MDS discharge assessment was not completed until 6/12/19. 2. Review of the discharge record revealed R#3 was discharged from the facility on 2/20/19. Review of R#3's MDS list revealed there was an Admission assessment completed on 2/13/19, but there was no MDS discharge assessment listed. 3. Review of the discharge record revealed R#4 was discharged from the facility on 4/15/19. Review of R#4's MDS list revealed there was an Admission assessment completed on 2/7/19, but there was no MDS discharge assessment listed. 4. Review of the discharge record revealed R#6 was discharged from the facility on 4/26/19. Review of R#6's MDS list revealed there was an Admission assessment completed on 3/23/19, but there was no MDS discharge assessment listed. During an interview on 8/1/19 at 1:45 p.m. MDS Coordinator Licensed Practical Nurse JJ revealed that she left in (MONTH) of (YEAR) and assessments were current. She stated when she returned in (MONTH) of 2019, the assessments were behind. The four late discharge assessments were completed on 8/1/19. | 2020-09-01 |
| 192 | 192 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-08-01 | 803 | D | 0 | 1 | FRPF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, residents and staff interviews, the facility failed to follow their menu of choice for two residents (R) (#113 and R#322) of 44 sampled residents. Findings include: 1. Review of the clinical record revealed R#113 was admitted to the facility on [DATE]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment on Section C. 2.Review of the clinical record revealed R#322 was admitted to the facility on [DATE]. MDS was not complete but baseline care plan was done and noted R#322 was alert and oriented to person, place and things. During a dining observation during lunch on 7/29/19 at 1:00 p.m., R#113 and R#322 were served baby lima beans, rice, tilapia and bread rolls. Both residents requested green beans as printed on the meal ticket. Dietary Aide FF stated they did not have any green beans. R#113 and R#322 left and went to their rooms. During an interview on 7/29/19 at 1:38 p.m., R#322 also stated the facility has limited items. She stated the facility always changes the menu and does not change the meal ticket or inform the residents. Interview on 7/29/19 at 1:45 p.m., with Dietary Aide FF revealed the menu was changed and she did not know why the meal tickets were not updated. Dietary staff were supposed to notify the residents, but she had no idea why it was not done. During an interview on 7/29/19 at 2:00 p.m., Dietary Manager stated she did change the menu, but forgot to change the meals tickets and notify the residents. | 2020-09-01 |
| 193 | 193 | SIGNATURE HEALTHCARE AT TOWER ROAD | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2019-01-31 | 561 | D | 0 | 1 | TKWX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (R#11) out of 44 sampled residents was provided with a choice regarding showers/baths. R#11 preferred showers; she received bed baths. Findings include: R#11 was admitted to the facility on [DATE]. Review of a Physician's Note dated 11/9/18 revealed the resident was [AGE] years old. The resident's medical history and [DIAGNOSES REDACTED]. Surgical history included a [MEDICAL CONDITION] (surgically created hole in the windpipe that provided an alternative airway for breathing). The Physician's Note indicated, The patient is oriented to person, place, and time. Speech is fluent and words are clear. Thought processes are coherent, insight is good. There are no obsessive, compulsive, phobic or delusional thoughts; there are no illusions or hallucinations .recent and remote memory intact. The patient's fund of knowledge: awareness of current events and past history is appropriate for age. The patient's higher cognitive functions are intact . Review of the Annual Minimum Data Set ((MDS) dated [DATE] under the section for Customary Routines and Activities revealed it was very important for the resident to be able to choose between a bed bath, sponge bath, tub bath or shower. Review of the Quarterly MDS dated [DATE] Cognitive Patterns section revealed R#11 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of a total of 15. The Behavior and Mood sections revealed no behavioral or mood concerns. The Hearing, Speech, and Vision section revealed the resident was unable to speak. The Functional Status section revealed the resident was totally dependent on staff for transfers, locomotion on and off the unit, dressing, toilet use, hygiene, and baths. The resident was impaired in range of motion on one side in both her upper and lower extremities. The care plan dated 8/21/18 to address the resident's impairment in activities of… | 2020-09-01 |
