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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10555 | 10555 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2009-07-22 | 371 | E | LY2811 | Based on observations , staff interviews, and the facility inservice records, the facility failed to ensure that dietary staff wore the proper facial hair restraint. Findings include: Observation on 7/20/09 at 1:00 pm and 1:45 pm, revealed a male dietary staff walking around in the kitchen area with the beard restraint hanging around his neck, under his chin. He was observed standing over food near the serving line area, talking to staff. During an interview with Dietary Staff "CC" on 7/20/09 at 1:47 pm, it was revealed that the dietary male staff should had been wearing a hair restraint.. Interview on 7/20/09 at 2:50 pm with the Registered Dietian "DD" revealed that the dietary staff should be wearing beard restraints over facial areas. A review of the Dietary Monthly Inservice Record held on 5/26/09 revealed that all hair must be covered including beard and mustaches with hair restraints. Further review revealed documented evidence that the dietary staff member had attended this particular inservice. | 2014-04-01 | ||
| 10554 | 10554 | BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER | 115531 | 1000 BRIARCLIFF ROAD | ATLANTA | GA | 30306 | 2010-04-30 | 514 | D | I73X11 | Based on record review and staff interview the facility failed to ensure that the clinical record contained sufficient information including a Quarterly Minimum Data Set (MDS) assessment for one (1) resident (#15) of the sampled thirty-five (35) residents. Findings include: Review of the clinical record for resident #15, revealed that a Comprehensive MDS was completed on 12/11/2009. There was no evidence in the clinical record that a required Quarterly MDS due in March 2010 had been completed. Interview on 4/29/2010 at 1:20 p.m. with the MDS/Care Plan Nurse revealed that they were short of help in the MDS office and had a temporary nurse helping her. She acknowledged that the resident should have been assessed in March but it had not been done. Review during the Quality Assurance Process revealed a Quarterly MDS had been completed on 3/10/10 but there was no evidence in the clinical record of the assessment and the MDS/Care Plan Nurse was not aware that an assessment had been completed. | 2014-04-01 | ||
| 10553 | 10553 | BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER | 115531 | 1000 BRIARCLIFF ROAD | ATLANTA | GA | 30306 | 2010-04-30 | 278 | D | I73X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of one (1) resident (#15) of the sampled thirty-five (35) residents. Findings include: Review of the clinical record for resident #15, revealed a Comprehensive Minimum Data Set (MDS) was completed on 12/11/2009, which included a weight of one-hundred-ninety-six (196) pounds. Interview on 4/29/2010 at 1:20 p.m. with the MDS/Care Plan Nurse revealed that she was not familiar with this resident . She stated that they were short of help in the MDS office and had a temporary nurse helping her. Continued interview revealed that the resident had weight loss that was not identified. Review during the Quality Assurance Process revealed a Quarterly MDS had been completed on 3/10/10.. Review of the Quarterly MDS, dated [DATE] revealed, that resident #15, weighed 179 pounds. Continued review of the Quarterly MDS assessment, (Section "K", question number 3) revealed, that the weight status was coded incorrectly indicating that there had been no change in the weight of the resident. | 2014-04-01 | ||
| 10552 | 10552 | BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER | 115531 | 1000 BRIARCLIFF ROAD | ATLANTA | GA | 30306 | 2010-04-30 | 520 | D | I73X11 | Based on facility record review and staff interview, the facility failed to conduct the Quality Assurance Program with the required staff for three (3) of four (4) quarters. Findings include: Review of the Quality Assurance (QA) minutes, attendance sign in sheets for the last calendar year revealed that the Medical Director had attended only two (2) of the quarterly meetings and that one (1) of the quarterly meetings had been attended by only four (4) of the five (5) required staff members.. Interview on 04/30/10 at 1:30 p.m., with the Administrator, revealed that at a minimum, the Director of Nursing, Assistant Director of Nursing, Medical Director and the Administrator were in attendance at most of the Quarterly Meetings meetings throughout the year. | 2014-04-01 | ||
| 10551 | 10551 | BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER | 115531 | 1000 BRIARCLIFF ROAD | ATLANTA | GA | 30306 | 2010-04-30 | 157 | D | I73X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that the physician was notified of a change in condition related to weight loss for one (1) resident (#15) of the sampled thirty-five (35) residents. Findings include: Review of the clinical record weight history for resident #15, revealed a twenty-seven (27) pound weight loss since admission on 12/01/2009. Review of the January 2010, physician progress notes [REDACTED]. Interview on 4/30/2010 at 12:30 p.m. with the Nurse Consultant revealed that the physician was not aware of the weight loss until notified on 4/29/10. | 2014-04-01 | ||
| 10550 | 10550 | BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER | 115531 | 1000 BRIARCLIFF ROAD | ATLANTA | GA | 30306 | 2010-04-30 | 325 | D | I73X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that interventions were implemented for a significant weight loss for one (1) resident (#15) of the sampled thirty-five (35) residents. Findings include: Observation on 4/29/2010 at 8:10 a.m. and 12:30 p.m. of the meals for resident #15, revealed the resident was served a regular diet with thin liquids and after set-up by staff was able to feed him/herself with supervision. Review of the clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed an admission weight of one-hundred-ninety-six (196) pounds (lbs) and the resident was seventy-four (74) inches tall. Review of the weight history revealed that on 12/23/09 the resident weighed 186 lbs., which indicated a ten (10) lb. weight loss and/or a five percent (5%) weight loss in two (2) weeks. Continued clinical record review revealed that the Dietary Manager (DM), assessed the significant weight loss on 1/11/2010 and recommended that a nutritional supplement be provided to the resident twice a day. Further review revealed no evidence that a nutritional supplement was ever physician ordered and/or administered to the resident. The resident continued to lose weight, with the last recorded weight dated 4/6/10 at 170 lbs., thus a total weight loss of 26 lbs in four (4) months. Interview on 4/30/2010 at 10:30 a.m. with the DM, revealed that there was no systematic method to assure that nursing or the physician had received recommendations for supplements. Interview on 4/29/2010 at 1:30 p.m. with Licensed Practical Nurse (LPN) "AA", acknowledged that prior to 4/06/10, the resident had not received nutritional supplements. Review of the clinical record revealed that on 4/06/2010 the resident was placed on a Weight Loss Risk Alert Program and Medals, a nutritional supplement, four (4) ounces was to be administered, three (3) times a day and weekl… | 2014-04-01 | ||
| 10549 | 10549 | BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER | 115531 | 1000 BRIARCLIFF ROAD | ATLANTA | GA | 30306 | 2010-04-30 | 280 | D | I73X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to update the plan of care to address weight loss for one (1) resident (#15) of the sampled thirty-five (35) residents. Findings include: Review of the clinical record for resident #15, revealed the resident was re-admitted to the facility on [DATE]. Continue review of the clinical record revealed, a plan of care dated 12/2/09, that addressed the nutritional/hydration status and the potential for weight loss related to risk factors including age and need of assistance. Continued review of the clinical record revealed that the Dietary Manager (DM) had identified a weight loss of five (5) percent (%) or ten (10) pounds in two (2) weeks on 1/11/2010. The DM had recommended a dietary supplement be given twice a day and that the resident be weighed once a week for two (2) weeks. Further review revealed that a Quarterly Minimum Data Set (MDS) was completed on 3/10/10 but there was no evidence that the nutritional status of the resident had been updated to reflect the weight loss. The DM had clearly identified the significant weight loss in January and the weight records revealed a seventeen (17) pound weight loss since admission. | 2014-04-01 | ||
| 10548 | 10548 | BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER | 115531 | 1000 BRIARCLIFF ROAD | ATLANTA | GA | 30306 | 2010-04-30 | 371 | F | I73X11 | Based on observation and staff interview the facility failed to store food under sanitary conditions for all ninety-four (94) residents who consumed food orally. Findings include: Observation on 4/29/2010 at 11:00 a.m. of the dry storage area revealed the following: the lid for the sugar container was cracked and taped together with frayed duct tape; the lid for the thickener container was not on properly leaving a gap open on the top; the cornmeal was stored in a plastic bag in a bin with no lid and a portable compact disc player was on the top of the bin. Continued observation revealed the HVAC system, running the length of the kitchen, was coated in dust and there was dust observed in the grill cover on the front of the system. Interview on 4/29/10 at 11:00 a.m. with the Dietary Manager, revealed that the HVAC system was only used in the kitchen and they tried to keep it clean but were unable to remove the sticky substance and dust off the grill cover. During continued interview, the Dietary Manager acknowledged the food storage concerns. | 2014-04-01 | ||
| 10547 | 10547 | BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER | 115531 | 1000 BRIARCLIFF ROAD | ATLANTA | GA | 30306 | 2010-04-30 | 156 | B | I73X11 | Based on record review and staff interview, it was determined that the facility failed to include all of the required elements of the Medicare Denial notices issued for two (2) of three (3) residents reviewed. Findings include: Review of three (3) Medicare Denial notices that were issued to residents/family members revealed that notices failed to inform the residents of their right for an immediate appeal of the facility's determination and potential liability for payment of non-covered services in order to allow them to make an informed decision. Interview on 04/30/10 at 3:25 p.m. with Social Service Director (SSD), revealed that she is responsible for Medicare Denial Notices, using the Liability Beneficiary (LBN) Notices, Continued interview revealed that she does not issue the "Skilled Nursing Facility Advanced Beneficiary Notice" (CMS ), which informs the resident and/or responsible parties of an estimate of their cost if they decide to remain in the facility once skilled services are no longer needed. | 2014-04-01 | ||
| 10546 | 10546 | BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER | 115531 | 1000 BRIARCLIFF ROAD | ATLANTA | GA | 30306 | 2010-04-30 | 281 | D | I73X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to clarify a physician's order related to wound care and failed to follow the facility program related to weekly weights for two (2) residents (#15 and #235) of the sampled thirty-five (35) residents. Findings include: 1. Review of the clinical record for resident (#235) revealed physician's order dated 4/23/10, for [MEDICATION NAME] ointment to be applied topically every day. Review of the "Treatment Administration Record" (TAR) revealed that [MEDICATION NAME] ointment was being applied topically every day but there was no evidence of where the [MEDICATION NAME] ointment was being applied. Observation on 04/29/10 at 2:39 p.m. of wound care for resident #235, performed by Treatment Nurse "HH" revealed that the nurse applied the [MEDICATION NAME] inside the sacral pressure ulcer, the right buttock pressure ulcer and the left buttock pressure ulcer. Interview on 04/30/10 at 10:03 a.m., with Treatment Nurse "HH", revealed that the [MEDICATION NAME] ointment should not have been applied to the inside of the pressure ulcers but should have been applied on the outside of the pressure ulcer areas. The facility failed to clarify the use of the [MEDICATION NAME] ointment. 2. Review of the clinical record for resident #15 revealed the resident was admitted to the facility on [DATE] with a weight of one-hundred-ninety-six (196) pounds (lbs). Review of the weight history revealed that on 12/23/09 the resident weighed 186 lbs., which was a 10 lb. weight loss and/or a five percent (5%) weight loss in two (2) weeks. Further review revealed that the resident continued to lose weight, with the last recorded weight dated 4/6/10 at 170 lbs., thus a total weight loss of 26 lbs in four (4) months. Continued review of the clinical record revealed that on 4/06/2010 the resident was placed on a Weight Loss Risk Alert Program and Medals, a nutritional supplement, four (4) ounces three (3) times a day, the… | 2014-04-01 | ||
| 10545 | 10545 | BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER | 115531 | 1000 BRIARCLIFF ROAD | ATLANTA | GA | 30306 | 2010-04-30 | 314 | D | I73X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to assess and provide treatments to pressure ulcers for one (1) resident (#235) of the sampled thirty-five (35) residents. Findings include: Review of the clinical record for resident #235, revealed that the resident was admitted to the facility on [DATE] at 12:14 p.m. with [DIAGNOSES REDACTED]. Review of the clinical record revealed no evidence that the pressure ulcers had been assessed by the facility staff, including staging and measuring, until 04/27/10, three days after admission. Review of the pressure ulcer assessment dated [DATE] revealed the following pressure ulcers: on the right buttock a Stage IV, five by three by two centimeter (5x3x2 cm) with tunneling; on the sacrum a Stage IV, 1x1x1 cm with tunneling; on the left heel an unstageable 2x2 cm, black color eschar pressure ulcer and on the right heel an unstageable 3x1 cm black color eschar covered pressure ulcer. Observation 04/29/10 at 2:39 p.m. of the identified pressure ulcer areas revealed the following: two (2) Stage IV pressure ulcers as assessed on 4/27/10 and one (1) Stage II. pressure ulcer to the left buttock that was previously not assessed. Observation and interview on 04/30/10 at 10:03 a.m. with Treatment Nurse "HH" revealed that the small area on the left buttock had not been staged or measured. The Treatment Nurse assessed the smaller area, revealing a 4x2 cm, Stage II pressure sore Review of the clinical record revealed a physician's order dated 4/23/10, for Dakins wet-to-dry dressings daily to the sacral pressure ulcers and [MEDICATION NAME] ointment to be applied topically every day. Review of the "Treatment Administration Record" (TAR) revealed that the sacral pressure ulcer was being treated with Dakins wet-dry dressing twice a day, [MEDICATION NAME] ointment was being applied topically every day but there was no evidence of where the [MEDICATION NAME] ointment was being applied. Observ… | 2014-04-01 | ||
| 10544 | 10544 | NEW HORIZONS LIMESTONE | 115487 | 2020 BEVERLY ROAD NE | GAINESVILLE | GA | 30501 | 2010-09-29 | 371 | E | OSSL11 | Based on observation and staff interview the facility failed to store and serve food under sanitary conditions in "B" Building. This failure was evidenced by storing spoiled and unlabeled meat, and storing cooking, serving and eating utensils that have not been appropriately dried in one (1) of two (2) kitchens. Findings include: Observation of the kitchen on 9/27/10 between 10:30 a.m. to 12:00 p.m. with the Dietary Supervisor and the Patient Food Service Manager revealed the following concerns: The reach-in refrigerator had a clear container dated 9/08/10 that was approximately 1/3 full of sliced cooked meat. The container was not labeled with the type of meat. The meat had several spots of gray discoloration. The Dietary Supervisor acknowledged that the meat was spoiled and should be discarded. Dietary staff wrapping silverware that was still wet 4 of 6 soup bowls were stored wet 3 of 5 smaller soup bowls were stored wet 3 of 6 scoops in a draw were wet 2 of 5 serving utensils were in a draw wet Review of the facility's Nutrition Service Infection Control Guidelines revealed that food prepared and held refrigerated for more than 24 hours should be clearly marked with the date by which it must be served, which must be no more than seven (7) days. | 2014-04-01 | ||
| 10543 | 10543 | NEW HORIZONS LIMESTONE | 115487 | 2020 BEVERLY ROAD NE | GAINESVILLE | GA | 30501 | 2010-09-29 | 312 | D | OSSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to consistently provide oral hygiene for one (1) totally dependent resident ('A') and one (1) resident ('B') who needed limited to extensive assistance with hygiene. Both residents resided in the "B" building. The total sample size was twenty-eight (28) residents. Findings include: 1. On 9/27/10 at 3:07 p.m., resident 'A' stated the staff didn't clean his/her teeth. The resident added that they would ask staff to help brush his/her teeth, but was usually told that they'd be back to do it, but they would never come back. He/she added that the last time they saw a dentist, the dentist said their teeth needed to be brushed every day. Review of the resident's Activities of Daily Living (ADL) care plan developed 7/25/10 noted the resident was dependent for all ADLs including bathing, grooming and hygiene due to [MEDICAL CONDITION] with multiple contractures, and interventions included to provide oral care every shift and as needed. A Dental Treatment/Exam document for resident 'A' dated 4/05/10 noted that the oral hygiene status included heavy plaque and heavy calculus and that oral hygiene needed improving, and recommended that the teeth must be brushed twice a day. The Certified Nursing Assistants' (CNA) ADL Notebook noted that the resident was dependent for teeth/mouth care. 2. On 9/28/10 at 10:45 a.m., resident 'B' stated that the staff only assisted him/her with oral hygiene weekly. They added that they usually had to ask the staff to assist them, because the staff didn't do it routinely. Review of the resident's ADL care plan developed 4/16/10 noted the resident needed limited to extensive assist with ADLs due to [MEDICAL CONDITION], and interventions included to assist with/provide mouth care every shift. On 9/29/10 at 9:00 a.m., the resident was noted to have paralysis of the left arm, and needed a wheelchair for mobility due to an amputation of the righ… | 2014-04-01 | ||
| 10542 | 10542 | NEW HORIZONS LIMESTONE | 115487 | 2020 BEVERLY ROAD NE | GAINESVILLE | GA | 30501 | 2010-09-29 | 279 | D | OSSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that one (1) resident (#3) and One (1) resident (#121) both who resided in "B" Building had a care plan developed of the continuous use of a hypnotic medication (#3) and a care plan based on assessment of positioning needs (#121). Findings include: Review of the current quarterly Minimum Data Set assessment ((MDS) dated [DATE] as well as the annual MDS assessment dated [DATE] recorded resident #3 as receiving a hypnotic medication seven (7) times a week during these assessment periods . Review of the current Physician order [REDACTED]. Review of past four (4) months of Medication Administration Records (June 2010, July 2010, August 2010 and September 2010) documented the resident was administered the medication every night. No care plan had been developed for the hypnotic medication with interventions for possible side effects or for interventions to implement alternate sleep pattern techniques. Interview with the Care Plan/MDS Nurse (staff "BB") on 9/28/10 at 11:20 a.m. revealed she had not done a care plan for the routine use of this resident's hypnotic medication. She usually included hypnotic medication use as part of the psychoactive medication care plan but had failed to do so for resident #3. Resident #121 was observed on 9/27/2010 at 12:25 p.m. in the main dining room sitting in a Broda chair waiting for lunch to be served. The resident was leaning to the right. Multiple staff members were present in the dining room but did not attempt to reposition the resident. The resident's lunch tray was served at 1:00 p.m. Certified Nursing Assistant ( CNA) "ZZ" fed the resident. "Staff member "ZZ" made no attempt to reposition the resident to correct body alignment, but continued to feed the resident, whose head was resting on the staff member's shoulder. Review of the Comprehensive Care Plan did not identified any concerns with positioning. The Care Plan Coordinator was i… | 2014-04-01 | ||