| 194 | 194 | SIGNATURE HEALTHCARE AT TOWER ROAD | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2019-01-31 | 578 | D | 0 | 1 | TKWX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff and family interviews the facility failed to properly execute the advance directive wishes for one Resident (R), #18 of three residents reviewed for advance directives. Findings include: On [DATE] review of the medical record for R#18 revealed the front page had a large red sticker with the letters DNR (do not resuscitate). In the medical record behind the tab labeled Advance Directives were documents related to the code status and wishes of R#18. The first page was a document titled Specialty Care of[NAME]Advance Directive Checklist. This document was signed by R#18 on [DATE] indicating he wished to have the code status of Do Not Resuscitate. The second page is a facility document titled, DNR Face Sheet. This document is checked for R#18 to have the code status of DNR. Additional documents in this section of the medical record are the POLST (Physician order [REDACTED]. In Section A of the POLST the code status is marked to Allow Natural Death (AND)-Do Not Attempt Resuscitation. The POLST is signed by the physician on [DATE] at 1:00 p.m. A fourth document titled Official Code of Georgia Annotated Title 31. Health Chapter 39, Cardiopulmonary Resuscitation Section A states DO NOT RESUSCITATE and is signed by the attending physician. Section B of the same document also states, DO NOT RESUSCITATE (name of R#18) and is dated [DATE]. Review of the care plan for R#18 revealed there is a care plan in place with the identified concern as being a code status of DNR with Advanced Directives on record. The goal is listed as if the resident's heart stops, or if they stop breathing, CPR (cardiopulmonary resuscitation) will not be initiated in honor with their DNR wishes ongoing through next review date. Identified interventions include: 1. Discuss Advanced Directives with the resident and/or appointed health care representative. 2. Staff to follow Advance Directive for DO NOT RESUSCITATE. 3. Refer to Social Service… | 2020-09-01 |
| 195 | 195 | SIGNATURE HEALTHCARE AT TOWER ROAD | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2019-01-31 | 656 | G | 0 | 1 | TKWX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to implement a comprehensive person-centered care plan for falls for one resident (R#4). Failure to follow the care plan contributed to the resident sustaining harm. The sample size was 44 residents. Findings include: Record review of the policy and procedure titled Comprehensive Care Plans dated 9/21/16 revealed a person-centered comprehensive care plan meets the resident's medical, nursing, mental needs. The care plan will include how the facility will assist the resident to meet their needs, goals, and preferences. Review of the Fall Risk Evaluation dated 8/24/18 revealed the facility had assessed the resident as a 13 which indicated the resident was at risk for falls. Review of the Significant Change in Status Minimum Data Set (MDS) signed and dated 8/7/18 revealed the facility admitted R#4 with [DIAGNOSES REDACTED]. Continued review of the MDS revealed the resident to sometimes make self-understood and usually understands others, moderately impaired vision, short-term and long-term memory problems. The facility assessed the resident not to have displayed behaviors. Continued review of the MDS revealed R#4 required extensive assistance of two staff with bed mobility and personal hygiene, extensive assistance of one staff for dressing, toilet use, and was totally dependent on one staff for bathing. The resident was always incontinent of bowel and bladder. Review of the Care Area Assessment (CAA) Summary revealed the resident had triggered for falls. Review of R#4's care plan dated 8/7/18 revealed, Problem- resident is at risk for fall as he is dependent on staff for all are related to impaired mobility, [MEDICAL CONDITION], feeding tube and dementia. Goal- Resident will not sustain a fall or fall related injury through next review date. Approach- Staff to provide assistance to meet resident's needs for all activities of daily living. Review of the Fall-Fall with Inju… | 2020-09-01 |
| 196 | 196 | SIGNATURE HEALTHCARE AT TOWER ROAD | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2019-01-31 | 684 | D | 0 | 1 | TKWX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, one resident (R), #R156 out of 44 sampled residents failed to be positioned appropriately in bed. This created the potential for discomfort and impaired breathing. Findings include: R#156 was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. Review of the 11/14/18 Quarterly Minimum Data Set (MDS) revealed the resident was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of zero out of 15. The MDS indicated R#156 had no mood or behavior indicators. The MDS indicated the resident required extensive assistance with activities of daily living (ADLs) including bed mobility, transfers, dressing, toilet use and hygiene. The resident was impaired in range of motion (ROM) on one side of the upper extremities and both sides of the lower extremities. The Nurse' Note 1/12/19 revealed the resident was transferred to the hospital on this date for possible feeding tube placement due to the resident not eating or drinking. A feeding tube was not placed in the hospital and the resident was readmitted back to the facility on the same day Review of a Physicians Note dated 1/12/19 revealed the resident was a [AGE] year old female who went to the hospital due to increased fatigue, dysphasia and poor intake. The note indicated the resident had a urinary tract infection, was unable to express her needs, was incontinent of bowel and bladder, and needed total care with ADLs. The Physician recommended hospice/comfort care. Review of a Nurse's Note dated 1/17/19 revealed the resident was admitted to hospice on this date. The note indicated the resident required maximum to total assistance with activities of daily living that had to be attended to and met by staff. The head of the resident's bed was to be kept elevated 30 to 45 degrees as tolerated and the resident was to be repositioned frequently. Review of the care plan dated 1/23/19 revealed the resident… | 2020-09-01 |
| 197 | 197 | SIGNATURE HEALTHCARE AT TOWER ROAD | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2019-01-31 | 689 | G | 0 | 1 | TKWX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and policy review, the facility failed to ensure each resident received adequate supervision to prevent accidents. Harm was identified when one Resident (R), #4, sustained a [MEDICAL CONDITION] which required sutures after they fell out of the bed during a bath, unsupervised by staff. The sample size was 44 residents. Review of the policy titled, Fall Prevention dated 6/1/15 revealed it was the intent of the facility to provide residents with assistance and supervision to minimize the risk of falls and fall related injuries. Review of the Fall Risk Evaluation dated 8/24/18 revealed the facility had assessed the resident as a 13 which indicated the resident was at risk for falls. Review of the Significant Change in Status Minimum Data Set (MDS) signed and dated 8/7/18 revealed the facility admitted R#4 with [DIAGNOSES REDACTED]. Continued review of the MDS revealed the resident to sometimes make self-understood and usually understands others, moderately impaired vision, short-term and long-term memory problems. The facility assessed the resident not to have displayed behaviors. Continued review of the MDS revealed R#4 required extensive assistance of two staff with bed mobility and personal hygiene, extensive assistance of one staff for dressing, toilet use, and was totally dependent on one staff for bathing. The resident was always incontinent of bowel and bladder. Review of the Care Area Assessment (CAA) Summary revealed the resident had triggered for falls. Review of the Fall-Fall with Injury-Major Investigation dated 9/24/18 at 10:50 a.m. stated, Certified Nursing Assistant (CNA) OO was giving R#4 a bed bath, turned away to the closet to retrieve clothes and towels from the chair when the CNA heard the resident scream, patient noted lying on his right side on the floor beside the resident's bed. Small amount of bright red blood noted draining from the resident's right forehead, hematoma noted. Continued r… | 2020-09-01 |
| 198 | 198 | SIGNATURE HEALTHCARE AT TOWER ROAD | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2019-01-31 | 880 | D | 0 | 1 | TKWX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of Infection Control Reports and the policy titled [MEDICAL CONDITION] it was determined that the facility failed to ensure infection control procedures were followed to prevent the spread of infection for one Resident (R#106) with a [DIAGNOSES REDACTED]. Findings include: Review of the facility policy titled [MEDICAL CONDITION] revised in 2014 indicated preventive measures would be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions would be taken while caring for residents with [MEDICAL CONDITION] to prevent transmission. The policy documented in pertinent part, reservoirs for [MEDICAL CONDITION] included infected people and surfaces. The policy indicated spores could persist on resident care items and surfaces for several months and were resistant to common cleaning and disinfection methods. Steps towards prevention and early intervention included increasing awareness of risk factors, frequent hand washing with soap and water, wearing gloves, disinfectant of items with a disinfecting agent recommended for [MEDICAL CONDITIONS], household bleach or an EPA (Environmental Protection Agency) registered germicidal agent effective against [MEDICAL CONDITION]. The policy directed staff to wear gloves when caring for residents, washing hands with soap and water upon exiting the room of a resident and strict adherence to hand hygiene. The policy indicated contact isolation gloves and a gown must be worn by staff. Personal protective equipment (PPE) was to be utilized by all staff and visitors. The policy indicated for disposing of used PPE, staff where to place the dirty PPE in the red biohazard bags in the resident's room. PPE should be removed right away if it got soaked with blood or other body fluids and staff were to make sure the bags were not overfilled. The monthly Quality Assurance Performance Improvement (QAPI) infection Control Reports were reviewed for… | 2020-09-01 |