| 10541 | 10541 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 456 | E | FH9411 | Based on observation and staff interview, the facility failed to maintain two (2) of two (2) microwave ovens and one (1) of two (2) refrigerators on two (2) of two (2) units. Findings include: During the observational tour of the facility conducted on 8/25/09 at 11:00 a.m. the following areas of concern were noted in two (2) of two (2) pantries. 1. Unit I- the microwave contained a build up of a black/brown substance on the back wall, and a chipped burned area on the top inside door. 2. Unit II- the microwave contained an accumulation of dried food particles/stains on the inside, and the plastic on the inside of the door was melted in two (2) areas. The inside of the refrigerator contained a moderate amount of water on the bottom shelf, the rubber seal around the door was torn, detached and had a build up of mold/mildew. Resident and staff food was being stored inside the refrigerator. The Administrator was made aware of these concerns during an interview on 8/25/09 at 6:30 p.m. | 2014-04-01 | ||
| 10540 | 10540 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 365 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide liquids and food prepared to the consistency ordered by the physician for one (1) resident (#17) of a sample of twenty-four (24) residents. Findings include: Observation of the lunch service on 8/26/09 at 12:55 p.m. revealed resident #17 was served two (2) bowls of chili for residents on a regular diet. Review of the resident's current Physician order [REDACTED]. The Dietary Manager was interviewed on 8/26/09 at 2:15 p.m. and confirmed that the resident should have been served the pureed chili. Observation on 8/25/09 at 9:15 a.m. during medication pass revealed that a medication nurse administered medications to resident #17 with liquids that were not thickened. Review of the August 2009 physician's orders [REDACTED]. Observation in the resident's room revealed an image of a bumble bee over the resident's bed. Interview with Licensed Practical Nurse (LPN) "LL" on 8/26/09 at 10:00 a.m. confirmed that the image of the bumble bee is a reminder to staff to provide thickened liquids to the resident. She added, that the medication nurse should have given the medications with thickened liquids. | 2014-04-01 | ||
| 10539 | 10539 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 161 | E | FH9411 | Based on record review and staff interview, the facility failed to purchase a surety bond of sufficient value to assure the security of all resident trust funds deposited with the facility for 87 of 87 managed accounts. Findings include: Record review revealed the current surety bond was in the amount of $35,000.00. A review of bank statements for the Resident Trust Account revealed balances that exceeded this amount for the following months: 1. February 2009: 4 days were over the bond amount, the highest was $37,098.40 2. March 2009: 9 days over, the highest balance was $39,791.69 3. April 2009: 6 days over, the highest balance was $37,698.48 4. May 2009: The average daily balance was over the bond amount. 5. June 2009: The average daily balance was over the bond amount. 6. July 2009: The average daily balance was over the bond amount. Interview on 8/25/09 at 3:00 p.m. with the Business Office Manager revealed that she did not know the amount of the surety bond or that the account balance exceeded the bond amount. | 2014-04-01 | ||
| 10538 | 10538 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 332 | E | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to maintain an error rate of less than five (5) percent. During observation of medication pass on 8/25/09 between 8:30 a.m. and 10:45 a.m. two (2) nurses were observed, during forty five (45) opportunities to pass medications. Four (4) errors were observed on one (1) of two (2) units resulting in a medication error rate of 8.88%. Findings include: 1. Licensed Practical Nurse (LPN) "JJ" administered two (2) puffs of [MEDICATION NAME] Multidose Inhaler to a resident. The second puff was administered ten (10) seconds after the first puff. In an interview with the LPN "JJ" at 8:40 a.m. she acknowledged that she should have waited two (2) minutes between puffs. A review of the facility's policy for administration of Oral Inhalations confirmed that two (2) minutes should elapse before administering the second puff. 2. LPN "KK" administered two (2) puffs of [MEDICATION NAME] Multidose Inhaler. The first and second puff was administered three (3) seconds apart. In an interview with this LPN she acknowledged that she should have waited at least one (1) minute between puffs. 3 & 4. Record review for the same resident revealed a physician's orders [REDACTED]. In an interview with LPN "KK" she confirmed that these two medications were omitted. | 2014-04-01 | ||
| 10537 | 10537 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 325 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to put interventions in place to address the protein needs of one (1) resident (#5) of twenty-four (24) sampled residents. Findings include: Review of the clinical record for resident #5 revealed blood was drawn on 7/30/09 to determine the resident's protein levels. The results of the test indicated the resident's [MEDICATION NAME] and [MEDICATION NAME] levels were below the normal range. The physician ordered a repeat test in eight (8) weeks and a nutrition consult with the Registered Dietician (RD). Review of the Nutritional Progress Notes revealed the RD completed the consult on 7/31/09. No new interventions were recommended to address the low protein levels. The RD documented interventions were already in place. Review of the clinical record revealed the resident had been on fortified foods at all meals since 5/22/09. Review of the resident's current Comprehensive Care Plan revealed a new problem added 8/10/09 addressing the resident's recent six (6) month significant weight loss of ten point five percent (10.5%). Although the family states the weight loss was desirable and put the resident at her usual weight, low [MEDICATION NAME] levels put the resident at risk if further weight is lost. The Care Plan did not address interventions to specifically address the low protein. The Unit Manager was interviewed on 8/26/09 at 8:40 a.m. and stated residents with nutritional risk are discussed at weekly Standards of Care (SOC) meetings. Review of the Nurses' Notes revealed the resident was discussed at these meetings on 8/03/09, 8/13/09 and 8/20/09. There were no interventions discussed at these meetings to address the protein levels. The Unit Manager stated the RD does not attend these meetings. Nutritional concerns are referred verbally to the dietician as needed. The Dietary Manager was interviewed on 8/2/609 at 6:30 p.m. She stated fortified foods do not contain added protein. | 2014-04-01 | ||
| 10536 | 10536 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 315 | D | FH9411 | Based on observation, record review and staff interview the facility failed to follow acceptable technique to prevent urinary tract infections during incontinent care for two (2) residents (#4 and #14) of twenty-four (24) sampled residents. Findings include: 1. On 8/25/09 at 9:30 a.m. Certified Nursing Assistant (CNA) "GG" was observed providing incontinence care to resident #4. The CNA used a perineal spray cleanser and washcloths. When the CNA cleaned the perineal area some of the perineal spray came in contact with the resident's skin. The resident protested . When the CNA turned the resident on her side to cleanse the anal area she wiped from the back to the front. Review of the facility's policy on Perineal Care revealed that washing should be performed from front to back. Review of the clinical record for this resident revealed laboratory reports dated 8/04/09 and 8/22/09 for urine cultures and sensitivities. Both revealed a urinary tract infection and the infecting organism was Escherichia coli. The resident was treated on both occasions with antibiotic therapy. 2. Record review for resident #14 revealed the resident was assessed on the 6/24/09 Minimum Data Set as being incontinent of bowel/bladder and as being dependent on staff for assistance of activities of daily living and as having a history of urinary tract infections. An observation on 8/24/09 at 4:00 p.m. revealed two Certified Nursing Assistants were leaving the resident's room. Certified Nursing Assistants (CNA) "HH" and "II" assisted the resident to the bathroom to provide incontinence care. A soiled brief was removed as the resident had been incontinent of bowel and bladder. Using a clean washcloth, the resident's perineal area was cleaned of feces by wiping one time with a back to front motion. A second clean washcloth was used to wipe the resident at mid perineum toward the back. The resident began urinating and was seated back on the toilet seat. Urine and a small amount of feces was noted on top of the toilet seat as the resident sat back … | 2014-04-01 | ||
| 10535 | 10535 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 280 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to update the Comprehensive Care Plan for one (1) resident, #3 of twenty-four (24) sampled residents related to the resident's desire to lose weight. Findings include: Review of the Comprehensive Care Plan for resident #3 revealed an update added 5/23/09 to a problem concerning the resident's risk for weight loss. The update revealed the resident actually desired to lose weight and that any weight loss would be planned and desired. However, the goals were not updated to reflect this and a current goal continued until the next review was to avoid significant weight loss. Review of interventions revealed the resident was also to continue receiving fortified foods twice a day. Review of the Minimum (MDS) data set [DATE] revealed the resident was on a planned weight change program. The Care Plan Coordinator and the Unit Coordinator were interviewed on 8/26/09 at 9:00 a.m. and both stated they were aware of the resident's desire to lose weight and acknowledged that the care plan was not revised with interventions to achieve this goal. | 2014-04-01 | ||
| 10534 | 10534 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 279 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interview the facility failed to develop a comprehensive care plan related to long-term symptoms affecting daily care for two (2) residents, ("A" and "B") of a sample of twenty-four (24) residents. Findings include: 1. During the initial tour conducted on 8/24/09 beginning at 11:00 a.m. the Unit Manager stated Resident "A" had difficulty swallowing and was going to have a procedure performed to stretch her esophagus. The Unit Manager further stated this difficulty had been a long term problem for the resident, but she had declined the procedure in the past. The resident, who was assessed as cognitively intact on the Minimum Data Set ((MDS) dated [DATE], stated she had difficulty swallowing, could only take small bites of food at a time, needed to have her throat stretched, and could not eat some foods during interviews on 8/24/09 at 1:05 p.m., 8/25/09 at 8:05 a.m. and 12:50 p.m. and 5:50 p.m. and again on 8/26/09 at 7:50 a.m. These conversations took place during meals in the main dining room. Each time the resident explained her difficulty and either was eating very little or asking for alternates. The Dietary Manager was interviewed on 8/26/09 at 11:00 a.m. and stated she was aware of the resident's problem with swallowing. She further stated, the resident's weight had been stable over the past year and that the resident would ask for foods that she could comfortably eat and that she frequently asked for alternates. Review of the Comprehensive Care Plan for the resident did not reveal any problem related to eating patterns or difficulty swallowing. The Care Plan Coordinator was interviewed on 8/26/09 at 9:05 a.m. She acknowledged she had not included this problem. 2. Record review for resident "B" revealed a current physician's orders [REDACTED]. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of resident's care plan did … | 2014-04-01 | ||
| 10533 | 10533 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 225 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that injuries of unknown origin and allegations of abuse were immediately reported to the facility Administrator and to the State survey and certification agency, and that these allegations were thoroughly investigated for two residents (#1 and "A") of twenty four (24) sampled residents. Findings include: 1. Observation of resident #1 on 8/25/09 at 3:20 p.m. during a skin assessment revealed that Certified Nursing Assistants (CNA) "AA" and "BB" identified that the resident had an extensive, deep purple bruise between the fourth and fifth toe on the right foot. It extended behind the toes on the bottom of the foot and on the top of the foot. The CNA's indicated that they did not know how or when this injury occurred. They added that they discovered the bruise while getting the resident out of bed yesterday (8/24/09) and reported it to Licensed Practical Nurse (LPN) "DD" as soon as it was discovered. Record review revealed that there was no mention of the bruise in the nurses notes for 8/24/09. LPN "CC", the Unit Manager, located a Nurse/Physician Communication Record dated 8/24/09 included documentation of "Client has bruised area to right little toe area, ran over toe when rolling in wheel chair". This Communication Record was signed by LPN "DD". A telephone interview with LPN "DD"on 8/25/09 at 4:50 p.m. revealed that he had not witnessed the event but had been told by the Risk Manager that she had witnessed the event. An interview with the Risk Manager on 8/25/09 at 5:05 p.m. revealed that she had seen the resident with his foot behind the wheel of the wheelchair mid-morning on 8/24/09. She was aware that the CNA's had discovered the bruise before the resident got up for the morning on 8/24/09. She added, that she did not witness the resident's foot being run over with the wheel chair and acknowledged that this was an unwitnessed injury of unknown origin th… | 2014-04-01 | ||
| 10532 | 10532 | OAKS - ATHENS SKILLED NURSING, THE | 115419 | 139 ALPS ROAD | ATHENS | GA | 30606 | 2011-01-24 | 309 | D | ZGW511 | Based on record review and staff interview, the facility failed to provide care as specified by physician's orders for a hospital transfer for one (1) resident (#1) from a survey sample of five (5) residents. Findings include: Record review for Resident #1 revealed a Nurse's Note of 12/12/2010 at 4:00 p.m. which documented that at around 3:15 p.m., the resident pulled the fire alarm and in the process of trying to get away from the alarm, she hit her right forearm on the door frame. This Note documented that nurses noticed bruising and swelling to the right forearm, and that the resident complained of pain to the arm. This Note also documented that the physician was notified and gave an order to transfer the resident to the emergency room . However, a Nurse's Note of 12/12/2010 at 4:45 p.m. documented that the Director of Nursing (DON) stated not to send the resident to the emergency room , that the hospital could not do anything for a hematoma and that it would dissolve on its own. A Nurse's Note of 12/12/2010 at 7:08 p.m. documented that the physician was called to inform him that the resident was not being sent out as ordered, per the DON. This Note documented that the physician again ordered to send the resident out, but that the DON was calling a second doctor to discuss the resident's condition. This Note documented that the resident continued to complain of pain, and the swelling and bruising continued. A Nurse's Note of 12/12/2010 at 9:30 p.m. documented that the resident remained in the facility and that Tylenol had been administered for pain. A Nurse's Note of 12/13/2010 at 2:30 a.m. documented that no return call had been received from the second physician, and that the resident remained in the facility at that time, with the right arm continuing to be swollen and black. A Nurse's Note of 12/13/2010 at 7:30 a.m. documented the resident still remained in the facility at that time, that the wrist to elbow was dark purple, and that an X-ray was ordered. Further record review revealed that despite receivin… | 2014-04-01 | ||
| 10531 | 10531 | WARRENTON HEALTH AND REHABILITATION | 115321 | 813 ATLANTA HIGHWAY | WARRENTON | GA | 30828 | 2013-10-02 | 309 | D | 383J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to monitor for the effectiveness of Insulin administration for a high blood sugar level; failed to administer Insulin as ordered by the physician; failed to monitor for signs and symptoms of [MEDICAL CONDITION] ; and failed to document the resident's refusal of care and services for one resident (#1) of three (3) residents with diabetes from a total sample of ten (10) residents. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a 9/19/13 physician's orders [REDACTED]. every evening for dementia with behavioral disturbances, [MEDICATION NAME] 50 mg every bedtime for anxiety, [MEDICATION NAME] 5 mg every day for hypertension and [MEDICATION NAME] 5 mg. every bedtime for dementia. The physician also ordered staff to obtain laboratory tests including a comprehensive metabolic profile to be done the next day (9/20/13). The resident was admitted to the secured unit. The resident had an initial care plan dated 9/20/13 with appropriate interventions to address the resident ' s risk for falls; risk for pressure sores, skin tears or bruising; nutrition; potential for pain; potential for high blood pressure; and behaviors (depression, anxiety, aggression and combativeness). On 9/23/13, the results of the laboratory tests were obtained and revealed that the resident had a high glucose level of 455 (normal range was between 65 -100). The physician was notified and ordered staff to administer 15 units of [MEDICATION NAME] every day with supper (scheduled at 5:00 p.m.) and to obtain finger stick blood sugar levels every morning (scheduled for 6:00 a.m.). On 9/23/13, the resident ' s care plan was revised to address his/her new [DIAGNOSES REDACTED]. Licensed nursing staff documented in the 9/24/13 at 5:45 a.m. Interdisciplinary Progress Note (IDPN) that the resident's fingerstick blood sugar was 578 and that the resident was w… | 2014-04-01 | ||
| 10530 | 10530 | PLACE AT MARTINEZ, THE | 115308 | 409 PLEASANT HOME ROAD | AUGUSTA | GA | 30907 | 2011-01-14 | 203 | D | OC1P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and family interview, the facility failed to provide a written notice of discharge to one (1) resident (Resident "C"), and to the resident's family, on a survey sample of six (6) residents. Findings include: Review of the medical record for Resident "C" revealed a Nurse's Note of 12/27/2010 at 6:00 p.m. which documented that the resident had been evaluated for behavior. A telephone physician's orders [REDACTED]. Interview with the resident's family on 01/14/2011 at 9:45 a.m. revealed that they were told the resident could not return to the facility as the resident was being placed in the ambulance. Interview with the facility Social Worker on 01/14/2011 at 9:20 a.m. confirmed that she had called the hospital, talked to the social worker there and told the hospital staff member that it would not be safe for the resident to return to the nursing facility. However, during this interview, the facility Social Worker further stated that facility staff had not contacted the physician to place in writing why the resident could not return and did not issue the written notice of discharge to the family. Record review revealed no evidence to indicate that a written notice of discharge had been provided to the family, or to the resident, regarding the resident's 12/27/2010 discharge. Interview with the Administrator and the Director of Nurses on 01/14/2011 at 11:30 a.m. revealed that they were not aware they needed to put in writing the reasons for the resident's discharge and issue the written notice of discharge to the resident and to the family. | 2014-04-01 | ||
| 10529 | 10529 | PRUITTHEALTH - MACON | 115288 | 2255 ANTHONY ROAD | MACON | GA | 31204 | 2011-01-18 | 314 | G | PDM311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to implement recommended interventions in a timely maner for one (1) resident with a high risk for pressure ulcers. from a sample of six (6) resident. This resulted in actual harm for one (1) resident (#1) that was not immediate jeopardy. Findings include: Review of the medical record for this resident revealed that he was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident had a gastrostomy tube in place for tube feeding. Review of the admission body audit form dated 12/24/10 revealed no open areas on the sacrum, hips, buttocks, ankles, feet and heels. There was a reddened area on the buttocks but was documented as blanchable. Review of the weekly skin assessment performed on 01/03/1, ten days after admission to the facility, revealed the following: right plantar foot #2 stage II 1.8 centimeter (cm) x 1.1 cm with blister right plantar foot #1 stage ll 3.1 cm x 3.2 cm with blister right heel stage I 6 cm x 6 cm with no drainage left plantar foot stage II 3 cm x 4.5 cm with blister left heel unstageable 4 cm x 4 cm suspected deep tissue injury left heel unstageable 3.5 cm x 3.5 cm suspected deep tissue injury left ankle#1 0.5 cm x 0.5 cm x < 0.1 cm with granulation tissue, light drainage let ankle #2 unstageable 1 cm x 1 cm suspected deep tissue injury left ankle #3 stage II 1.1 cm x 1 cm left third toe stage I 0 .5 cm x 0..5 cm left buttocks stage II 1 cm x 2 cm x less than 0.1 cm left buttocks stage III irregular shape with granulation tissue with slough no drainage right buttocks #1 stage I 3 cm x 1.5 cm x < 0.1 cm granulation tissue and slough right great toe stage I I cm x 1 cm no drainage left third toe stage I 0 .5 cm x 0.5 cm During an interview with the Licensed Practical Nurse (LPN) "AA" on 01/18/11 at 10:00 a.m. and again at 12:30 p.m. she revealed that she had first assessed the resident on 12/24/10 and on 12/29/10 realized th… | 2014-04-01 | ||
| 10528 | 10528 | HUTCHESON MED CTR SUBACUTE UNI | 115040 | 100 GROSS CRESCENT CIRCLE | FORT OGLETHORPE | GA | 30742 | 2010-12-14 | 309 | D | 7FWP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide treatments as ordered by the physician for two (2) residents (#s 1 and 2) in a survey sample of six (6) residents. Findings include: 1. Record review for Resident #1 revealed a 10/20/2010 physician's orders [REDACTED]. However, further record review, to include review of the November 2010 Treatment record, revealed no evidence to indicate that this treatment was done on 11/18/2010 at 9:00 a.m., and on 11/01/2010, 11/02/2010, 11/03/2010, 11/23/2010 and 11/27/2010 at 9:00 p.m., as ordered and scheduled. 2. Record review for Resident #2 revealed an 11/04/2010 physician's orders [REDACTED]. However, further record review, to include review of the November 2010 Treatment record, revealed no evidence to indicate that this treatment was done on the 7:00 a.m.-7:00 p.m. shift on 11/07/2010, 11/08/2010, 11/09/2010, 11/12/2010, 11/14/2010, 11/23/2010, 11/26/2010, 11/27/2010, and 11/28/2010, as ordered and scheduled. During an interview with Nurse "AA" conducted on 12/14/2010 at 1:45 p.m., this nurse acknowledged that the treatments referenced above were not done as ordered for Resident #1 and Resident #2. | 2014-04-01 | ||
| 10527 | 10527 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2009-11-11 | 253 | B | TBSG11 | Based on observation and staff interview the facility failed to ensure for one (1) of two (2) common bathing areas (B Hall), and for two (2) of twelve (12) rooms observed that the environment was clean and not in need of repairs. Findings include: During environment observations on 11/10/09 at 11:25 a.m. the following was observed: 1. A build up of black mold was observed around the edges of the showers and wall in the common bathing areas on B Hall. Two (2) broken tiles were observed in the shower area. 2. Two (2) air conditioner/heater units in rooms B-23 and B-24 had broken control panel covers. On 11/11/09, accompanied by the Maintenance Director and Housekeeping Director, the common bathing area on B Hall was observed. The black mold in the first shower had been partially removed but the other shower, tub and sink area continued to have black mold and only one (1) of two (2) broken tiles had been repaired. | 2014-04-01 | ||
| 10526 | 10526 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2009-11-11 | 441 | F | TBSG11 | Based on observation and staff interview the facility failed to ensure for a resident census of one hundred and one (101) that linen was handled in a manner to prevent development or transmission of infection. On 11//10/09 at 10:20 a.m. observations of the laundry room revealed the following: The Housekeeping Supervisor (HS) and the Floor Technician (FT) were observed folding clean linen. The clean sheets were observed to touch the floor, the employees clothing and the employee chin, face, nose and body. Employees HS and FT were observed to handle soiled linen wearing no clothing protectors and only disposable gloves. Personal drink containers were observed on the folding table. Interview at that time with HS revealed they have to work in the laundry a couple of times a week. During a second observation on 11/11/09 at 8:50 a.m. the Housekeeping Supervisor, Floor Technician and a Housekeeper were observed in the laundry folding linen and the linen was again observed to touch the floor. Review of the facility protocol The Laundry Process , 6-15 1/1/2000, section: Transferring Soiled Linen, third paragraph instructs that personal protective equipment is to be used when handling laundry. | 2014-04-01 | ||
| 10525 | 10525 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2009-11-11 | 332 | E | TBSG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record reviews, it was determined that for two (2) of the eight (8) residents observed the facility failed to ensure a medication error rate that was less than 5%. Two (2) of four (4) nurses observed during forty-six (46) opportunities made three (3) errors resulting in a medication error rate of 6.25%. Findings include: During the morning medication pass on 11/10/09 the following errors were observed: 1. A resident on the B 1 Hall was given his medications at 8:45 a.m. Record review for this resident revealed current physician orders [REDACTED]. 2. A resident on the B 2 Hall was given his medications at 8:55 a.m. and an antihypertensive medication, [MEDICATION NAME] was included. The medications were given with water. Review of the current physician's orders [REDACTED]. 3. The same resident on the B 2 Hall was given an anticonvulsant medication, [MEDICATION NAME], 200 milligrams at 8:55 a.m. Review of the current physician's orders [REDACTED]. | 2014-04-01 | ||
| 10524 | 10524 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 368 | E | 3EK711 | Based on group interview and staff interview, it was determined that the facility failed to offer bedtime snacks to six of fourteen residents who attended the group interview. Findings include: During the group interview on 8/19/09 at 3:00 p.m., six of the fourteen residents said that they were not offered bedtime snacks. During interviews conducted on 8/20/09 between 8:20 a.m. and 9:00 a.m. with the six residents in the group interview who had reported not being offered bedtime snacks, they said that nursing staff did not offer them a bedtime snack on the previous evening (8/19/09). During an interview on 8/20/09 at 9:30 a.m., the Director of Nursing stated that bedtime snacks were kept stocked on the units and nursing staff was responsible for offering them to the residents. | 2014-04-01 | ||
| 10523 | 10523 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 253 | C | 3EK711 | Based on observations, it was determined that the facility failed to maintain an environment that was free from dust, rust, stains, missing baseboards, dirt, cobwebs and/or debris on all five hallways in the facility. Findings include: The following were observed on 8/18/09 between 8:55 a.m. and 11:00 a.m. and on 8/20/09 at 10:00 a.m. and 11:00 a.m. 500 Hall 1. There were rusty metal bedpan holders mounted on the bathroom walls in rooms 522 and 523. 2. There was a heavy build up of dust on the bathroom ceiling vents in rooms 523, 540, 541, 542, 543, 545 and 547. 3. There were rusty metal bases on the suction machines in rooms 512 and 541. 4. The laminate finish was peeling off of the side of the nightstand in room 544. 5. There were cobwebs on the furniture in room 531. 6. There was a dried brown liquid substance on the bathroom ceiling light fixtures in rooms 526 and 528. 7. The bathroom light fixture in room 526 was separated from the ceiling on two sides. 8. There was a Exelon medication patch dated 7/5/09 attached to the shower wall in room 521. 9. There were scuffs and gouges on the door of the common bath. 10. There was approximately a five foot section of baseboard missing in the dining area. 11. There was a section of baseboard missing in the hall next to the supply closet. 400 Hall 1. There were scuffs and paint peeling off of the wall next to the linen storage room. 2. There were scuffs and gouges on the door of the common bath. 3. The baseboards were scuffed and stained in the television area. 4. There were stains and paint peeling off of the bottom cabinets in the clean utility room. 300 Hall 1. There was a heavy build up of dust on the ceiling vents in rooms 310 and 331. 2. There were rusted out areas at the bottom of the bathroom door frames in rooms 313 and 331. 3. There were rusty grab bars in the bathrooms in rooms 315, 320 and 342. 4. There were dried brown stains on the bathroom ceiling in room 344. 5. There were dried brown splatter stains on the walls and ceiling of the soiled linen room. 6. … | 2014-04-01 | ||
| 10522 | 10522 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 505 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to promptly notify the physician about an abnormally high [MEDICATION NAME]/INR level and an abnormally high BUN level for one resident (#3) from a sample of 30 residents. Findings include: Nursing staff had given 5 milligrams (mgs) of [MEDICATION NAME] daily to resident #3 since his/her admission on 6/9/09. Licensed nursing staff had obtained a [MEDICATION NAME]/INR blood level on the resident on 6/15/09. Although, the INR was abnormally high at 3.69 (therapeutic range was between 2.0 and 3.0), licensed nursing staff had failed to notify the physician about that result until 7/7/09 (22 days later). At that time, the physician ordered nursing staff to hold the [MEDICATION NAME] that day and then decrease the dose to 2.5 mgs and alternating that with 5 mgs every other day. On 8/19/09 at 11:00 a.m., the consultant pharmacist stated that licensed nursing staff should have notified the resident's physician about the abnormally high INR result prior to 7/7/09. Resident #3 had an abnormally high BUN level of 52 reported on 8/4/09. The normal range for a BUN level was between 7 and 18. Although the resident had an abnormally high BUN level of 31 on 6/6/09 prior to his/her admission to the facility on [DATE], there was no evidence that licensed nursing staff had notified the resident's physician about the even higher BUN result on 8/4/09. | 2014-04-01 | ||
| 10521 | 10521 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 323 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to provide a chair alarm as planned to prevent falls for one resident (#27) of six residents with a history of falls from a total sample of 30 residents and failed to ensure that two handrails were secured to the wall on one unit (Unit IV) of five units in the facility. Findings include: 1. Resident #27 had a history of [REDACTED]. However, on 8/20/09 at 9:15 a.m., 10:15 a.m., 11:50 a.m. and 12:50 p.m., the resident was sitting in his/her wheelchair, but staff had failed to apply the chair alarm. On 8/20/09 at 12:50 p.m., certified nursing assistant "AA" confirmed that the resident did not have a chair alarm on his/her wheelchair. "AA" stated at that time that staff did not apply an alarm on the resident's wheelchair. On 8/20/09 at 12:55 p.m., licensed nursing staff "BB" stated that staff did not apply an alarm on the resident's wheelchair because, the resident did not attempt to get out of his/her wheelchair unassisted. However, according to the 7/15/09 at 9:10 p.m. nurses' notes, nursing staff had found the resident on the floor in his/her room next to his/her wheelchair. 2. During the General Observation Tour of the Facility on 8/20/09 at 11 a.m., two sections of handrails were loose in the Unit IV hall between the common bath and the residents' telephone room, and between rooms 442 and 440. | 2014-04-01 | ||
| 10520 | 10520 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 225 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to thoroughly investigate the past history of one of sixteen employees, and failed to report one injury of unknown origin to the State survey and certification agency. Findings include: 1. According to the 4/30/09 nurse's notes at 1:40 p.m., resident #12 had [MEDICAL CONDITION] and discoloration on his/her right hand, wrist and lower forearm, and complained of pain. The resident was sent to the emergency room (ER) for evaluation. It was determined that he/she did not have a fracture but had a contusion of the right wrist. Although the facility had investigated that injury and determined it had been of unknown origin, it was not reported to the State survey and certification agency. 2. Review of the personnel records for sixteen employees revealed that the facility hired an employee on 9/22/08. However, the facility failed to thoroughly investigate his/her history including having obtained a current criminal background check prior him/her working at the facility. On 8/20/09 at 1:00 p.m., the administrator stated that the facility staff were unable to locate the background check. | 2014-04-01 | ||
| 10519 | 10519 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 428 | E | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician acted on the consultant pharmacist's recommendations in a timely manner for nine residents (#2, #3, #9, #18, #19, #20, #24, #27 and #30) from a total sample of 30 residents. Findings include: 1. Resident #18 had a 7/30/09 consultant pharmacist recommendation to increase the dose of Stalevo to aid in reducing the potential of falls and to change the time of the resident's Flomax from morning to hour of sleep to reduce any orthostatic hypotension to aid in reducing falls. However, the physician did not act on those recommendations until 8/19/09, at which time he/she increased the dose of Stalevo and changed the time of administering of Flomax to bedtime. 2. Resident #19 had a 3/26/09 consultant pharmacist recommendation for a [DIAGNOSES REDACTED]. However, the physician did not act on that recommendation until 5/27/09, at which time he/she gave a [DIAGNOSES REDACTED]. 3. Resident #20 had a 7/30/09 consultant pharmacist recommendation for the resident's Miralax be mixed with 8 ounces of water or juice according to the manufacturer's recommendations instead of the 4 ounces of liquid that the nursing staff had been administering. However, the physician did not act on that recommendation until 8/18/09, at which time he/she ordered nursing staff to give the Miralax with 8 ounces of water or juice. The resident also had a 6/30/09 consultant pharmacist recommendation for a potassium replacement due to the resident receiving HCTZ daily without a potassium supplement. The resident's 6/30/09 potassium level was low at 3.1 (normal range 3.5-5.3). However, the physician did not act on that recommendation until 7/15/09, at which time, he/she ordered 20 miliequivalents (meq) of KDur daily. During an interview on 8/20/09 at 8:30 a.m., licensed nurse "DD" stated that the consultant pharmacist gave the recommendations to the D… | 2014-04-01 | ||
| 10518 | 10518 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 282 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to implement the plan of care to prevent falls for one resident (#27) of six residents with a history of falls from a total sample of 30 residents. Findings include: Resident #27 had a history of [REDACTED]. However, on 8/20/09 at 9:15 a.m., 10:15 a.m., 11:50 a.m. and 12:50 p.m., the resident was sitting in his/her wheelchair, but staff had failed to apply the chair alarm. See F323 for additional information regarding resident #27. | 2014-04-01 | ||
| 10517 | 10517 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 325 | E | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician reviewed and addressed the registered dietician's recommendations timely for five residents (#6, #18, #19, #26 and #30), and failed to follow a physician's orders [REDACTED].#2) of 15 residents with weight loss from a total sample of 30 residents. Findings include: 1. Resident #18 had [DIAGNOSES REDACTED]. Licensed staff coded the resident as independent in eating on the 4/1/09 Significant Change of Condition comprehensive assessment. He/She was on a Regular diet. Resident #18 had a 5/20/09 and 6/17/09 registered dietician's recommendation for 30 milliliters (ml) of protein supplement twice a day because of his/her significant weight loss of 10% in six months, a low [MEDICATION NAME] level and meal intake of less than 75%. Staff recorded the resident's weight as 188.8 pounds in May, 186.2 in June and 181.8 in July, 2009. The resident's [MEDICATION NAME] level on 6/1/09 was below normal at 18 (normal range, 20-40). However, despite the continued gradual weight loss and low [MEDICATION NAME] level, the resident's attending physician did not act on those recommendations until 7/21/09 (34 days later) at which time the physician ordered the protein supplement. 2. Resident #6 had [DIAGNOSES REDACTED]. Licensed staff coded the resident as independent with eating on the 4/11/09 MDS assessment. Resident #6 had a 4/22/09 registered dietician's recommendation for fortified meals because of meal intake of less than 75%, a body mass index (BMI) of less than 19, having wounds, a low [MEDICATION NAME] and a low [MEDICATION NAME] level. The resident's 4/9/09 [MEDICATION NAME] level was 10.7 (normal range 20-40) and his/her [MEDICATION NAME] level was 3.0 (normal range 3.4-4.8). However, despite the decreased intake, the recorded BMI of less than 19, and the low [MEDICATION NAME] and [MEDICATION NAME] levels, the resident's … | 2014-04-01 | ||
| 10516 | 10516 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 504 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that laboratory tests were obtained as ordered for five residents (#5, #7, #18, #19 and #30) from a total sample of 30 residents. Findings include: 1. Resident #18 had a 1/16/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. 2. Resident #19 had a 1/21/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. During an interview on 8/20/09 at 11:45 a.m., licensed nurse "DD" stated that the additional laboratory tests performed for residents #18 and #19 were obtained in error and did not have a physician's orders [REDACTED]. 3. Resident #5 had a physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. 4. Resident #7 had a Complete Metabolic Panel (CMP) obtained on 5/13/09 and 5/14/09. However, review of the resident's medical record revealed [REDACTED]. 5. Review of resident #20's closed record revealed a 3/30/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, nursing staff did not have a physician's orders [REDACTED]. During an interview on 8/20/09 at 11:15 a.m., licensed nurse "CC" stated that the additional laboratory tests performed on residents #5 and #7 were obtained in error. Nursing staff did not have a physician's orders [REDACTED]. | 2014-04-01 | ||
| 10515 | 10515 | BROWN'S HEALTH & REHAB CENTER | 115604 | 226 SOUTH COLLEGE STREET | STATESBORO | GA | 30458 | 2011-02-01 | 323 | D | 1 | 0 | S73111 | Based on record review and staff interview, the facility failed to ensure that one (1) resident (#1), on the survey sample of five (5) residents, received adequate supervision related to fall-prevention from the wheelchair during transport by staff. Findings include: Record review for Resident #1 revealed a Nurse's Note of 01/12/2011 at 6:45 p.m. which documented that the nurse was called to the resident's room to observe a hematoma to the forehead above the right eye. This Note documented the certified nursing assistant (CNA) stated that while the resident was being pushed in the wheelchair from the dining room to her room, the resident planted her feet firmly on the floor causing her to fall from the wheelchair and to hit her head on the floor. This Note documented that the CNA was able to catch the resident by the arm preventing the full impact of the fall. This Note further documented that an assessment of the resident revealed no open area, and some confusion and weakness, which were normal for the resident. The physician and family were notified. During interviews conducted with Licensed Practical Nurse (LPN) "BB", CNA "CC", LPN "DD", and Certified Occupational Therapy Assistant "EE" conducted on 02/01/2011 at 2:35 p.m., 2:40 p.m., 2:45 p.m., and 2:50 p.m., respectively, all staff members stated that they had observed Resident #1 to have the behavior of putting her feet down while being transported in the wheelchair. LPN "BB" specifically stated that staff had to cue the resident frequently to keep her feet up during transport via the wheelchair. Review of the resident's Care Plan revealed a 07/22/2010 entry identifying the resident to be at risk for falls. However, despite staffs' knowledge of the resident's behavior of lowering her feet during transport via wheelchair, record review revealed no evidence to indicate that the facility had evaluated the resident to develop interventions to address this behavior. A Nurse's Note of 01/13/2011 documented the consideration of the use of leg rests on the wheelcha… | 2014-06-01 |
| 10514 | 10514 | BROWN'S HEALTH & REHAB CENTER | 115604 | 226 SOUTH COLLEGE STREET | STATESBORO | GA | 30458 | 2011-02-01 | 280 | D | 1 | 0 | S73111 | Based on record review and staff interview, the facility failed to revise the care plan to put interventions in place to provide safe methods of transportation for one (1) resident (#1), who had been assessed to be at risk for falls, on the survey sample of five (5) residents. Findings include: Cross refer to F323 for more information regarding Resident #1. Record review for Resident #1 revealed a Quarterly Minimum Data Set of 10/21/2010 which indicated the resident had both long-term and short-term memory problems, required extensive assistance with all activities of daily living, required assistance with transfers, and ambulated via a wheelchair. Further review revealed the Resident Assessment Protocols (RAPs) triggered for the risk of falls, and a 07/22/2010 Care Plan entry identified this risk for falls. A Nurse's Note of 01/12/2011 at 6:45 p.m. documented that while a certified nursing assistant (CNA) was pushing the resident in a wheelchair from the dining room to her room, the resident planted her feet firmly on the floor causing her to fall from the wheelchair. During interviews conducted with Licensed Practical Nurse (LPN) "BB", CNA "CC", LPN "DD", and Certified Occupational Therapy Assistant "EE" conducted on 02/01/2011 at 2:35 p.m., 2:40 p.m., 2:45 p.m., and 2:50 p.m., respectively, all staff members stated that they had observed Resident #1 to have the behavior of putting her feet down while being transported in the wheelchair. However, despite the resident's assessed fall-risk and staffs' knowledge of the resident's behavior of lowering her feet during transport via wheelchair, record review revealed no evidence to indicate that the facility had reviewed and revised the resident's Care Plan to develop interventions to address this behavior until a 01/14/2010 entry on the Care Plan indicated that leg rests were to be placed on the wheelchair while staff were assisting the resident with locomotion. | 2014-06-01 |
| 10513 | 10513 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2011-02-08 | 460 | D | 1 | 0 | 4Q8L11 | Based on observation and staff interview, the facility failed to ensure that the rooms of four (4) residents (#2, #3, #4, and #5) were equipped to assure full visual privacy, in a total survey sample of five (5) residents. Findings include: During observations of the privacy curtains in the rooms of Residents #2, #3, #4, #5 conducted on 02/08/2011 at 9:45 a.m., 10:35 a.m., 10:00 a.m., and 11:13 a.m., respectively, the privacy curtains were approximately four (4) feet too short to provide privacy for the residents. Interview with the House Keeping Supervisor conducted on 02/08/2011at 1:20 p.m. revealed that the wrong curtain were placed around the beds of Residents #2, #3, #4, and #5 and they were too short to provide privacy. | 2014-06-01 |
| 10512 | 10512 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2011-02-08 | 312 | D | 1 | 0 | 4Q8L11 | Based on observation and staff interview, the facility failed to provide incontinence care in a manner to maintain good hygiene for two (2) residents (#4 and #5) of five (5) sampled residents. Findings include: Observation of Certified Nursing Assistant "BB" on 02/08/2011 at 10:00 a.m. providing incontinence care for Resident #4, who was observed to have a fecal-soiled diaper, revealed that the resident's groin area and labia were cleaned utilizing repeated motions from the front of the perineal area toward the rectal area and back to the front perineal area with the same soiled area of the cloth. The certified nursing assistant was then observed to clean the rectal area in a motion toward the front perineal area, and back to the rectal area, repeating the motion several times. Observation of Certified Nursing Assistant "AA" on 02/08/2011 at 11:13 a.m. providing incontinence care for Resident #5 revealed that the resident's groin area and labia were cleaned with a front-to-back motion four (4) times using the same soiled area of the wash cloth. During interview with the Director of Nursing at conducted on 02/08/2011 at 12:00 p.m., the Director of Nursing stated that during incontinence care, the area of the wash cloth was to be changed after each wipe and the care was to be provided in a front-to-back motion. | 2014-06-01 |
| 10511 | 10511 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2011-02-08 | 164 | D | 1 | 0 | 4Q8L11 | Based on observation and staff interview, the facility failed to ensure personal privacy during the provision of incontinence care for one (1) resident (#5) in a survey sample of five (5) residents. Findings include: During observation of incontinence care provided by Certified Nursing Assistant (CNA) "AA" for Resident #5 on 02/08/2011 at 11:13 a.m., the privacy curtain was opened next to the entrance door to the room. During the provision of care, a nurse opened the room door, exposing the resident's perinea to residents and staff in the activity/dining area. Interview with the Director of Nursing conducted on 02/28/2011 at 12:15 p.m. revealed that the privacy curtain in the resident's room was too short to provide privacy for the resident. | 2014-06-01 |
| 10510 | 10510 | LAKE CITY NURSING AND REHABILITATION CENTER LLC | 115535 | 2055 REX ROAD | LAKE CITY | GA | 30260 | 2011-02-08 | 309 | D | 1 | 0 | R5SJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician's orders related to the administration of the medications [MEDICATION NAME] and [MEDICATION NAME] for one (1) resident (#1) of seven (7) sampled residents. Findings include: Cross refer to F329 for more information regarding Resident #1. Record review for Resident #1 revealed a Physician's Telephone Orders sheet dated 12/07/2010 ordering that the resident was to receive [MEDICATION NAME] 50 milligrams (mgs.) each morning, and [MEDICATION NAME] 0.5 mgs. each morning. The December 2010 Medication Administration Orders (MAO) sheet documented that the resident had received doses of [MEDICATION NAME] 50 mgs. and [MEDICATION NAME] 0.5 mgs. at 9:00 a.m. on 12/10/2010, 12/11/2010, 12/12/2010 and 12/13/2010, and that both medications were then discontinued on 12/13/2010. However, a 12/14/2010 Psychiatric Consultation: Follow-Up Evaluation for Resident #1 documented that upon consultation per telephone with facility staff on 12/09/2010, the Nurse Practitioner had ordered for staff to discontinue both the [MEDICATION NAME] and [MEDICATION NAME], but that the Nurse Practitioner had received another call on 12/13/2010 during which facility staff indicated that the original orders had not been discontinued, and that the resident had received four (4) doses of each medication. This Evaluation further documented that the Nurse Practitioner then gave another order to discontinue the [MEDICATION NAME] and [MEDICATION NAME]. During an interview conducted on 02/08/2011 at 1:45 p.m. with Nurse "PP", this nurse acknowledged that the Nurse Practitioner had ordered her to stop administration of the medications, but that the order for discontinuation was not written and that the resident continued to received the medications. | 2014-06-01 |
| 10509 | 10509 | LAKE CITY NURSING AND REHABILITATION CENTER LLC | 115535 | 2055 REX ROAD | LAKE CITY | GA | 30260 | 2011-02-08 | 329 | D | 1 | 0 | R5SJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician's orders related to the administration of the antipsychotic medication [MEDICATION NAME] and the antidepressant medication [MEDICATION NAME] for one (1) resident (#1) of seven (7) sampled residents. Findings include: Record review for Resident #1 revealed a Physician's Telephone Orders sheet dated 12/07/2010 ordering that the resident was to receive [MEDICATION NAME] 50 milligrams (mgs.) each morning, and [MEDICATION NAME] 0.5 mgs. each morning. A nursing Departmental Notes entry dated 12/08/2010 at 7:14 a.m. documented that when notified of these new MEDICATION ORDERS FOR [REDACTED]. This Notes entry also documented that the family member requested that the medications not be administered and requested for staff to follow-up with the physician for discontinuation of the medications. A nursing Departmental Notes entry of 12/08/2010 at 3:26 p.m. documented that a facsimile had been sent to the physician regarding clarification of the orders for administration of these medications. The December 2010 Medication Administration Orders (MAO) sheet documented that [MEDICATION NAME] and [MEDICATION NAME] therapy was initiated for Resident #1 on 12/10/2010, and that the resident received doses of [MEDICATION NAME] 50 mgs. and [MEDICATION NAME] 0.5 mgs. at 9:00 a.m. on 12/10/2010, 12/11/2010, 12/12/2010 and 12/13/2010. Entries on this MAO sheet indicated that both medications were then discontinued on 12/13/2010, and a 12/13/2010 Physician's Telephone Orders sheet referenced orders to discontinue [MEDICATION NAME] and [MEDICATION NAME]. A 12/14/2010 Psychiatric Consultation: Follow-Up Evaluation for Resident #1 documented that [MEDICATION NAME] and [MEDICATION NAME] had been discontinued, and documented that upon consultation per telephone with facility staff on 12/09/2010, the Nurse Practitioner had ordered for staff to discontinue both medications. However, this Evalu… | 2014-06-01 |
| 10508 | 10508 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-10-28 | 514 | D | 0 | 1 | CXVR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Findings include: 1.The review for resident #10 revealed physician's orders [REDACTED]. Protein Powder, mix two (2) scoops in water and take by mouth twice daily. Review of September 2009 MAR indicated [REDACTED]. and 5:00pm; and 9/26 and 9/27 at 5:00pm. there was no documentation that this medication had been given. [MEDICATION NAME] 3.9 mg/24hr Patch apply 1 patch topically twice a week (Tues and Sat). The MAR indicated [REDACTED]. [MEDICATION NAME] 5mg/5ml solution take 10ml by mouth twice daily. MAR indicated [REDACTED]. [MEDICATION NAME] 125mg/5ml suspension take 150mg by mouth twice a day: MAR indicated [REDACTED]. Mirtazepine 7.5 mg tablet take one by mouth at bedtime. MAR indicated [REDACTED]. physician's orders [REDACTED]. 2. Record review for resident #11 revealed physician's orders [REDACTED]. [MEDICATION NAME] 20mg capsule by mouth once daily. MAR indicated [REDACTED]. [MEDICATION NAME] 5mg by mouth daily: MAR indicated [REDACTED]. Multivitamin one tablet by mouth daily. MAR indicated [REDACTED]. [MEDICATION NAME] HFA 115/21 Inhaler one puff orally twice daily. MAR indicated [REDACTED]. Interview with Director of Nursing on 10/27/09 at 9:00am and at 10:40am regarding documentation of medications being administered revealed that she could not verify if medications were administered due to the fact the the nurses assigned to administered medications were terminated and no longer work at the facility. Facility policy for medication procedures revealed that after a medication is administered, the name of the ordered medication, the time of administration, the dosage, route, and frequency must be recorded as soon as possible. | 2014-06-01 |
| 10507 | 10507 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-10-28 | 428 | D | 0 | 1 | CXVR11 | Based on record review, review of the facility's policy for pharmacy recommendations and staff interviews,the facility failed to follow consultant pharmacist recommendations for which the physician agreed for one resident (#15) from a sample of nineteen residents. Findings include: Review of the medical record for resident #15 revealed a Pharmacy Consultant Report recommendation dated 10/28/08 suggesting the physician attempt a trial of antidepressant therapy. On 11/18/08, the physician accepted the recommendation of Lexapro ten (10) milligrams (mg) daily. On 11/26/08 the consulting pharmacist again recommended a trial of antidepressant therapy. On 12/10/08, the physician accepted the recommendation with the modification to administer Paxil twenty (20) mg. daily. There was no evidence in the medical record that the physician's response to the pharmacist recommendation for these medications were acted upon. Review of the facility policy/procedure on Medication Regimen Review (MRR) indicated the facility would alert the physician if the MRRs have not been acted upon. Interview with the Director of Nursing (DON) on 10/28/09 at 8:50am revealed the pharmacy recommendations are placed in the physicians's folder for response and signature. The Unit Managers retrieve the addressed forms and ensure new orders are transcribed. The form is then placed in the resident's medical record. Interview with the Medical Records Staff "EE" on 11/28/09 at 10:30am revealed that when the completed MRR is placed in the medical record basket, they are filed in the residents' charts. "EE" further revealed that these forms are not always placed in the medical records basket for filing. A second interview with the DON on 11/28/09 at 11:15am revealed that apparently the facility protocol for Physician response to Pharmacy recommendations was not followed resulting in the physician responses dated 11/18/08 and 12/10/08 not being transcribed as orders. | 2014-06-01 |
| 10506 | 10506 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-10-28 | 275 | D | 0 | 1 | CXVR11 | Based on record review and staff interview, the facility failed to ensure that a comprehensive assessment was completed timely for one (1) resident (#5) from a sample of nineteen (19) residents. Findings include: Record review for resident # 5 revealed that the last assessment contained in the medical record was a quarterly dated 6/21/09 and that the resident's last comprehensive assessment was dated 10/12/08. There was no evidence in the medical record that a comprehensive assessment had been conducted within 366 days of the most recent comprehensive assessment. Interview on 10/26/09 at 2:35 pm with the Minimum Data Set (MDS) Coordinator "AA" revealed that she had not completed the comprehensive assessment. She further indicated that she was behind, the assessment was not ready and it was past due. Review of the comprehensive assessment completed 10/27/09 revealed the Assessment Reference Date was 9/29 /09, a difference of twenty-eight (28) days between the last day of observation and the completion date. | 2014-06-01 |
| 10505 | 10505 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-10-28 | 334 | E | 0 | 1 | CXVR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical records, review of facility policy on Resident Vaccine Administration Guidelines, and staff interviews, the facility failed to ensure that each resident receives education regarding side effects/ benefits and is offered Influenza and Pneumococcal immunization unless medically contraindicated for four (4) residents (#3, #4, #5, and #15,) from a sample of nineteen(19) residents. Findings include: 1.) Review of the medical record for resident # 3 revealed the resident was admitted to the facility on [DATE]. Record review revealed a Master Immunization Record, which indicated that the resident had received the two (2) step [MEDICAL CONDITION] (TB) test. This immunization record had no evidence related to Influenza or Pneumococcal Vaccine. Further review of the medical record for resident # 3 revealed no documentation of education regarding benefits, side effects, contraindications, administration or refusal. Interview conducted 10/27/09 at 2:45pm with registered nurse "CC" revealed that all residents should be assessed on admission for immunizations. She was unable to locate any information regarding the immunization status of resident #3. Interview conducted 10/27/09 at 3:00pm with Licensed Practical Nurse (LPN) "FF" revealed no information in the medical record reflected the resident's immunization status. 2.) Review of the medical record for resident # 4 revealed the resident was admitted [DATE]. Record review revealed a Master Immunization Record, which indicated that the resident had received the two (2) step [MEDICAL CONDITION] (TB) test. This immunization record had no evidence related to Influenza or Pneumococcal Vaccine. Further review of the medical record for resident # 3 revealed no documentation of education regarding benefits, side effects, contraindications, administration or refusal. Interview with the unit manager "CC" on 10/27/09 at 2:45pm revealed all residents should be assessed on admission for … | 2014-06-01 |
| 10504 | 10504 | ETOWAH LANDING | 115348 | 809 SOUTH BROAD ST | ROME | GA | 30161 | 2009-10-28 | 309 | D | 0 | 1 | CXVR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews, the facility failed to ensure physicians' orders were followed for completing Accuchecks, administering Insulin for sliding scale coverage, positioning, and medication transcription for three (3) residents (#3, #6, and #14) from a sample of nineteen (19) residents. Findings include: 1. Record review for resident # 6 revealed a physician's orders [REDACTED]. Observations conducted 10/26/09 at 8:45 am; 10/27/09 at 7:25am and 9:35am, and 10/28/09 at 8:30am revealed the resident was out of bed in a geri-chair with no body pillow. Interview on 10/28/09 at 10:30 am with the unit manager "CC" revealed the resident was suppose to have a tiger stripped body pillow when up in the geri-chair. Review of the resident's care plan revealed that one of the approaches for falls was that when the resident was out of bed in the geri-chair a body pillow was to be used. 2. Review of the medical record for resident # 3 revealed the resident was admitted to the facility on [DATE], post hospitalization for diabetic ketoacidosis, altered mental status and blood glucose measuring greater than 1200 milligrams per deciliter(mg/dl). Further record review revealed physician's admission orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2009 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 10/1/09 8:00pm glucose was 413 and 4 units of insulin was given, but only 2 units should have been given 10/2/09 6:00am no evidence that glucose was done or any insulin administered. 10/3/09 4:30p glucose was 447 and 12 units of insulin was given but the dose should have been 4 units 10/4/09 6:00am the glucose was 483 and there is no evidence that insulin was administered. The resident should have received 5 units of insulin. 10/5/09 8:00pm glucose was 464 and 4 units was administered by only 2 units should have been given. 10/6/09 8:00pm glucose was 450 and… | 2014-06-01 |
| 10503 | 10503 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2010-08-31 | 309 | D | 1 | 0 | KJRG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure one resident (Resident #1) from a sample of three residents, received ordered antibiotic medication timely after order was clarified with the physician to provide the necessary care and services to maintain the highest practicable physical well-being of the resident, in accordance with the physician's orders [REDACTED]. The findings include: A review of the physician's orders [REDACTED]. However, also there was a hospital Therapy Review and Reorder Form faxed at 12:06 p.m. to the facility that indicated that the [MEDICATION NAME] was not to be reordered. This form was a inter-hospital form used for ordering medications from the hospital pharmacy. The resident was readmitted to the nursing home on 7/20/2010 at 8:15 p.m. During review of the orders the next day the DON during interview on 8/31/210 at 12:10 p.m. said that the nurse called the physician to clarify the [MEDICATION NAME] orders the next day after the evening admission. The [MEDICATION NAME] orders were clarified at 2:00 pm. on 7/21/10. However, the medication was not sent from the Pharmacy, thus the resident's 8:00 p.m. dose on 7/21/10 was not given. The facility staff failed to call the after hours pharmacy to obtain the drug to be able to administer the [MEDICATION NAME] on 7/21/2010, for the p.m. dose. The resident's Medication Record revealed the [MEDICATION NAME] was not started timely, and the first dose documented was the 8:00 p.m. dose on 7/22/2010. Thus, there was significant delay in getting the antibiotic started. | 2014-06-01 |
| 10502 | 10502 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2010-03-16 | 166 | D | 1 | 0 | F8LS11 | Based on facility document review, family interview, and staff interview, it was determined that the facility failed to ensure promptly efforts to resolve a grievance filed by the family of one (1) resident ("A") in a survey sample of five (5) residents. Findings include: A Concern/Comment/Compliment form dated 01/30/2010 filed by the family of Resident "A" alleged that the resident did not get morning eye drops, that no toilet paper was available in the resident's bathroom from the evening of 01/29/2010 until the time this grievance was filed at approximately noon on 01/30/2010, and that the call light had been turned on at 11:14 a.m. on 01/30/2010 but was not answered until 11:45 a.m. Further review of this Concern/Comment/Compliment form, and review of a facility In-Service form dated 02/03/2010, revealed documentation indicating that a staff inservice was conducted on 02/03/2010 related to the call light issue. However, further record review revealed no evidence to indicate that the other issues related to eye drop administration and the unavailability of toilet paper had been addressed. During an interview with the family of Resident "A"on 03/10/2010 at 10:00 a.m., this family member stated that issues identified in the grievance dated 01/30/2010 had not been addressed and there was no resolution. During an interview with the Director of Nursing (DON) conducted on 03/10/2010 at 1:15 p.m., the DON acknowledged that the grievances filed by the family of Resident "A" related to eye drop administration and availability of toilet paper were not addressed and resolved. | 2014-06-01 |
| 10501 | 10501 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2011-02-28 | 225 | D | 1 | 0 | Y1TN11 | Based on clinical record review, facility document review, and staff interview, it was determined that facility staff failed to immediately report an injury of unknown source, related to bruising, to the administrator for one (1) resident (#1) in a survey sample of four (4) residents. Findings Include: Review of a facility investigation into an injury of unknown source for Resident #1 revealed a statement from Certified Nursing Assistant (CNA) "AA" which documented that during the 3:00 p.m.-11:00 p.m. shift of 01/25/2011, she had noted bruising on the resident's left hip and down the leg. CNA "AA" further documented that she had reported this to Nurse "BB". However, further record review revealed no evidence to indicate that Nurse "BB" assessed the resident's bruising at that time or notified the administrator of this injury of unknown source. Further review of the facility's investigative documents revealed a statement by Nurse "BB" in which the nurse acknowledged that on 01/25/2011, at around 8:00 p.m. or 9:00 p.m., CNA "AA" had mentioned bruising on the resident's left leg, and that he had intended to look to determine if it was a documented wound or not, but that he had gotten busy and had forgotten. A Nursing Daily Skilled Summary, labeled as a late entry for 01/26/2011 at 5:00 a.m., documented that nursing staff had again been notified by direct care staff of thigh bruising for Resident #1, and that the nurse had assessed Resident #1 at that time and observed bruising. However, further record review revealed no evidence to indicate that the administrator was notified of this injury of unknown source at that time. A Nurse's Note of 01/26/2011 at 2:30 p.m. documented that nursing assessment revealed bruising to the resident's let hip down the lateral side of the leg, and noted the resident's left leg appeared slightly shorter and slightly rotated inward. Further review of facility investigative documents revealed that it was only at that time that the facility initiated an investigation into the resident's in… | 2014-06-01 |
| 10500 | 10500 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2009-04-16 | 514 | E | 1 | 0 | RX6X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized for one (1) resident (#1) from a sample of four (4) residents and other resident's documents ranging from 2008 to 3/25/09, at which time the situation was corrected. Findings include: In the facility's Mortality Review Summary dated 3/25/09 for Resident #1, one of the issues that was documented as a problem during the review, was loose documents found in a drawer in the Nurse's Station (i.e. these items were not filed in the record for review). These items consisted of Medication Administration Records for February 2009 and March 2009, Client Flow Sheets for January 2009 and March 2009, Food and Fluid sheets for February 2009 and March 2009, Vital Sign records for 6/15/08 through 3/01/09, 2008 [MEDICAL CONDITION] Records, some Laboratory Reports that had been seen by the physician, but not filed in the record, Pharmacy/Consultant Notes of 10/29/08 and 9/25/08, Pain Assessments with various dates, Monthly Nursing Review note dated 10/08, One integrated progress note sheet dated 9/25/08 through 10/07/08, Physician's Progress note dated 11/10/08, and Renewal Orders dated 11/10/08. During interview with Administrative Nurse "AA" on 4/16/09 at 3:30 p.m., she stated that during this period of time, there was not a full-time clerk assigned to this unit and thus the filing had not been kept up to standards. At the time of this survey, the above deficiency had been corrected, as the facility had implemented the following: 1. Assigned a clerk to cover this unit to ensure that all filing is kept up to date and in accordance with standards. 2. Administrative Nursing Staff had developed a policy that addressed the practice of recording vital signs in multiple places, as the above method made tre… | 2014-07-01 |
| 10499 | 10499 | SPRING HARBOR AT GREEN ISLAND | 115716 | 200 SPRING HARBOR DRIVE | COLUMBUS | GA | 31904 | 2009-03-31 | 323 | G | 1 | 0 | 9H8311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and observation, the facility failed to ensure the safe use of a heating pad for one (1) resident ("A") from a survey sample of seven (7) residents. This failure resulted in actual harm, a second degree burn, to the resident. Findings include: Record review for Resident "A" revealed a March 2009 Minimum Data Set assessment which indicated that the resident had no short-term or long-term memory problems. A 03/19/2009, 4:20 p.m. physician's orders [REDACTED]. A Daily Skilled Nurses Note of 03/19/2009 at 10:00 p.m. documented that a heating pad had been brought to the facility by the resident's spouse, and the March 2009 Medication Administration Record indicated to apply the heating pad to the resident's lower back every two-to-three hours for 20 minutes. During an interview with Nurse "AA" conducted on 03/30/2009 at 1:30 p.m., Nurse "AA" stated that the resident's family had brought a heating pad for the resident's use, and that the heating pad had been left in the resident's room for the resident to apply. During an interview with Resident "A" conducted on 03/30/2009 at 3:05 p.m., the resident stated that the heating pad had been applied most of the day of 03/20/2009. However, further record review revealed no evidence to indicate that facility staff had monitored the application or use of the heating pad throughout the day of 03/20/2009. During the 03/30/2009, 1:30 p.m. interview with Nurse "AA" referenced above, Nurse "AA" acknowledged that nursing staff had did not monitor the use and application of the heating pad throughout the day of 03/20/2009. A Daily Skilled Nurses Note of 03/20/2009 at 5:00 p.m. documented that a quarter-size blister had been noted to the resident's mid-back, with red, splotchy areas surrounding the blister, and that the nurse practitioner was notified. A 03/20/2009, 5:00 p.m. physician's orders [REDACTED]. twice daily until healed. During the 03/30/2009, … | 2014-07-01 |
| 10498 | 10498 | OAKS HEALTH CTR AT THE MARSHES OF SKIDAWAY ISLAND | 115715 | 95 SKIDAWAY ISLAND PARK ROAD | SAVANNAH | GA | 31411 | 2009-05-06 | 282 | D | 1 | 0 | JSSY11 | Based on observation, record review, and staff interview the facility failed to update the plan of care for pain management and safety devices one resident (#1) on a survey sample of three (3) residents. Findings include: Review of the Significant Change Minimum Data Set (MDS) dated 3/18/09, revealed the resident had sustained a fall in the past 30 days. Furthermore, the resident experienced hip pain on a daily basis that was of moderate intensity. Review of the current plan of care dated 04/22/09 for falls revealed a notation that the resident had a fall and the approach was listed as a chair alarm. However, there was no plan designating when the chair alarm was to be utilized and who was responsible to apply and monitor the chair alarm. Also, a bed alarm is being utilized but was not included on the careplan. Additionally, there was no plan of care for the resident's daily complaints of pain. Interview with the sitter on 05/06/09 at 12:40 p.m., who is present with the resident Monday through Friday from 9:00 a.m. to 3:00 p.m., revealed that the chair alarm is not utilized when she is present during the day. However , when the resident is in bed a bed alarm is utilized. Further interview with the charge nurse, at 12:45 p.m., revealed that the chair alarm is not utilized when the sitter is present, but should be used when someone is not present with the resident. Additionally, the bed alarm is utilized at all times when the resident is in bed. Observation of resident #1 at 11:30 a.m. revealed the resident was sitting up in the wheelchair with the sitter present in the room. There was no chair alarm present. Further observation at 12:40 p.m. revealed a bed alarm was in place. | 2014-07-01 |
| 10497 | 10497 | OAKS - BETHANY SKILLED NURSING, THE | 115705 | 1305 EAST NORTH STREET | VIDALIA | GA | 30475 | 2010-12-27 | 242 | D | 1 | 0 | V2FN11 | Based on observation, facility document review, resident interview, family interview, and staff interview, the facility failed to ensure resident choice related to food preferences for two (2) residents ("A" and "E") on a survey sample of seven (7) residents. Findings include: Review of the Grievance File revealed grievances from the months of October and November 2010 related to food, which included Resident "A's" food preferences not being honored and not being available, and Resident "E" not receiving her preferred snacks. Interview with Resident "A" conducted on 12/27/2010 at 12:00 p.m. revealed the staff had updated her food preferences recently, but she was still receiving sweets including cake with icing instead of the requested fruit. The resident stated this concern had been expressed numerous times, but that the issue had not been resolved. During observation of meal service on 12/27/2010 at 12:30 p.m., the tray delivered to the room of Resident "A" did not contain any dessert. Interview with the family of Resident "E" conducted on 12/27/2010 at 3:26 p.m. revealed the resident preferred a sweet snack, but was given a non-sweet snack. During interview with the Certified Dietary Manager conducted on 12/27/2010 at 1:45 p.m., the Dietary Manager stated she was having difficulty getting staff to read and follow resident preferences on the diet cards. She stated there was misunderstanding related to foods that were available, including ice cream and yogurt, and that items provided to the units were not always served to those who requested them. | 2014-07-01 |
| 10496 | 10496 | OAKS - BETHANY SKILLED NURSING, THE | 115705 | 1305 EAST NORTH STREET | VIDALIA | GA | 30475 | 2010-07-08 | 225 | D | 1 | 0 | LHXU11 | Based on facility document review and administrative staff interview, the facility failed to immediately report allegations of physical and verbal abuse to the State survey and certification agency for one (1) resident (#1) from a survey sample of five (5) residents. Findings include: Review of a facility complaint form dated 06/28/2010 revealed documentation indicating that Resident #1 voiced allegations of physical and verbal abuse by a certified nursing assistant (CNA) on 06/21/2010. Further record review revealed that the facility did investigate these allegations of physical and verbal abuse, however, there was no evidence to indicate that these allegations of abuse had been reported to the State survey and certification agency. During an interview with the Administrator conducted at 12:25 p.m. on 07/08/2010, the Administrator indicated that the facility had conducted an investigation into the allegations referenced above. During additional interview with the Administrator conducted at 3:15 p.m. on 07/08/2010, the Administrator acknowledged that the State office was not notified of the allegations of abuse. Furthermore, the Administrator stated that it was felt this allegation did not need to be reported since the resident desired the accused CNA to continue to care for him/her. | 2014-07-01 |
| 10495 | 10495 | OAKS - BETHANY SKILLED NURSING, THE | 115705 | 1305 EAST NORTH STREET | VIDALIA | GA | 30475 | 2010-09-23 | 280 | K | 1 | 0 | KDKL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident medical record review, facility Incident Report review, review of the facility's Fall Occurrence Reduction Program Policy, and staff interview, it was determined that the facility failed to appropriately review and revise care plans to ensure the ongoing development of effective interventions and approaches to provide adequate supervision related to repeated falls for four (4) residents (#1, #2, #7, and #8), who had been assessed as being at risk for falls, on a total survey sample of twenty (20) residents. These four (4) residents experienced a total of forty-three (43) falls during the period extending from 03/09/2010 through 08/22/2010, sustaining injuries including hematomas to the head, bleeding from the nostril, eye and cheek swelling, an eyeball hemorrhage, elbow lacerations, and bruising to the hip. Additionally, Residents #1, #2, and #7, all of whom received anticoagulant drug therapy, struck their heads a total of five (5) times, two (2) times, and three (3) times, respectively, during these falls. The failure of the facility to reassess and reevaluate these residents and their Plans of Care appropriately to develop interventions and approaches to minimize falls had resulted in a situation in which the non-compliance was likely to cause serious injury, harm, impairment or death for these four (4) residents, and for all residents at risk for falls. It was therefore determined that an immediate and serious threat to resident health and safety existed on April 28, 2010, and was removed on September 23, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Review of the facility's Fall Occurrence Reduction Program Policy revealed the policy indicated that all residents would be assessed for their risk for falls upon admission, and then quarterly and upon any decline or improvement in status, residents would be reassessed for their fall risk, with the implementation of t… | 2014-07-01 |
| 10494 | 10494 | OAKS - BETHANY SKILLED NURSING, THE | 115705 | 1305 EAST NORTH STREET | VIDALIA | GA | 30475 | 2010-09-23 | 323 | K | 1 | 0 | KDKL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident medical record review, facility Incident Report review, review of the facility's Fall Occurrence Reduction Program Policy, and staff interview, it was determined that the facility failed to provide adequate supervision, related to repeated resident falls, for four (4) residents (#1, #2, #7, and #8), who had been assessed as being at risk for falls, on a total survey sample of twenty (20) residents. These four (4) residents experienced a total of forty-three (43) falls during the period extending from 03/09/2010 through 08/22/2010, sustaining injuries including hematomas to the head, bleeding from the nostril, eye and cheek swelling, an eyeball hemorrhage, elbow lacerations, and bruising to the hip. Additionally, Residents #1, #2, and #7, all of whom received anticoagulant drug therapy, struck the head a total of five (5) times, two (2) times, and three (3) times, respectively, during these falls. The failure of the facility to appropriately and adequately supervise these residents and implement effective interventions to minimize falls resulted in a situation in which the non-compliance was likely to cause serious injury, harm, impairment, or death for these four (4) residents, and for all residents at risk for falls. It was therefore determined that an immediate and serious threat to resident health and safety existed on April 28, 2010, and was removed on September 23, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Review of the facility's Fall Occurence Reduction Program Policy revealed the policy indicated that all residents would be assessed for their risk for falls upon admission, and then quarterly and upon any decline or improvement in status, residents would be reassessed for their fall risk, with the implementation of the appropriate interventions. However, during an interview conducted with Nurse "EE" on 09/02/2010 at 9:30 a.m., this nurse acknowledged that t… | 2014-07-01 |
| 10493 | 10493 | SMITH MEDICAL NURSING CARE CTR | 115691 | 501 EAST MCCARTY ST | SANDERSVILLE | GA | 31082 | 2010-04-06 | 280 | D | 1 | 0 | WS1Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to revise the Care Plan to reflect the current pressure ulcer status of two (2) residents (#2 and #3) in a total survey sample of seven (7) residents. Findings include: 1. A review of the medical record for Resident #2 revealed a 02/22/2010 Physician's Interim/Telephone Orders sheet specifying to clean a wound on the resident's sacral area with normal saline and to apply [MEDICATION NAME] Ointment daily with a dry dressing until healed. An observation conducted on 04/06/2010 at 2:35 p.m. revealed the resident had a stage 2 pressure ulcer on the sacral area. Review of the resident's Care Plan revealed that the Care Plan did identify the resident to be at risk for skin breakdown due to referenced risk factors and identified multiple approaches to prevent skin breakdown. However, this Care Plan also indicated that the resident had no current breakdown, and did not reflect the presence of the resident's sacral pressure sore. During an interview with the Administrator conducted on 04/06/2010 at 3:00 p.m., the Administrator acknowledged that the resident's Care Plan did not identify the stage 2 sacral pressure ulcer. 2. A review of the medical record for Resident #3 revealed the resident's Care Plan documented a 09/18/2009 entry indicating that the resident was admitted to the facility with a stage 4 pressure ulcer to the sacrum, a stage 2 pressure sore to the right buttock, and a stage 4 pressure sore to the left heel. During an observation of Resident #3 conducted on 04/06/2010 at 3:00 p.m., the resident presented with only a stage 2 pressure sore to the sacral area. However, further review of the Care Plan revealed that the Care Plan had not been revised to reflect that the stage 2 right buttock ulcer and the stage 4 left heel ulcer had healed, nor that the stage 4 pressure ulcer had healed to a stage 2 pressure ulcer. During an interview with the Administrato… | 2014-07-01 |
| 10492 | 10492 | NANCY HART NURSING CENTER | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2009-10-06 | 156 | D | 1 | 0 | F20711 | Based on record review and staff interview the facility failed to ensure that residents who received a stimulus check, did not have these funds used to pay for the cost of care, for one (1) resident, #3 on a sample of five (5) residents. Findings include: Record review revealed that the facility had received a stimulus check for $250.00 for resident #3 in May 2009. The resident's liability had increased and the facility had taken $82.00 of this stimulus check to cover the liability difference and returned $168.00 to the resident. Interview with the Administrator on 10/06/2009 at 9:45 a.m. revealed that the stimulus checks did not come to the nursing home but were sent to the corporate office. Interview with the family of resident "DD" on 10/06/2009 at 10:00 a.m. confirmed that they had received the stimulus check in the full amount of $250.00 Interview with the owner of the facility on 10/06/2009 at 10:30 a.m. revealed that they did receive the stimulus checks and that were made payable to the nursing home. She added that after these checks were deposited, individual checks were written to the families. She stated that she knew that the Department of Medical Assistance could not count the money as income, but was not aware that the money could not be used to cover nursing home expenses. | 2014-07-01 |
| 10491 | 10491 | PRUITTHEALTH - OLD CAPITOL | 115681 | 310 HIGHWAY #1 BYPASS | LOUISVILLE | GA | 30434 | 2009-03-19 | 284 | E | 1 | 0 | US8H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop post-discharge plans of care to address the continuing care needs after discharge for five (5) residents (#2, #3, #4, #5 and #7) in a survey sample of seven (7) residents. Findings include: 1. Record review for Resident #7 revealed a Discharge Summary Form which documented that the resident had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This Discharge Summary Form also documented that while in the facility, the resident had received [MEDICATION NAME] anticoagulant drug therapy, and that the resident had been subsequently discharged to home with the family on 02/27/2009. A physician's orders [REDACTED]. However, further record review, to include review of the facility's Discharge Plan Of Care Form and the Discharge Summary Form, revealed no evidence to indicate that discharge planning had been done and that information and training regarding the resident's post-discharge continuing care needs, to include diet and drug therapy, had been provided. During an interview conducted on 03/19/2009 at 12:45 p.m., Social Services Staff "AA" acknowledged that he was uncertain of follow-up regarding the discharge. 2. Record review for Resident #2 revealed a 09/17/2008 Minimum Data Set (MDS) assessment which indicated that the resident had a [DIAGNOSES REDACTED]. While in the facility, physicians' orders specified for the resident to receive oxygen therapy, and drugs including [MEDICATION NAME] and Fordel Inhaler. A Discharge Summary Form documented that while in the facility, the resident had received oxygen on an as-needed basis, and that the resident was discharged from the facility on 02/12/2009 to a personal care home. However, further record review, to include review of the facility's Discharge Plan Of Care Form and Discharge Summary Form, revealed no evidence to indicate that discharge planning had been done and that information and training regarding t… | 2014-07-01 |
| 10490 | 10490 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2009-10-07 | 203 | D | 1 | 0 | VQYY11 | Based on record review and staff interview, the facility failed to ensure that the Discharge Notice included the location of the proposed discharge and information regarding the State long term care ombudsman for one (1) resident (#1) on a survey sample of five (5) residents. Findings include: Record review for Resident #1 revealed a Discharge Notice letter dated September 15, 2009, addressed to Resident #1, indicating that the resident would be involuntarily discharged from the facility on October 16, 2009. However, further review of this Discharge Notice revealed that the Notice did not include the location to which the resident was to be discharged , and did not include the name, address and telephone number of the State long term care ombudsman. During an interview with the Assistant Administrator and the Director of Nursing conducted on 10/07/2009 at 4:00 p.m., both acknowledged that the Notice did not include the location to which the resident was to be discharged . | 2014-07-01 |
| 10489 | 10489 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2009-08-11 | 371 | F | 1 | 0 | U6FQ11 | Based on observation, the facility failed to ensure that food items held on the residents' food service steam table were at or above 135 degrees Fahrenheit. The resident census was 153 residents. Findings include: During an observation of the facility's steam table conducted on 08/11/2009 at 8:20 a.m., oatmeal was 100 degrees Fahrenheit (F), eggs were 101 degrees F., and bacon was 101 degrees F. During a prior observation of the steam table conducted on 08/10/2009 at 5:19 p.m., staff were not able to calibrate the thermometer to obtain temperatures, and there was no other thermometer available to monitor temperatures. | 2014-07-01 |
| 10488 | 10488 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2009-08-11 | 166 | E | 1 | 0 | U6FQ11 | Based on facility document review, staff interview, and resident interview, the facility failed to make prompt efforts to resolve a grievance relating to food temperatures for nine (9) Resident Council members who voiced complaints related to cold food in Resident Council meetings on 05/20/2009 and 06/09/2009, and for one (1) resident ("A") on the survey sample of five (5) residents. Findings include: Review of the Resident Council minutes of 05/20/2009 revealed that nine (9) residents complained that food was served cold. The response from the Dietary Manager on 05/21/2009 was to place plate covers on the food. However, review of the 06/09/2009 Resident Council meeting minutes revealed there continued to be resident complaints regarding cold food being served. There was no evidence to indicate that additional actions had been taken to address this problem. During an interview with Resident "A" conducted on 08/10/2009 at 3:30 p.m., Resident "A" acknowledged that food temperatures had been discussed in the Resident Council meetings, but that there had been little change. During an interview with the Dietary Manager (DM) conducted on 08/11/2009 at 8:29 a.m., she stated that she was at a loss as to how to keep food temperatures satisfactory for residents. Cross refer to F371. | 2014-07-01 |
| 10487 | 10487 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2010-03-23 | 242 | D | 1 | 0 | 2S7T11 | Based on record review, facility policy review, and resident interview, it was determined that the facility failed to permit one (1) resident ("A") to smoke cigarettes, of four (4) residents on the survey sample who smoked, from a total survey sample of eight (8) residents. Findings include: The facility's Smoking Policy, dated as having been adopted on 12/18/2009, included a provision which specified a penalty for residents who violated the smoking regulations, further stipulating that a second violation of the facility's smoking regulations would lead to permanent loss of smoking privileges. Record review for Resident "A" revealed a January 2008 Minimum Data Set (MDS) assessment which documented the resident's admission to the facility in December of 2007. The resident's current January 2010 MDS indicated that the resident had only short-term memory problems and modified independence in decision-making. A Social Service Progress Note of 01/18/2010 documented that due to non-compliance with the smoking policy, the resident had lost smoking privileges permanently. A Social Service Progress Note of 03/15/2010 documented that the doctor had suggested consideration of allowing the resident's smoking privileges to be reinstated, but further indicated that the facility would not allow the resident to smoke. During an interview with Resident "A" conducted on 03/23/2010 at 10:30 a.m., the resident stated that his/her smoking privileges had been taken away, but further expressed a desire to smoke. | 2014-07-01 |
| 10486 | 10486 | LIFE CARE CTR OF LAWRENCEVILLE | 115659 | 210 COLLINS INDUSTRIAL WAY | LAWRENCEVILLE | GA | 30045 | 2009-04-15 | 309 | D | 1 | 1 | 9OJ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and family interview the facility failed to ensure that one (1) resident ("B") of twenty-three (23) sampled residents, received services recommended by a consulting physician to promote the healing of a fracture. The findings include: Resident "B" was admitted to the facility on [DATE] for therapy following a fractured femur. Review of the clinical record revealed a Physician's Consultation report dated 2/20/09 which recommended that the resident have an EBI Bone Stimulator for ten (10) hours every day. The Director of Nursing (DON) was interviewed on 4/15/09 at 10:15 a.m. and stated the facility did not provide bone stimulators. She was unable to provide any additional information about the recommendation. The Rehabilitation Department Manager was interviewed on 4/15/09 at 10:30 a.m. and stated a bone stimulator would have to be special ordered specific to the resident. He was not aware of resident "B" ever having a bone stimulator. Physical Therapist (PT) "FF" was interviewed on 4/15/09 at 10:35 a.m. and stated a company representative was called after the order was received, but the representative became ill and was unable to complete the order. PT "FF" further stated the facility did not follow-up on the bone stimulator with the company. A family member of resident "B" was interviewed on 4/15/09 at 10:45 a.m. and stated they had personally made sure the therapy department had the order for the bone stimulator when the resident returned to the facility on [DATE]. | 2014-07-01 |
| 10485 | 10485 | LIFE CARE CTR OF LAWRENCEVILLE | 115659 | 210 COLLINS INDUSTRIAL WAY | LAWRENCEVILLE | GA | 30045 | 2009-04-15 | 312 | D | 1 | 1 | 9OJ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure that one (1) resident (#3) on a sample of twenty three (23) residents received personal hygiene and grooming of fingernails. The findings include: Record review revealed that resident #3 had a Minimal Data Set (MDS) assessment dated [DATE] that indicated the resident had long and short term memory loss, and required extensive care with personal hygiene and bathing. Observation of this resident on 4/13/09 at 2:40 p.m. and again on 4/14/09 at 10:30 a.m. revealed the resident had a brown/black substance under his/her fingernails on both hands. Interview with the Treatment Nurse on 4/14/09 at 10:30 a.m. revealed that this resident often eats with his/her hands and scratches his/herself. This is how his/her fingernails get dirty. Review of the facility's policy related to fingernail care indicated that nail care included daily cleaning and regular trimming. Dirt should be gently removed from around and under each fingernail with an orange stick. | 2014-07-01 |
| 10484 | 10484 | LIFE CARE CTR OF LAWRENCEVILLE | 115659 | 210 COLLINS INDUSTRIAL WAY | LAWRENCEVILLE | GA | 30045 | 2009-04-15 | 314 | D | 1 | 1 | 9OJ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that two (2) residents with pressure sores (#3, #7) on a sample of twenty three (23) residents received the necessary care and treatment to promote healing, and prevention of new sores from developing. This failure was evidenced by the lack of communication related to the need for pressure sore treatment and problems with skin integrity. The findings include: Record review for resident #3 revealed she developed a Stage II pressure sore on her coccyx on 2/06/09. The most recent measurements for this pressure sore was done on 4/08/09. The pressure sore measured 1.0 by 1.0 by 0.4 centimeters in size. Observation of the pressure sore on 4/13/09 at 11:50 a.m. revealed that it did not have a dressing covering the area as ordered by the physician. Interview with the Certified Nursing Assistant (CNA) "BB" at that time indicated that he had performed pericare on the resident at approximately 9:00 a.m. on 4/13/09. At that time the dressing was not in place. He added that he did not report this concern to the Treatment Nurse. Interview with Treatment Nurse "AA" indicated that the resident's dressing was always off when she did the treatment. Another observation during pericare on 4/14/09 at 9:30 a.m. revealed the pressure sore dressing was not in place. Interview at that time with CNA "BB" indicated that when he did pericare at approximately 7:45 a. m., the resident did not have a dressing covering the pressure sore on her coccyx, and he reported this information to the nurse. Also at that time another Stage I pressure sore was seen on the residents right lower buttock. CNA "BB" stated this was not seen when he did the resident's pericare earlier. Another observation with Treatment Nurse "AA" on 4/14/09 at 10:25 a.m. revealed the dressing on the coccyx pressure sore was again not in place. Interview with the Treatment Nurse at that time indicated that she was not aware… | 2014-07-01 |
| 10483 | 10483 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2009-08-25 | 492 | F | 1 | 0 | YU2J11 | Based on observation, interview and record review, the facility failed to have a current licensed nursing home administrator employed to manage the facility in the day to day operations as required by state law. Findings include: A report on August 17, 2009 received by the state survey agency reported that the facility had no licensed nursing home administrator currently employed. During an onsite investigation on August 25, 2009 there was no administer onsite or employed. An interview conducted at 1:00 p.m. with administrative nursing staff member "AA" confirmed that the facility had no licensed nursing home administrator currently employed. | 2014-07-01 |
| 10482 | 10482 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2011-03-23 | 282 | D | 1 | 0 | 8TVO11 | Based on observation and record review, the facility failed to provide care, as specified by the Care Plan, for three (3) residents (#1, #2, and #6) on a total survey sample of six (6) residents. Findings include: 1. Cross refer to F314, Example 1, for more information regarding Resident #6. Record review for Resident #6 revealed a Care Plan entry which specified an Approach to apply bilateral heel protectors daily. However, during a 03/23/2011, 5:25 p.m. observation, the resident had no heel protectors applied on both feet. 2. Cross refer to F314, Example 2, and F312, Example 1, for more information regarding Resident #1. Record review for Resident #1 revealed a Care Plan entry which specified as an Approach to apply bilateral heel protectors. However, observations of the resident on 03/22/2011 at 2:40 p.m. and 5:05 p.m. revealed no heel protector on the right heel. Additional record review for Resident #1 revealed a Care Plan entry which specified as an Approach for staff to provide nail and skin care as needed. However, Resident #1 was observed on 03/22/2011 at 2:40 p.m. to have long fingernails on the first, second, third and fourth fingers of the right hand and on the thumb of the left hand, a dark substance underneath the other fingernails on the left hand, a build-up of dead/dry skin on the bottom of both feet, and a build-up of dead skin between all the toes on both feet. 3. Cross refer to F312, Example 2, for more information regarding Resident #2. Record review for Resident #2 revealed a Care Plan entry which specified to provide nail care and a podiatrist consultation as needed. However, Resident #2 was observed on 03/22/2011 at 2:55 p.m. to have a dark substance underneath all her fingernails, and the second toes had toe nails that were long and curling underneath the toes on both feet. | 2014-07-01 |
| 10481 | 10481 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2011-03-23 | 281 | D | 1 | 0 | 8TVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and review of the facility's written [DEVICE] procedure, the facility failed to ensure that the appropriate care was given in accordance with professional standards of quality, as specified by facility procedure, during administration of medications through gastrostomy tubes for two (2) residents (#1 and #4) from a total survey sample of six (6) residents. Findings include: Review of the facility's written [DEVICE] (gastrostomy tube) procedure revealed that licensed staff were to inject 1 cubic centimeter (cc.) of air into the tube while listening for air in the tube with the stethoscope to check for placement prior to medication administration. Also, the procedure indicated that licensed staff were to flush the [DEVICE] with 30 ccs. of water prior to medication administration. Additionally, the procedure specified that crushed medications were to be dissolved in 10 to 15 ccs. of water. 1. During an observation of medication administration through a gastrostomy tube ([DEVICE]) for Resident #4 on 03/23/2011 at 12:15 p.m., Nurse "CC" failed to check placement of the [DEVICE] and to administer 30 ccs. of water, per facility procedure, before the administration of crushed [MEDICATION NAME] in water through the [DEVICE]. 2. During an observation of medication administration through a [DEVICE] for Resident #1 on 03/23/2011 at 12:40 p.m., Nurse "BB" administered a crushed [MEDICATION NAME] 50 milligram tablet without adding water to the crushed tablet, per facility procedure, before it was administered via the [DEVICE]. Some residue of the crushed tablet was observed to be left in the piston syringe used for the medication administration. | 2014-07-01 |
| 10480 | 10480 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2011-03-23 | 441 | D | 1 | 0 | 8TVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's Infection Control log, and staff interview, the facility failed to log causative agents of infections for one (1) resident (#4) from a survey sample of six (6) residents. Findings include: Record review for Resident #4 revealed a culture and sensitivity of drainage from the gastrostomy tube ([DEVICE]) site done on 01/20/2011, with the final report being sent to the facility on [DATE]. The final laboratory report indicated that the causative agents were a heavy growth of Proteus mirabilis, a heavy growth of Staphylococcus aureus, a light growth of Escherichia coli and a moderate growth of [DIAGNOSES REDACTED] Streptococcus. However, review of the January 2011 Infection Control log revealed that there was no listing of the Proteus mirabilis, the Staphylococcus aureus and the Streptococcus with the date or the location of these causative agents for this resident.. This resident had another culture and sensitivity of drainage from the [DEVICE] site done on 02/16/2011 and the final report was sent to the facility on [DATE]. The final laboratory report indicated that the causative agents were a heavy growth of Proteus mirabilis and a heavy growth of Escherichia coli. However, the review of the February 2011 Infection Control log revealed that there was no listing of the Proteus mirabilis and the Escherichia Coli with the date or the location of these causatives agents for this resident. During an interview conducted on 03/23/2011 at 4:45 p.m., Nurse "AA", who was responsible for the Infection Control Log, acknowledged that she must have missed getting the laboratory reports referencing the above infections. | 2014-07-01 |
| 10479 | 10479 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2011-03-23 | 314 | D | 1 | 0 | 8TVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of a Skin And Bath Report sheet, and staff interview, the facility failed to ensure that the appropriate care was provided to prevent pressure sores and/or to promote healing of existing pressure sores for two (2) residents (#1 and #6), who had a history of [REDACTED]. Findings include: 1. Review of a Skin And Bath Report sheet dated 03/14/2011 revealed that staff had documented Resident #6 to have "bottom broken skin". At the top of this sheet, there was a notation that all wounds or other findings were to be addressed immediately by the charge nurse with follow-up by the resident's physician. However, during an interview with Nurse "BB", the treatment nurse, on 03/23/2011 at 4:30 p.m., Nurse "BB" stated that she had not assessed the broken skin area on the resident's buttocks for size and staging on the date it was discovered on 03/14/2011, and that when first measured on 03/23/2011, the date of this interview, the area was found to measure 1.5 centimeters (cms.) by 1.5 cms. by 0.1 cms.. Nurse "BB" also stated that the physician had not been notified of the broken skin area on the resident's buttocks from 03/14/2011 until 03/23/2011, the date of this interview. Record review revealed a Physician's Telephone Orders sheet of 03/23/2011 which documented that after the physician was notified of the broken area, a new treatment order was given to clean the broken area with wound cleanser, and to apply wound gel and a foam dressing daily. During an observation of Resident #6 with Nurse "AA" at 5:25 p.m. on 03/23/2011 while the resident was in bed, the resident was noted to have a Stage two area on the coccyx, measuring approximately two (2) centimeters. Additional record review for Resident #6 revealed a Care Plan entry of 09/16/2010 identifying that the resident was at risk for skin breakdown, and specified as an Approach to apply bilateral heel protectors daily. However, during the 03/23/2011… | 2014-07-01 |
| 10478 | 10478 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2011-03-23 | 312 | D | 1 | 0 | 8TVO11 | Based on observation, record review, and staff interview, the facility failed to ensure that the appropriate care was provided in regards to grooming and nail care for three (3) residents (#1, #2, and #3), for residents who required assistance from, on a survey sample of six (6) residents. Findings include: 1. Record review for Resident #1 revealed a 06/03/2010 Care Plan entry identifying the resident to had a self-care deficit, and specified as an Approach for staff to provide total assistance with activities of daily living, and to provide nail and skin care as needed. Resident #1 was observed on Tuesday, 03/22/2011 at 2:40 p.m. to have long fingernails on the first, second, third and fourth fingers of the right hand and on the thumb of the left hand. There was a dark substance underneath the other fingernails on the left hand. There was a build-up of dead/dry skin on the bottom of both feet and a build-up of dead skin between all the toes on both feet. During interview with Nurse "BB" who was in the room at the time of this observation, Nurse "BB" acknowledged the above. 2. Record review for Resident #2 revealed a Care Plan entry indicating that the resident was dependent on staff for hygiene care. The resident's Care Plan also identified the resident to be an insulin-dependent diabetic, and indicated to provide nail care and a podiatrist consultation as needed. Resident #2 was observed on 03/22/2011 at 2:55 p.m. and noted to have a dark substance underneath all her fingernails. On both of the resident's feet, the second toes had toe nails that were long and curling underneath the toes. Nurse "BB", who was in the room at that time, acknowledged the above, and stated that the podiatrist had not visited the facility since December 2010. 3. Resident #3 was observed on 03/22/2011 at 5:00 p.m. to have long fingernails on all fingers of both hands. There was an odor coming from the right hand, which was mildly contracted. Nurse "BB" was present at that time and acknowledged the above. During an interview with the Di… | 2014-07-01 |
| 10477 | 10477 | PRUITTHEALTH - DECATUR | 115647 | 3200 PANTHERSVILLE ROAD | DECATUR | GA | 30034 | 2010-11-05 | 323 | G | 1 | 0 | UCS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that one (1) resident (#1) who had been assessed to need the assistance of a Sit-to-Stand Lift for safe transfer, on the survey sample of eight (8) residents, was transferred utilizing the lift. This resulted in Resident #1 sustaining a fall and a femur fracture. Findings include: Record review for Resident #1 revealed a Minimum Data Set (MDS) assessment of 09/29/2010 which indicated that the resident had medical [DIAGNOSES REDACTED]. This MDS also indicated that the resident was totally dependent on staff for transfers and toilet use. The resident's Care Plan, which documented the resident's original date of admission as 04/04/2009, also documented a problem of the resident being at risk for falls. This Care Plan specified, as an approach to address this resident's risk for falls, to assist with transfers as indicated. An assessment by the physical therapist, documented in the Therapy Notes and dated 01/07/2010, recommended the use of a Sara Lift (Sit-to-Stand Lift) for daily transfers. A Lift/Transfer Assessment Form, originally dated 12/29/2009 and dated as having been reviewed on 03/22/2010, 07/07/2010 and 10/01/2010, also indicated that a Sit-to-Stand Lift was required. Additionally, the resident's current ADL Care Plan record specified the use of a Sit-to-Stand Lift for mobility. A Nurse's Note dated 10/25/2010 documented that a Certified Nursing Assistant (CNA) had informed the nurse that she had to lower Resident #1 to the restroom floor while attempting to toilet the resident. This Note documented that the resident was assessed and complained of discomfort in the right leg, that the physician was made aware of the fall, and that an order was received to X-ray the resident's tibia, fibula and femur. The Radiological Consultation X-Ray report dated 10/25/2010 at 7:43 p.m. documented a moderately displaced fracture of the proximal femur. A Nurse's Note of 10/25/20… | 2014-07-01 |
| 10476 | 10476 | PRUITTHEALTH - DECATUR | 115647 | 3200 PANTHERSVILLE ROAD | DECATUR | GA | 30034 | 2009-05-13 | 157 | D | 1 | 0 | FLRQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility document review, family interview, and staff interview, the facility failed to immediately consult with the physician, and notify the family, of bruising of the right eye and left arm for one (1) resident ("A") in a survey sample of five (5) residents. Findings include: Record review for Resident "A" revealed that the resident had current physician's orders [REDACTED]. A Nurse's Note of 04/28/2009 at 4:30 a.m. documented that the resident was combative and had sustained a skin tear on the top of the left arm during an altercation with a staff member, and that a treatment was applied to the area. A Nurse's Note of 04/28/2009 at 5:00 a.m. documented that the physician was notified of the incident and that the residence of the responsible party was called. In a written statement dated 04/28/2009, Certified Nursing Assistant (CNA) "CC", who was the CNA providing care to the resident at the time of the altercation referenced above, documented the injury to the resident's arm, but further documented that no bruising was noted on the residents' head or face at the time of the incident. In a written statement by CNA "AA", this CNA documented that she had been told during the 7:00 a.m. report that Resident "A" had been combative earlier in the morning, and that when she made rounds and began the provision of morning care, she noticed a nickle-size reddish-purple bruise on the right side of the resident's eye. The facility's Investigative Summary documented that during interview, CNA "AA" had indicated that she then reported her findings to Registered Nurse "DD". In a written statement by Registered Nurse "DD", this nurse documented that upon assessment on 04/28/2009, she had observed a red area on right outer eye area of Resident "A" which then darkened throughout the day. However, further record review revealed no evidence to indicate that the physician was immediately consulted, or the the family was notified, of the… | 2014-07-01 |
| 10475 | 10475 | PRUITTHEALTH - DECATUR | 115647 | 3200 PANTHERSVILLE ROAD | DECATUR | GA | 30034 | 2009-03-05 | 225 | D | 1 | 0 | BGXJ11 | Based on record review, staff and resident interview, the facility failed to conduct a thorough investigation of an allegation of physical abuse for one (1) resident (#4) from fourteen (14) sampled residents. The findings include: Record review revealed an investigation into two allegations of physical abuse towards resident #4. These investigations were initiated on 2/09/09 regarding an incident which happened on 2/06/09. The facility was made aware of the two allegations of physical abuse toward resident #4 by the family member of the resident and also by resident "D" who stated that they witnessed both events. The investigation included interviews and written statements from all staff that had been identified in the allegations and other staff members that could have witnessed or were aware of other incidents by the two nurses identified in the complaint. Review of the investigation into the two allegations of physical abuse against resident #4 and other allegations that were also noted by the family member and resident "D" revealed no documentation that interviewable residents were questioned about each allegation of physical abuse. In an interview with resident "L" on 3/05/09 at 4:22 p.m., he/she stated that they witnessed the incident when LPN "M" slapped the hand of resident #4. He/she stated that it happened about two weeks ago and that the nurse also told the resident to behave. In an interview with the Director of Nursing on 3/05/09 at 2:35 p.m. she indicated that all staff identified in the allegations of physical abuse were interviewed along with any staff that could have witnessed the incident. In an interview with the Administrator and Director of Nursing on 3/05/09 at 7:00 p.m., they stated that other residents that lived on the same floor with resident #4 were interviewed regarding the allegations of physical abuse. However, they confirmed that they did not interview other interviewable residents who frequently visited that floor and could have witnessed the incidents. | 2014-07-01 |
| 10474 | 10474 | SCEPTER HEALTH & REHAB OF SNELLVILLE, LLC | 115643 | 3000 LENORA CHURCH DRIVE | SNELLVILLE | GA | 30078 | 2010-12-13 | 205 | D | 1 | 0 | R9QZ11 | Based on staff interview and record review, the facility failed, before hospital transfer, to provide to the resident and a family member or legal representative written notice which specified the duration of the bed hold policy for one (1) resident (#1) from a survey sample of eight (8) residents. Findings include: Record review for Resident #1 revealed a Nurse's Note of 11/17/2010 at 9:00 p.m. which documented that an order had been received to transport the resident to the emergency room for evaluation and treatment, and a Nurse's Note of 11/17/2010 at 9:30 p.m. documented that the resident had left the facility via ambulance. However, further record review revealed no evidence to indicate that, at the time of the hospital transfer, the family/legal representative had been provided written notice specifying the duration of the facility's bed-hold policy. During an interview with the Director of Administrative Services on 12/13/2010 at 11:15 a.m., she stated that the resident and responsible party were notified of the facility's Bed Hold Policy, and the Bed Hold Policy was signed, upon initial admission to the facility. However, she further stated that subsequent notification regarding this policy is provided verbally, and that written notification was not sent upon transfer or discharge. During an interview with the Director of Nursing (DON) conducted on 12/13/2010 at 1:30 p.m., the DON stated that a written Bed Hold notice was sent with the resident, along with the Resident Transfer form, when the resident was transferred to the hospital, but that the family was not provided with a written notice at that time. The DON stated that family notification was provided by the Business Office, by telephone. | 2014-07-01 |
| 10473 | 10473 | AZALEA HEALTH AND REHABILITATION | 115642 | 300 CEDAR ROAD | METTER | GA | 30439 | 2009-03-31 | 364 | E | 1 | 0 | ZVRN11 | Based on resident interview and a test tray, the facility failed to serve foods at the proper temperature for four (4) residents of ten (10) sampled residents. Findings include: During an interview conducted on 03/31/2009 at 10:30 a.m., Resident "D" stated that the food that was served was cold, and that staff did not ask to reheat the food. During an interview conducted on 03/31/2009 at 10:05 a.m., Resident "A"stated the food that was served earlier that morning was cold and that the three (3) meals served the previous day were all cold. Also, the resident stated that the food had always been cold since he/she had lived in the facility. Resident "B" stated during an interview conducted on 03/31/2009 at 10:20 a.m. that the food was sometimes cold and that staff never asked if they could reheat the food. Resident "C" stated during an interview conducted on 03/31/2009 at 10:55 a.m. that the food was always cold at breakfast. The surveyor was served a test tray at 12:15 p.m. on 03/31/2009, and the pork chop and gravy were only lukewarm. | 2014-07-01 |
| 10472 | 10472 | PORTER FIELD HEALTH & REHAB CENTER LLC | 115636 | 3051 WHITESIDE ROAD | MACON | GA | 31216 | 2011-02-03 | 279 | D | 1 | 0 | 0SVN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of medical record and staff interview, the facility failed to develop a careplan related to wandering behaviors and resistance to care for one (1) resident #13 from a sample of thirty-four (34) residents. Findings include: Review of the resident #13's medical record revealed [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] and a quarterly MDS assessment dated [DATE] revealed that the resident was assessed with [REDACTED]. Review of the Resident Assessment Protocol (RAP) completed with the annual MDS assessment revealed that a care plan would be initiated for wandering behaviors. Review of the nurses notes revealed numerous accounts of wandering behaviors and resistance to care. Review of the resident careplan revealed no evidence that wandering behaviors or resistance to care had been care planned. Interview with the MDS coordinator on at 3:00 p.m. 02/01/11 revealed that there were no careplans related to wandering behaviors and/ resistance to care. | 2014-07-01 |
| 10471 | 10471 | BAPTIST VILLAGE, INC. | 115615 | 2650 CARSWELL AVE | WAYCROSS | GA | 31502 | 2009-08-03 | 225 | D | 1 | 0 | 0HJT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to report an injury of unknown origin and send the findings of their investigation to the State Survey and Certification Agency for one (1) resident, Resident #1, on a survey sample of five (5) residents. Findings include: Record review for resident #1 revealed a Departmental Note dated 7/20/09 at 9:52 a.m., that documented right leg pain. Medications were administered and the physician was notified with resulting orders to monitor the resident. At 3:12 p.m. the resident continued to complain of right leg pain from the thigh down. The family elected to have the resident evaluated in the emergency room due to a history of blood clots in that extremity. The physician was notified and the resident was transported to the hospital for evaluation. The resident was subsequently admitted with a [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON), on 8/3/09 at 3:00 p.m., revealed that an investigation was conducted of the incident once it was reported to the facility by the family member after the emergency room surmised the resident had a fall. The cause of the injury was of unknown origin, thus requiring the incident to be report to the State Survey Agency. However the facility did not report the injury of unknown origin to the State Survey and Certification Agency, as required. | 2014-07-01 |
| 10470 | 10470 | WESTWOOD NURSING CENTER | 115601 | 101 STOCKYARD ROAD | STATESBORO | GA | 30458 | 2009-07-07 | 514 | E | 1 | 0 | XBED11 | Based on observation, record review, resident interview, and staff interview, the facility failed to consistently document that bathing and activities of daily living were completed for four (4) residents ("A", "B", "C" and "D") of seven (7) sampled residents. Findings include: 1. Review of the June 2009 Verification of Daily Resident Care sheet (the documented purpose of which was for Certified Nursing Assistants to document resident care and observation of residents as indicated in resident Care Plans) for Resident "A" revealed no Certified Nursing Assistant (CNA) signatures to indicate that resident observation and care had been provided for the 7:00 a.m.-3:00 p.m. shifts on 06/01/2009, 06/29/2009, and 06/30/2009; for the 3:00 p.m.-11:00 p.m. shifts on 06/13/2009, 06/17/2009, 06/18/2009, and 06/20/2009; and for the 11:00 p.m.-7:00 a.m. shifts on 06/09/2009, 06/21/2009, 06/29/2009, and 06/30/2009. During an observation of Resident "A" conducted at 1:05 p.m. on 07/07/2009, the resident was observed to be neat and clean. During an interview conducted at the time of this observation, the resident stated that staff did provide routine grooming. 2. Review of the July 2009 Verification of Daily Resident Care sheet for Resident "B" revealed no CNA signatures to indicate that resident observation and care had been provided for the 7:00 a.m.-3:00 p.m. shift of 07/06/2009; for the 3:00 p.m.-11:00 p.m. shifts of 07/05/2009 and 07/06/2009; and for the 11:00 p.m.-7:00 a.m. shifts of 07/02/2009, 07/03/2009, and 07/05/2009. During an observation of Resident "B" conducted on 07/07/2009 at 10:10 a.m., the resident was observed to be neat and clean. During an interview conducted at the time of this observation, the resident stated that staff did provide routine bathing and grooming. 3. Review of the July 2009 Verification of Daily Resident Care sheet for Resident "C" revealed no CNA signatures to indicate that resident observation and care had been provided for the 7:00 a.m.-3:00 p.m. shifts of 07/04/2009, 07/05/2009, and 07/06/… | 2014-07-01 |
| 10469 | 10469 | WESTWOOD NURSING CENTER | 115601 | 101 STOCKYARD ROAD | STATESBORO | GA | 30458 | 2009-07-07 | 279 | D | 1 | 0 | XBED11 | Based on observation, record review, and staff interview, the facility failed to appropriately update the care plan, regarding supervision during smoking, for one (1) resident (#2) on a survey sample of seven (7) residents. Findings include: Record review for Resident #2 revealed a 04/08/2009 Care Plan entry which indicated that the resident was a smoker and required supervised smoking. However, a Safe Smoking Evaluation dated 06/15/2009 for Resident #2 assessed the resident to be capable of smoking independently, or with set-up, and unsupervised. During an interview with the Director of Nursing (DON) conducted on 07/07/2009 at 1:38 p.m., the DON acknowledged that the resident had been assessed as being a safe smoker in June 2009 and that the resident's Care Plan was to be revised to reflect the smoking assessment. Observation of the smoking porch conducted on 07/07/2009 from 9:50 a.m. until 10:10 a.m. revealed the resident smoking without staff supervision. | 2014-07-01 |
| 10468 | 10468 | PINEWOOD MANOR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2009-02-18 | 314 | D | 1 | 0 | 9HB611 | Based on record review, observation, and staff interview, the facility failed to provide the necessary treatment, per a physician's treatment order, to promote the healing of a pressure sore for one (1) resident (#3) of ten (10) sampled residents. Findings include: Record review for Resident #3 revealed a 02/12/2009 wound assessment sheet which documented that the resident had an existing Stage III pressure ulcer on her/his coccyx, with the date of onset being 06/03/2008. The resident had a current physician's treatment order to pack the ulcer with collagen and to apply a foam dressing everyday until healed. Observation on 02/18/2009 at 10:55 a.m. during a wound/skin assessment, with Nurse "BB" and Certified Nursing Assistant "CC" in attendance, revealed that the resident did have a Stage III pressure sore on the coccyx, but had no wound dressing on the pressure sore. During an interview conducted at the time of this wound assessment on 02/18/2009 at 10:55 a.m., Nurse "BB" acknowledged that no dressing was covering the wound. During an interview also conducted at the time of this observation, Certified Nursing Assistant "CC" stated that when he/she provided incontinence care to the resident earlier in the morning of 02/18/2009 at 7:05 a.m., the resident did not have a wound dressing covering the pressure ulcer, but further acknowledged that he/she did not report to anyone that the dressing was off the wound. | 2014-07-01 |
| 10467 | 10467 | FOX GLOVE CENTER | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2011-03-15 | 441 | D | 1 | 0 | ZVWY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that staff maintained a clean field during dressing change of a pressure ulcer for one (1) resident (#2) from four (4) sampled residents. Findings include: Observation of a pressure ulcer treatment for [REDACTED]. all supplies and placed them on the built in dresser in the resident's room. The supplies were a box of gloves, a small pink tray with two (2) stacks of gauzes, a box of Santyl, a bottle of wound cleanser, tape and on top of one (1) stack of gauze was a non-stick dressing. Also, a clear plastic bag was placed on the bed. The nurse washed her hands and donned gloves prior to starting. The old dressing was already removed, so the nurse cleansed the wound, removed her gloves, and placed her balled up gloves to the left side of the pink tray with the gauzes and non-stick dressing. The nurse then washed her hands, gloved and cleaned the wound. After cleaning she removed her gloves and placed them in the bag on the bed, then washed hands and gloved again. At that time, she moved the non-stick dressing from the stack of gauze and placed it on the balled up soiled gloves and proceed to open the Santyl and place Santyl on the dressing. Then the nurse cleanse the wound again, removed gloves, and her washed hands. At this point, when the nurse went to get gloves out of the box, which was next to the dressing with the Saintly on it, the gloves were hard to come out and the nurse had to pull on the box which caused the bos to be lifted up and when lowered back down was lowered onto the Santyl dressing. She then applied the dressing to the resident's wound and secured the dressing with tape. Interview with the Director of Nursing (DON) on 3/15/11 at 3:15 p.m. revealed the soiled gloves should never have been placed next to the tray nor should have the Santyl dressing have been placed on the resident after contact with the glove box. Interview with the Staff Development Coordi… | 2014-07-01 |
| 10466 | 10466 | FOX GLOVE CENTER | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2011-03-15 | 157 | D | 1 | 0 | ZVWY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the facility failed to notify the family in a timely manner of a change in condition for one (1) resident (#1) out of a sample of four (4) residents. Findings include: Review of the Interdisciplinary Progress Notes dated 1/2/11 revealed that resident #1 was observed during care to have a skin tear to the right buttock, the physician was contact and a [MEDICATION NAME] dressing was ordered. The responsible party was notified. On 1/10/11 the physician's order was changed to cleanse the right buttocks with wound cleanser and apply santyl ointment, and a wet to dry dry dressing with Dakin's solution daily. Continue review from 1/2/11 until resident went to the hospital on [DATE], revealed there was no evidence that the responsible party/family was notified that the skin tear progressed to a bed sore and/or that the treatment had changed. Review of the Pressure Ulcer Documentation Form for January 2011 for resident #1 revealed that there was a stage three (3) pressure sore on the sacrum, which progressed from 4x6 on 1/6/11 to 4x6.3 on 1/12/11 with no tunneling and/or undermining present. However, there was no evidence the family was notified of this change. Review of the facility policy, "Change in Condition of a Resident", effective date 1/2008, revealed the facility is to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident. Interview with the Director of Nursing (DON) on 3/15/11 at 2:20 p.m., revealed that the family should have been notified and was unable to give a particular reason why they were not notified in change of condition. | 2014-07-01 |
| 10465 | 10465 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2009-02-04 | 514 | C | 1 | 0 | SLGD11 | Based on record review and staff interview, it was determined that the facility had failed to ensure that the Completed Care Tasks records for all residents in the facility, including Resident #1, were accurate. Findings include: A review of the Completed Care Task record for resident #1 revealed that there were time discrepancies documented on 10/23/08 and 10/24/08 in relation to when the actual time of care was provided. It was documented on 10/23/08 at 1:22 p.m. that the tasks of serving both breakfast and lunch were performed and the resident had eaten 100% of those meals. It was documented on 10/23/08 at 9:40 p.m. that the resident was out of the bed, in the wheelchair and in the dining room for supper. At 1:27 a.m. it was documented that the resident was bathed by washing his/her face. It was documented on 10/24/08, from 2:21 p.m. to 3:35 p.m., that various tasks were performed for the resident, including that the resident was repositioned in the chair, was "continent of urine?", had his/her face washed, voided three times, had 360 cubic centimeters (cc) of fluid, ate 100% of breakfast and 75% of lunch and had another 360 (cc) of fluid. Although on that date, it was documented in the Nurse's Notes that the resident had been out of the facility from 12:00 p.m. to 5:45 p.m., to the hospital getting his/her right arm x-rayed. Further, it was documented that at 3:39 a.m. the resident was bathed by washing his/her face. An interview conducted with the Assistant Director of Nursing on 2/4/09 at 3:15 p.m. revealed that the Completed Care Tasks Records for that resident and all of the other residents in the facility were from a computer system for charting care tasks. He/she stated that the certified nursing assistants (CNAs) used worksheets throughout the day in regards to the care tasks completed. Then at the end of their shifts, the CNAs' keyed that information into the computer system. He/she stated that the times that they keyed the information into the computer was not the "real time" that the tasks were comp… | 2014-07-01 |
| 10464 | 10464 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2009-04-09 | 157 | D | 1 | 1 | Q75711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and physician interview, it was determined that the facility failed to consult with one resident's (#16) physician regarding a significantly elevated body temperature from a total sample of 24 residents. Findings include: Review of the 4/4/09 nurses notes for resident #16 revealed that the resident had developed a fever of 102.2 at 5:53 p.m. Although 650 milligrams of [MEDICATION NAME] was administered to the resident at that time, staff failed to consult with the resident's attending physician regarding the elevated body temperature. During an interview with the resident's physician on 4/9/09 at 2:20 p.m., he stated that he would expect to be notified if the resident had a fever of 102.2. | 2014-07-01 |
| 10463 | 10463 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2010-02-03 | 309 | D | 1 | 0 | 8WCG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer sliding scale insulin as the physician ordered for one (1) resident (#2) of the six (6) sampled residents. Findings include: Review of clinical record for Resident #2 revealed a February 2010 physician's orders [REDACTED]. This physician's orders [REDACTED].= 0 units; 200-274 = 4 units; 275-350 = 6 units; greater than or equal to 351 = 8 units. However, review of the resident's January 2010 Medication Administration Record [REDACTED]. When the resident's 7:00 a.m blood sugar level on 01/26/2010 was recorded as 266, 6 units of [MEDICATION NAME]were administered instead of 4 units as ordered. The resident's 7:00 a.m. blood sugar level on 01/31/2010 was recorded as 263 but, 6 units of [MEDICATION NAME]were given iinstead of 4 units as ordered. During an interview conducted on 02/03/2010 at 4:00 p.m., the Director of Nursing and Administrator acknowledged that the resident had been given 6 units of insulin on the dates and times referenced above instead of 4 units as ordered by the physician. | 2014-07-01 |
| 10462 | 10462 | FRIENDSHIP HEALTH AND REHAB | 115559 | 161 FRIENDSHIP ROAD | CLEVELAND | GA | 30528 | 2010-12-01 | 312 | D | 1 | 0 | 7GRM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, it was determined that the facility failed to provide appropriate toenail care for one (1) resident ("A") in a survey sample of five (5) residents. Findings include: Record review for Resident "A" revealed the Minimum Data Set (MDS) assessment of August 2010 indicated that the resident had required the assistance of staff with activities of daily living, including personal hygiene, and that the resident had [DIAGNOSES REDACTED]. This MDS also indicated under the Foot Problems And Care Section that the resident had not had the nails trimmed during the last 90 days. A podiatry progress note signed by the podiatrist and dated 08/06/2009 documented that the resident's ten nails had been debrided on 08/06/2009, and that the resident was to be seen again in three months or sooner if needed. This note also documented that the resident complained of long, painful toenails, which had been present for years and were increasing in severity. However, further record review revealed no evidence to indicate that the resident was seen again by the podiatrist. During an interview with the Administrator conducted on 12/01/2010 at 3:40 p.m., the Administrator acknowledged that the resident had not been placed on the podiatrist's list to have the toenails cut during 2010, and acknowledged that the last documented time the resident was seen by a podiatrist was 08/06/2010. During an interview with the family of Resident "A" conducted on 12/01/2010 at 12:00 p.m., the family stated that prior to the resident's November 2010 death, the resident's toenails were overgrown and curved under the toes. | 2014-07-01 |
| 10461 | 10461 | LILLIAN G CARTER HEALTH AND REHABILITATION | 115550 | 225 HOSPITAL STREET | PLAINS | GA | 31780 | 2010-07-14 | 333 | D | 1 | 0 | 27W911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, facility policy review, and review of drug manufacturer's instructions, it was determined that the facility failed to administer the medication [MEDICATION NAME] in accordance with the manufacturer's directions and facility policy for one (1) resident ("A"), who had a [DIAGNOSES REDACTED]. Findings include: Record review for Resident "A" revealed the July 2010 physician's orders [REDACTED]. This physician's orders [REDACTED]. The manufacturer's instructions for administration indicated that [MEDICATION NAME] should be administered in the abdomen. Additional manufacturer's instructions indicated that [MEDICATION NAME] should not be injected anywhere other than in the abdominal area. Manufacturer's instructions further indicated that [MEDICATION NAME] should be injected into fatty tissue only, which was why the abdomen was the recommended injection site, and that failure to utilize the appropriate site could cause bruising and discomfort. In addition, injection site instructions in the medication book and on each medication cart specified that [MEDICATION NAME] injections should only be given in the abdomen. However, review of the June 2010 Medication Administration Record [REDACTED]. Review of the resident's July 2010 MAR indicated [REDACTED]. During an interview with Resident "A" conducted on 07/14/2010 at 10:00 a.m., the resident stated that staff would sometimes administer [MEDICATION NAME] in his/her arms. During an interview with the Administrator conducted on 07/14/2010 at 12:40 p.m., the Administrator acknowledged this medication error. | 2014-07-01 |
| 10460 | 10460 | CROSSVIEW CARE CENTER | 115541 | 402 E. BAY ST | PINEVIEW | GA | 31071 | 2009-04-16 | 314 | D | 1 | 0 | XCY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility had failed to provide the appropriate care for one resident with a pressure sore, Resident #3, from a sample of four residents: Findings include: According to the medical record Resident #3 had a history of [REDACTED]. According to the wound care clinic note of 12/16/08, it was documented that the right heel ulcer had healed in June of 2008. The resident had an order in place, at least since 9/08 and prior to 12/3/08, for [MEDICATION NAME] border to the right heel every three days and to pull the dressing back daily and check the status of the heel. Review of the documentation on the treatment record for 12/3/08 revealed a notation that the right heel had re-opened. The facility continued to use [MEDICATION NAME] and dry dressing every three days without notifying the physician that the right heel had re-opened. There was no documentation found with a description of the newly opened area, in regards to the size or stage of the open area on the right heel, on 12/3/08. Also, there was no documented evidence that the dressing was pulled back over the heel and monitored daily as ordered. There was no documented evidence that the physician was notified until 6 days later of the open area on the right heel, on 12/9/08, at which time it was described as an open area (no stage), 5 centimeter (cm.) by 1 cm. with large amounts of brown drainage with a very foul odor. The physician ordered a wound culture on that date. The culture showed a heavy growth of Escherichia coli and [MEDICATION NAME] faecalis. Interview with licensed administrative staff "AA" on 4/16/09 at 3:00 p.m. revealed that he/she stated that the physician should have been notified on 12/3/08 when the right heel area had re-opened. | 2014-07-01 |
| 10459 | 10459 | CROSSVIEW CARE CENTER | 115541 | 402 E. BAY ST | PINEVIEW | GA | 31071 | 2009-04-16 | 157 | D | 1 | 0 | XCY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility had failed to ensure that the physician was promptly consulted when there were changes in physical condition for two residents, Residents #1 and #2 from a sample of four residents. Findings include: 1. Record review for resident #1 revealed that he/she had a [MEDICAL CONDITION] of the left leg before his/her admission to the facility in 2005. According to the 12/12/08 (Friday) at 9:10 p.m. nursing note, he/she was found on the bathroom floor. He/she stated that the left knee popped but had no complaints of pain. The nursing note further documented that the physician would be notified the next office day (Monday). The resident had an order for [REDACTED]. He/she was medicated with [MEDICATION NAME] 100/650 for each of these complaints of pain. A nursing note of 12/15/08 at 12:30 a.m. documented that the resident complained of left upper extremity pain, was tender to touch and had swelling. It was noted that the resident cried out with pain at times. He/she was medicated with [MEDICATION NAME] again. However, licensed staff failed to notify the physician timely of this continued complaint of increasing severity of left knee pain until 12/15/08 at 9:00 a.m. (Monday). The resident was sent to the physician on 12/15/08 and was diagnosed with [REDACTED]. The above was acknowledged by licensed administrative staff "AA on 4/16/09 at 3:00 p.m.. 2. According to the 3/9/09 (Monday) at 10:00 a.m. nursing note for resident #2, it was noted that it had been been reported to this nurse that the resident had diarrhea over the weekend and the resident continued with diarrhea that morning. There was no documentation in the clinical record that the resident had experienced diarrhea or if anything was done to treat the diarrhea episodes of Saturday and Sunday (3/7 and 3/8/09). Documentation revealed the physician was not notified about the continued diarrhea until the morning of 3/9… | 2014-07-01 |
| 10458 | 10458 | CROSSVIEW CARE CENTER | 115541 | 402 E. BAY ST | PINEVIEW | GA | 31071 | 2009-03-11 | 323 | D | 1 | 0 | 5EVK11 | Based on record review, observation, and staff interview, the facility failed to develop or implement interventions to address the potential for accidents for two (2) residents (#1 and #2) from a total survey sample of six (6) residents. Findings include: 1. Record review for Resident #1 revealed Nurse's Note of 1/20/09 at 10:40 a.m. that the resident was found to have a hematoma over the left clavicle area. According to a Resident Assessment Protocol of 1/22/09, it was documented that the physician had felt that the resident had sustained the injury as the result of the siderails. According to the Nurse's Note of 1/25/09 at 2:10 p.m., the resident had been placed on a low bed with no siderails. The family members of this resident had objected to the low bed. The Nurse's Note of 1/26/09 at 1:00 p.m. documented that the resident had been placed back on a regular bed with bilateral siderails. This note also documented that bilateral siderails guards had been placed on the siderails. During an interview with licensed staff "AA" on 3/11/09 at 2:00 p.m., he/she stated that the resident would throw his/her legs over the siderails and would try to come through the siderails. This was also documented on a facility Incident Report of 1/20/09. A current Resident Care Plan entry indicated that the resident was at risk for falls. However, further record review, to include review of this Care Plan, revealed no evidence to indicate that, after 1/26/09, that the facility had evaluated the use of siderails as a potential accident hazard for this resident or to develop interventions to address the resident's attempts to come over the siderails Observations of the resident on 3/10/09 at 5:40 p.m. and on 3/11/09 at 2:00 p.m. revealed that he/she was on the bed with both siderails up and with no protective coverings or siderail guards. 2. Resident #2 was identified on the careplan as being at increased risk for skin impairment with an intervention added to the care plan on 11/6/08 to apply arm sleeves bilaterally to decrease risk fo… | 2014-07-01 |
| 10457 | 10457 | ARROWHEAD HEALTH AND REHAB | 115539 | 239 ARROWHEAD BOULEVARD | JONESBORO | GA | 30236 | 2009-10-15 | 441 | D | 0 | 1 | 901T11 | Based on observation and staff interview the facility failed to maintain infection control practices to decrease the likelihood of the transmission of infection for one (1) resident (#12) on a sample of twenty-one (21) residents. Findings include: Observation on 10/14/09 at 10:50 a.m. of incontinence care for resident #12 provided by Certified Nursing Assistant (CNA) "BB" revealed that the privacy curtain was only partially closed during the care. Another CNA attempted to enter the room after knocking, CNA "BB" stopped care and attempted to close the section of the curtain that was opened with her gloved hands and then resumed incontinence care for the resident without changing her gloves. Interview with Licensed Practical Nurse/Unit Manager "AA" on 10/14/09 at 11: 05 a.m. revealed that the CNA should have changed her gloves once they became contaminated by touching the curtains, prior to continuing incontinence care. | 2014-07-01 |
| 10456 | 10456 | ARROWHEAD HEALTH AND REHAB | 115539 | 239 ARROWHEAD BOULEVARD | JONESBORO | GA | 30236 | 2009-10-15 | 164 | D | 0 | 1 | 901T11 | Based on observation and staff interview the facility failed to ensure that full visual privacy was provided during care for one (1) resident (#12) of the twenty-one (21) sampled residents. Findings include: Observation on 10/14/09 at 10:50 a.m. of incontinence performed by Certified Nursing Assistant (CNA) "BB" for resident #1, revealed the CNA failed to pull the privacy curtains completely around the bed prior to the beginning of the care. The resident was in a bed beside the entrance doorway and the curtain was not pulled to enclose the foot of the bed. During the care another CNA entered the room, opening the door and leaving the resident exposed. Interview on 10/14/09 at 11:05 a.m. with Licensed Practical Nurse/ Unit Manager (LPN/UM) "AA" revealed that the CNA should have pulled the curtains entirely around the resident to ensure privacy. | 2014-07-01 |
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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 );