| 199 | 199 | SIGNATURE HEALTHCARE AT TOWER ROAD | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2017-02-03 | 164 | D | 0 | 1 | 4LIP11 | Based on observation, record review, interview, and review of facility documents it was determined the facility failed to ensure privacy for two sampled residents while providing incontinent care and administering medications from a total of 24 sampled residents. (Residents #233 and #276) resulting in potential for visitors and staff to observe care being provide to the residents. The findings include: A review of the facility's undated document titled Georgia Resident Handbook and Admissions section 290-5-35-.18 Residents' Rights (page #29) documents . (f) Each resident shall be treated with respect and be given privacy in the provision of personal care. Each resident shall be accorded privacy and freedom for the use of the bathroom at all hours. 1. During an observation on 2/1/17 at 8:45a.m. R #233 informed the surveyor that she was incontinent twice since 7:00 a.m. and still had not been changed. At 9:30a.m., a request was made for the assigned Certified Nursing Assistant (CNA) to check the resident. CNA OO entered the private room and closed the door however failed to close the room's window blinds. The resident's room window faces the side parking (utilized by staff and visitors). From the resident's window you can observe people and cars passing on the street. To the right of the resident's window outside was a table with bench seats. CNA OO proceeded to undress the resident without informing the resident of what she was doing, R#233 was incontinent of urine and stool. R #233's genital area was exposed and the window blinds in the room remained opened An additional observation 15 minutes later revealed the CNA had completed incontinence care for R#233 and was redressing the resident with the windows blinds still open. A review of the resident's incontinence care plan dated 2/13/16, revealed as an intervention the facility staff would maintain privacy and dignity when providing incontinence care after each episode. An interview with CNA OO on 2/1/17 at 9:53 a.m. concerning providing privacy for R#233 during … | 2020-09-01 |
| 200 | 200 | SIGNATURE HEALTHCARE AT TOWER ROAD | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2017-02-03 | 280 | D | 0 | 1 | 4LIP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to revise the care plan to reflect the appropriate use of hand orthotic splint for one resident (R#110) and notification of changes in resident care for one resident (R#72) from a sampled 24 residents. The findings include: 1. Record review for R #110 revealed according to the quarterly Minimum Data Set ((MDS) dated [DATE]the resident was assessed as being cognitively impaired and was totally dependent on staff for activities of daily and the resident had limited range of motion of upper and lower extremities. A review of the Occupational Therapy Discharge Summary dated 11/28/16, indicated the caregiver and restorative staff instructed and educated on in the wear and care of right elbow hand wrist orthotic device. Resident to wear orthotic device to improve alignment of right elbow and right hand it is recommend to wear the device two hours on and two hours off. A review of R #110's Restorative Range of Motion (passive) interdisciplinary care plan dated 8/20/16 with a revision date of 11/20/16 revealed it was documented the resident had actual contractures to the hand; the only intervention added on 11/20/16 was a splint to the left hand. The intervention identified the wrong hand but also failed to identify the frequency and the duration of time the splint was to be in place. Interview with Assistant Director of Nursing (ADON) DD on 2/2/17 at 9:10 a.m. revealed R # 110 is supposed to wear a splint during the dayshift for two hours at a time. Reviewed the restorative care plan and was not aware the care plan was not revised to reflect the splint on the resident's right hand and the frequency/duration of the orthotic splint device. The care plan should have been revised in the care plan meeting but all the nurses have ability to revise the resident's care plans as needed and agreed this resident care plan should have been revised. Cross refer to F318 [DIAGNOSES REDACTED]. Review of the q… | 2020-09-01 |
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CREATE TABLE [cms_GA] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );