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 ▼ |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 10556 | 10556 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2009-07-22 | 315 | D | LY2811 | Based on a review of the Resident Census and Condition report, facility's policy/procedure for Bladder Retraining, Bowel and Bladder Elimination Pattern Assessment tool, resident and staff interviews, the facility failed to restore/maintain as much normal bladder function for one (1) resident ( "Y" ) from a sample of twenty four (24) residents. Findings include: During an interview with resident "Y" on 7/21/09 at 10:30 am, revealed that she was continent during the day but uses a brief at night. She further revealed that she occasionally has accidents if she does not get to the toilet fast enough. She indicated that the Certified Nursing Assistants ( CNAs) check and change her when she wears the briefs at night. During a review of the admission MDS ( Minimum Data Set ) assessment for resident "Y" dated 8/20/08, and quarterly assessments dated 1/16/09 and 7/1/09 revealed the resident was assessed as being continent of bladder but required extensive assistance with transfers. Record review revealed a Bladder Elimination Assessment form dated 3/7/08 through 3/13/08, which was to determine the resident's bladder function/toileting schedule, was incomplete. A review of the facility policy/procedure for Bladder Independence/Retraining that was in effect since 11/03 revealed the following criteria: Assess the resident for factors that would create difficulty for the resident to toilet safely. Establish interventions to meet individual resident's goals. Maintain a voiding schedule that is based on the resident's voiding assessment Further record review revealed the facility had failed to follow their policy/procedure to assess/maintain this residents' bladder function. Interview with the Director of Nursing (DON) on 7/22/09 at 11:15am revealed that the facility had continued to use a three (3) day voiding and bowel assessment for residents on admission. She further revealed that the last assessment for a resident for a bowel and bladder program was October 2008. There are no residents currently on a Bowel and Bladder Ret… | 2014-04-01 | ||
| 10557 | 10557 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2009-07-22 | 356 | B | LY2811 | Based on observations and review of the facility posted staffing data forms, the facility failed to post the daily census for three (3) days of the survey (7/20/09 through 7/22/09). Findings include: Observations of the staffing data forms posted on 7/20/09 through 7/22/09, at 1:00pm each day, revealed no resident census posted on the staffing data form. | 2014-04-01 | ||
| 10558 | 10558 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2009-07-22 | 469 | D | LY2811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to ensure that one (1) resident ( "Z" ) from a sample of twenty-four (24) residents was free of pests. Findings include: Observation on 7/22/09 at 8:15 am revealed tiny insects crawling on resident "Z's " right hand and lower part of arm. Further observation revealed tiny insects crawling on the resident's bed on the right side rail and on the call light. Further observation at 8:30 am revealed tiny insects crawling on a bottle of baby powder on the bedside table near the resident's bed and the insects were crawling on the call light cord from the wall to the bed. During an interview with charge nurse "EE" on 7/20/09 at 8:30 am, revealed that the tiny insects were ants and that the ants were also on the bedside table. During an interview with resident "Z" on 7/20/09 at 9:00 am revealed that the resident had problems with ants before in the past, but has never been bitten. She further indicated that she has never had ants on her or in her bed before. Interview with maintenance staff "GG" on 7/22/09 at 9:35 am revealed that there had been no problens in this room with ants, however; ants had been a problem in resident room 128 in the past. A review of the pest management invoice dated 7/15/09 revealed resident room 128 was treated for [REDACTED]. Further interview with maintenance staff "GG" on 7/22/09 at 3:15 pm revealed that the Pest Control Company had determined that the ants in resident's "Z" room were coming in from the outside due to a crack in the wall near the air conditioner unit. | 2014-04-01 | ||
| 10559 | 10559 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2010-12-10 | 365 | K | WE6B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility records, resident medical records review, interviews with family, emergency medical technicians, and staff, it was determined the facility failed to provide food in a form that met the individual needs of six (6) sampled residents ("A", #2, #3, #4, #6 and #7) of 13 sampled residents. This failure resulted in serious harm (death) for Resident "A" and had a high potential for serious harm for the five sampled residents who had orders for ground meat diets or house ground diets that were reviewed. Additionally, further residents were identified at risk based on review of the Centers for Medicare and Medicaid Services (CMS), Form 672, that denoted 65 residents in the facility required mechanically altered diets, either pureed or all chopped food. Of these 65, according to review of the facility's Diet Listing, 52 residents required gound meat and/or foods, thus all 52 of these residents would be at potential risk for serious harm. It was determined that an immediate and serious threat to resident health and safety existed as of 10/30/10 and was removed on 12/09/10, at which time a plan was implemented by the facility to remove the immediate jeopardy situation. Findings include: A review of the facility's Saturday Week #3 Fall-Winter Menus revealed that on October 30, 2010, the planned supper menu for residents receiving regular diets listed the meat being served as beef tips over noodles. For the ground diets, the meat was to be three ounces of ground beef tips. On December 7, 2010, the Tuesday Week #1 Fall-Winter Menus had a planned supper menu of homemade beef stew listed as the meat for regular diets. The menu for "ground" consistency read 6 ounces (soft veggies) and did not denote the amount nor the consistency of meat to be served. The Registered Dietician stated during an interview on 12/10/10 at 3:00 p.m., that since 12/8/10, she had revised the menu for homemade beef stew, for ground diets, to read 6 ounces of … | 2014-04-01 | ||
| 10560 | 10560 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2010-12-10 | 361 | K | WE6B11 | Based on review of facility records, review of resident medical records, observations, and staff interviews, the facility failed to ensure that menus for residents having physicians ' orders for ground consistency specified the amount and consistency of meat to be served, and failed to ensure that staff were knowledgeable about proper procedures for food preparation and service regarding food form, for five (5) residents (#s 2, 3, 4, 6 and 7), who had physicians ' orders for ground meat diets or house ground diets, of thirteen (13) sampled residents. This failure resulted in a high potential for serious harm for these five (5) sampled residents. Further, residents were identified at risk based on review of the Centers for Medicare and Medicaid Services Form 672, which denoted that sixty-five (65) residents required mechanically altered diets, either pureed or all-chopped food. According to review of the facility ' s Diet Listing, fifty-two (52) of these sixty-five (65) residents required ground meat and/or foods, thus placing all fifty-two (52) residents at potential risk for serious harm. It was therefore determined that an immediate and serious threat to resident health and safety existed as of 10/30/2010, and was removed on 12/09/2010, at which time a plan was implemented by the facility to remove the immediate jeopardy situation. Findings include: A review of the facility's Saturday Week #3 Fall-Winter Menus revealed that on October 30, 2010, the planned supper menu for residents receiving regular diets listed the meat being served as beef tips over noodles. For the ground diets, the meat was to be three ounces of ground beef tips. On December 7, 2010, the Tuesday Week #1 Fall-Winter Menus had a planned supper menu of homemade beef stew listed as the meat for regular diets. The menu for "ground" consistency read 6 ounces (soft veggies) and did not denote the amount nor the consistency of meat to be served. Interview with dietary staff "AA" on 12/8/10 at 4:35 p.m. revealed that she had prepared the evening mea… | 2014-04-01 | ||
| 10561 | 10561 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2010-12-01 | 253 | E | YYPJ11 | Based on observation, resident interview, and staff interview, it was determined that the facility had failed to maintain an orderly environment on one (1) hall (200 hall) of two (2) halls observed. The findings include: During interview with Resident "A" conducted on 12/01/2010 at 2:30 p.m., the resident stated that there were leaks in rooms 209, 208 and 207. Observations of rooms 210, 209, 208 and 207 on 12/01/2010 at 3:45 p.m. revealed the following: 1. In room 210, there was a stained, wet and bulging ceiling tile over the lavatory. 2. In room 209, there were two missing ceiling tiles over where the "A" bed should have been. The insulation in the ceiling was saturated and a dark substance was observed in the area around the wet insulation. There was a large bedspread on the floor under this area. 3. In room 208, there was a missing ceiling tile over the bedside table at the "A" bed. The ceiling tiles around this area were soaked and bulging. 4. In room 207, there were bulging and wet ceiling tiles at the fluorescent light at the foot of the "A" bed and in front of the closets. During an interview with the Assistant Maintenance Director, who had worked at the facility since August of 2009, he stated that there had been leaks on the 200 hall since he had been at the facility. Some of the leaks had been in rooms 207 and 212. He provided a current receipt, dated 11/17/10, for Lexel to fix the leaks in the rooms on the 200 hall. He stated that he had used such things as Lexel, Mastic and other caulking to try to repair the leaks in these rooms and on this hall, however, these measures had only fixed the leaks temporarily. | 2014-04-01 | ||
| 10562 | 10562 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2010-12-01 | 312 | D | YYPJ11 | Based on observation, record review, and staff interview, it was determined that the facility failed to ensure the provision of the appropriate incontinence care for one (1) resident (#5) from a survey sample of five (5) residents. Findings include: Record review for Resident #5 revealed the resident's Care Plan of 10/26/2010 indicated that the resident was totally dependent on staff for all activities of daily living care, including incontinence care. During an observation of incontinence care for Resident #5 at 12:35 p.m. on 12/01/2010, two (2) certified nursing assistants (CNAs) initially cleaned the resident with a disposable blue pad that had been dampened with water. However, these CNAs failed to wash any portion of the resident's penis. It was observed that the resident had been incontinent of urine. Licensed Staff "AA" was in the room during this observation and acknowledged that this incontinence care was not performed appropriately. | 2014-04-01 | ||
| 10563 | 10563 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2010-12-01 | 225 | D | YYPJ11 | Based on facility document review, it was determined that the facility had failed to report allegations of neglect and mistreatment to the State survey and certification agency for one (1) resident (#1) from a survey sample of five (5) residents. Findings include: A 10/29/2010 facility complaint form which referenced Resident #1 documented that Resident #1 alleged via an e-mail to facility staff, including the Director of Nursing, that on 10/23/2010 at approximately 4:50 a.m., a certified nursing assistant (CNA) on the 11:00 p.m. - 7:00 a.m. shift told the resident that if she had to provide care at that time, then she would not get the resident up in the morning. The resident also alleged that the CNA then "snatched the call light" and "snatched the pillows from underneath" the resident's legs. Review of the facility's investigation revealed that the facility did conduct an investigation into these allegations of neglect and mistreatment, but there was no evidence to indicate that the allegations had been reported to the State survey and certification agency. | 2014-04-01 | ||
| 10564 | 10564 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 371 | F | DOSV11 | Based on observations, record review and staff interview the facility failed to prepare food under sanitary conditions for all residents consuming food (facility census 89.) The findings include: Observation of the kitchen on 08/03/09 at 9:00 a.m. revealed the can opener blade contained a thick build-up of a dark, sticky substance. Review of the Daily and Weekly Cleaning Assignments revealed that washing and sanitizing of the can opener blade was not listed. Observation on 08/04/09 at 10:50 a.m. revealed multiple raw chicken pieces in a preparation sink under cold, running water. The water was running over the raw chicken and draining down the sink. Interview with a dietary staff member "AA" at this time revealed she did not know that raw meat must also be submerged in water for proper thawing by this method. Interview with the dietary manager on 8/4/09 at 2:35 p.m. revealed she also was not aware this requirement. | 2014-04-01 | ||
| 10565 | 10565 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 323 | D | DOSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview the facility failed to ensure that an intervention, clip alarm, to prevent falls was implemented for one (1) resident (#1) from a sample of twenty one (21) residents. The findings include: Observations of resident #1 conducted 08/03/09 at 10:55 a.m. and 12:50 p.m. revealed the resident had no clip alarm on the bed. Further observation on 08/04/09 at 7:55 a.m. revealed there was no alarm on the bed. A second observation on 8/04/09 at 10:30 a.m. revealed the resident was in bed and no clip alarm was on. Interview with Licensed Practical Nurse ( LPN) "BB" on 8/4/09 at 11:00 a.m. revealed an clip alarm was located and applied to the resident. Review of the clinical record for resident #1 revealed he was admitted [DATE]. Review of Nurse's Notes revealed he had three (3) falls since admission. These falls occurred on 06/13/09, 07/25/09 and 07/27/09 and were a results of the resident attempting to toilet himself. Following the 07/27/09 fall, the facility added an intervention of a bed clip alarm. Review of the care plan for resident #1 revealed he was care planned for the risk for falls on 05/09/09. On 7/27/09 the care plan was updated to include a clip alarm to bed. | 2014-04-01 | ||
| 10566 | 10566 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 365 | D | DOSV11 | Based on observation, record review and staff interview the facility failed to provide the correct consistency diet to meet the needs of one (1) resident (#1) from a sample of twenty one (21) residents. The findings include: Review of the clinical record for resident #1 revealed that on June 24, 2009 the resident's diet was changed to mechanical soft. On June 25, 2009 this diet order was clarified to a Liberalized Diabetic, Mechanical Soft with nectar thick liquids. Observation of the resident's meal on 08/03/09 at 12:50 p.m. revealed the resident received a pureed diet with nectar thick liquids. Observation of the breakfast meal on 08/04/09 at 7:45 a.m. revealed the resident received a pureed diet with nectar thick liquids again. Interview with the Dietary Manager on 08/04/09 at 7:50 a.m. revealed the dietary department did not receive the diet change from the nursing department. | 2014-04-01 | ||
| 10567 | 10567 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 520 | E | DOSV11 | Based on staff interviews and review of facility quality assurance records, the facility failed to ensure that the performance improvement plan for missing physician's progress notes was effective for ten (10) residents (#3, #4, #6, #7, #8, #9, #10, #15, #16, and #20) from a sample of twenty-one (21) residents. Findings include: Record reviews for residents #3,#4, #6, #7, #8, #9, #10, #15, #16, and #20 revealed missing physician's progress notes. Interview on 8/4/09 at 3:40 pm with the physician revealed that there has been a problem with progress notes missing from resident's medical records. She further indicated that she has had problems with missing progress notes since October 2008. Interview of 8/5/09 at 9:45 am with the Director of Health Services revealed that the physician's progress notes were missing from resident's medical records. Review of the quality assurance improvement action plan revealed that the facility identified the problem with missing progress notes in February 2009. The plan revealed that physician's progress notes were discussed in the 3/20/09 and 6/29/09 meetings. Each meeting indicated that notes were still missing from medical records. There was no evidence that the approaches developed to resolve the missing progress notes have been effective. According to the plan the last approach was to involve corporate, with a target date of 8/30/09. | 2014-04-01 | ||
| 10568 | 10568 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 226 | D | DOSV11 | Based on staff interviews, review of facility policy and records, the facility failed to ensure that two (2) Certified Nurses Assistants (CNA) of five (5) CNAs interviewed had received training on abuse prohibition. Findings include: Review of the facility's Abuse Policy for staff training indicated that training on abuse will be done during initial orientation for all new staff and volunteers. This will include oriented to the facility policy related to abuse prohibition including what constitutes abuse, what to do if they hear or see abuse, and the appropriate interventions to deal with aggressive and/or catatropic reactions of residents/patients,including burnout, stress management and conflict resolution. Interview on 8/4/09 at 3:30 pm with CNA "ZZ" revealed that when she was asked about what training she had received related to abuse and neglect, she indicated that she had not received any training at this facility. She further revealed that she had been employed for four (4) months. Interview on 8/4/09 at 3:35 pm with CNA "XX" revealed that she has not had any training regarding abuse and that she had not received any facility orientation. She was unaware of who in the facility was responsible for abuse prevention. She further revealed that she had been working for four (4) days. Interview on 8/4/09 at 4:15 pm with the Staff Development Coordinator revealed that she had been at the facility for three (3) weeks and had not conducted any inservices. She further revealed that the facility policy is to teach abuse training during orientation Interview on 8/5/09 at 8:30 am with the Director of Health Services revealed that the last three (3) employees hired and currently working had not had any orientation or abuse training. During review of abuse investigations conducted by the facility and reported to the state agency, revealed two (2) incidents of residents allegations of verbal abuse by CNAs | 2014-04-01 | ||
| 10569 | 10569 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 333 | D | DOSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and review of the Medication Adminisrtation Record (MAR) the facility failed to administer [MEDICATION NAME] according to physician's orders for one (1) resident (#1) on a sample of twenty one (21) residents. The findings include: Review of the clinical record for resident #1 revealed that on 7/23/09 the [MEDICATION NAME] was changed from 100 milligrams (mgs.) two (2) capsules twice a day (b.i.d.)to [MEDICATION NAME] 4mgs (100mgs) suspension per tube every six (6) hours (q6h). The resident has a history of [MEDICAL CONDITION] disorder according to the facility's admission history and physical. Review of the July 2009 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The July MAR indicated [REDACTED]. Further review of the July MAR indicated [REDACTED]. Further review of the medical record revealed a physician's order dated 7/26/09 to "increase [MEDICATION NAME] to 100mgs three times a day (t.i.d.). The July MAR indicated [REDACTED].i.d. with the times of administration as 9am, 3pm, and 9pm. The dates that for administration are 7/23/09 to 7/31/09. There is no evidence that the [MEDICATION NAME] was given on the following dates and times: 7/24 at 9am and 3pm; 7/26 at 9am; and 7/31 at 9am and 3pm. Record review revealed a nurses' note dated 8/3/09 that the physician's and responsible party were notified of the missed [MEDICATION NAME] dosages. The physician ordered a [MEDICATION NAME] level. The results of the [MEDICATION NAME] level was 2.5 ml, which was below the normal range of 10.0 - 20.0. The physician was notified of of this results and ordered the [MEDICATION NAME] be changed to 100mgs every am (Qam), and every pm (Qpm) and 200mgs at bedtime (Qhs). | 2014-04-01 | ||
| 10570 | 10570 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 514 | E | DOSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility failed to ensure that physician's progress notes were in the resident's medical record for ten (10) residents (#3, #4, #6, #7, #8, #9, #10, #15, #16, and #20) and that physician's orders [REDACTED]. Findings include: 1. Record reviews for residents #3,#4, #6, #7, #8, #9, #10, #15, #16, and #20 revealed missing physician's progress notes. Interview on 8/4/09 at 3:40 pm with the physician revealed that there has been a problem with progress notes missing from resident's medical records. The physician indicated that she brings her progress notes and facility staff is suppose to place the notes in the residents' records. She further indicated that she has had problems with missing progress notes since October 2008. Interview of 8/5/09 at 9:45 am with the Director of Health Services revealed that the physician's progress notes were missing from resident's medical records. She further revealed that the physician's visits at least once a week but there are no progress notes and that medical records staff are responsible for placing progress notes in the records. 2. Record review for resident # 1 revealed that a [MEDICATION NAME] order written on 7/26/09 by a nurse indicated an "increase" in the [MEDICATION NAME] dose to 100mgs. three times a day (t.i.d.). Further record review revealed that on 7/23/09 the [MEDICATION NAME] was ordered 100mgs every six hours (q6h), which is four times a day. The order on 7/26/09 did not reflect an "increase" Review of the July 2009 MAR for resident #1 revealed that [MEDICATION NAME] is written as " [MEDICATION NAME] 4mls (100mgs) per tube q6h t.i.d. with hours of administration as 9am, 3pm, and 9pm. Every six hours (q6h) is not the same as t.i.d. During post survey review of the June 2009 MAR for resident #1 revealed that [MEDICATION NAME] two (2) capsules via tube twice a day (b.i.d) had been marked through and [MEDICATION NAME] 125 mgs/5mls. suspension 4 ml… | 2014-04-01 | ||
| 10571 | 10571 | GOLDEN LIVINGCENTER - KENNESTONE | 115660 | 613 ROSELANE STREET | MARIETTA | GA | 30064 | 2010-12-13 | 203 | D | JYL811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined that before transfer/discharge, the facility failed to notify the resident and a family member/legal representative of the transfer/discharge, and of the required information, in writing for one (1) resident (#1) from a survey sample of six (6) residents. Findings include: Record review for Resident #1 revealed a 10/07/2010 physician's orders [REDACTED]. During a telephone interview conducted on 11/01/2010 at 11:30 a.m. with Staff Member "AA", this staff member stated that upon review after the resident's hospital transfer, it was determined that the facility could not meet the resident's needs and the decision was made to not readmit the resident. However, further record review revealed no evidence to indicate that the resident and the family member/legal representative were notified, in writing, of the transfer/discharge, the reasons for the transfer/discharge, the effective date of the transfer/discharge, the location to which the resident was transferred/discharged , a statement that the resident had the right to appeal the action to the State, and the name, address and telephone number of the State long term care ombudsman. During an interview with Administrative Staff "BB" conducted on 12/13/2010 at 9:45 a.m., this staff member acknowledged that a transfer/discharge notice letter had not been sent. | 2014-04-01 | ||
| 10572 | 10572 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 282 | D | 5C5911 | Based on record review and staff interview the facility failed to ensure that a care plan related to constipation was followed for one (1) resident ("C") on a sample of twenty seven (27) residents. Findings include: Review of the care plan developed for a problem of constipation for resident "C" included interventions of assess the resident's bowel elimination pattern, monitor for signs and symptoms of constipation such as no bowel movement in three days and to administer laxatives as ordered. Review of the Activities of Daily Living Care Plan Sheet for July 2010 revealed that between 7/15/10 and 7/22/10 (6 days) there was no documentation that the resident was having bowels movements. Interview with the resident's family on 9/22/10 at 10:45 am revealed that the resident was having symptoms of nausea, spitting up as well as abdominal and rib pain during this time and the facility did nothing until they brought it to their attention. Interview with Director of Nursing (DON) on 9/23/10 at 8:55 am revealed that the care plan was not followed related to the resident's bowel elimination problem. Cross refer to F309 | 2014-04-01 | ||
| 10573 | 10573 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 309 | D | 5C5911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and family interview the facility failed to ensure that physician orders [REDACTED]. Findings include: Review of a Nurses Note dated 5/30/10 documented that a resident's ("C") family member requested that the resident be given medications for constipation, a problem the resident had had since admission to the facility. Review of the Physician order [REDACTED]. On 5/31/10 there was a Physician order [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Activities of Daily Living Care Plan sheets for July 2010 revealed there was no documentation that the resident had a bowel movement between 7/16/10 and 7/22/10 (6 days). On 7/22/10 a Physician order [REDACTED]. Review of the August 2010 physician's orders [REDACTED]. The August 2010 MAR documented the [MEDICATION NAME] was given as ordered. The September 2010 Physician order [REDACTED]. A physician's orders [REDACTED].[REDACTED] Interview with the resident's family member on 9/22/10 at 10:45 am revealed that when the facility stopped giving the resident the [MEDICATION NAME] and [MEDICATION NAME] in July 2010 and the resident became impacted, was having abdominal pain and nausea. She stated the staff only addressed this problem after she brought it to their attention. Interview with the DON on 9/22/10 at 11:10 am revealed she received the Physician order [REDACTED]. She confirmed that the [MEDICATION NAME] and the [MEDICATION NAME] were documented as being given in June 2010 even though there was an order to discontinue it on 5/31/10. She also revealed that after the [MEDICATION NAME] and [MEDICATION NAME] was reordered on [DATE] neither medication was carried over on the September 2010 Physician order [REDACTED]. | 2014-04-01 | ||
| 10574 | 10574 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 279 | D | 5C5911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to developed a care plan for one (1) resident (#164) on a sample of twenty seven (27) residents when the resident had a change in condition that required a defibrillator implant. Findings include. Review of the discharge summary dated 6/01/10 for resident #164 revealed the resident was discharged from the hospital to the nursing home with a [DIAGNOSES REDACTED]. Review of Nurses Notes dated 6/23/10 revealed the resident was sent to the hospital for a cardiac defibrillator implant. He returned to the facility on [DATE] with the defibrillator to his left chest with steri-strips intact. There was no evidence in the record that a care plan was developed related to the care and monitoring of the defibrillator implant. Interview with the Licensed Practical Nurse (LPN) Minimal Data Set Assessment Coordinator on 9/22/10 at 8:25 a.m. confirmed there was no care plan for the resident's defibrillator and interventions should have been put into place when the resident returned with the defibrillator implant. | 2014-04-01 | ||
| 10575 | 10575 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 372 | E | 5C5911 | Based on observation and staff interview the facility failed to ensure that trash and garbage was transported from the main kitchen to dumpsters located outside of the building in a manner to prevent potential contact with residents. Findings include: Observations on 9/21/10 at 10:45 a.m., 9/22/10 at 10:50 a.m., and 9/22/10 at 2:25 p.m. revealed that staff from the facility's kitchen were transporting trash and garbage in open receptacles that were not covered with lids. The observations further revealed that food scraps from resident meals and trash from the kitchen were in these open, unlidded garbage receptacles and that the garbage bags inside the receptacles were not tied to secure their contents. The garbage was transported from the kitchen through the main dining room, through the main facility lobby and then down the 200 hall corridor. The emptied garbage receptacles were returned from the trip to the dumpsters back to the kitchen via the same reverse route. This information was confirmed in an interview with the facility's Food Service Director (FSD) on 9/23/10 at 11:30 a.m. | 2014-04-01 | ||
| 10576 | 10576 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 248 | D | 5C5911 | Based on observation, record review and staff interview the facility failed to provide an activity program that met the needs of one (1) resident, #58, from a sample of twenty-seven (27) residents. Findings include: Record review of resident #58 revealed that she had experienced a recent mental and physical decline and spent her days in her room because she did not feel like attending group activities. The resident also ate all of her meals in her room. Observations of the resident during the course of a standard survey conducted on September 20-23, 2010 confirmed that the resident remained in her room during this period of time. There were no observed visits by the Activity Department staff to the resident during this time frame. There was also no Activity Calendar posted in the resident's room. A review of the resident's Care Plan dated 7/05/10 and updated on 9/15/10 revealed that the resident was at risk for social isolation and her Care Plan had interventions which included the provision of 1:1 in room visits by the activity staff as well as the provision of activity supplies for the resident. The interventions also provided for an Activity Calendar to be posted in the resident's room. An interview with the facility's Activity Director (AD) on 9/22/10 at 3:00 p.m. revealed that the resident was placed on an activity plan in July 2010 that provided her with 1:1 visits at least twice per week. These personal visits were to include reading, massages, nail care, aroma therapy and social visits. However, the AD confirmed in the interview that the resident had not been provided with an individualized program and that she had not been provided with any in-room activities as planned. | 2014-04-01 | ||
| 10577 | 10577 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 463 | E | 5C5911 | Based on observation and staff interview the facility failed to ensure that all call lights located in resident rooms were functioning properly. Eight (8) of forty-five (45) call lights tested were found to be defective. Findings include: During the course of the standard survey investigative process, 45 call lights were tested to see if they were functional. The following resident rooms contained call lights that were not working: 107A; 201 bathroom; 313A; 313B; 313C; 315A; 315B; and 315C. This information was confirmed by Licensed Practical Nurse "JJ" at the time of observation on 9/21/10 at 1:50 p.m. | 2014-04-01 | ||
| 10578 | 10578 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 161 | E | W1TL11 | Based on record review and staff interview, the facility failed to maintain a surety bond of equal or greater value, than the balance in the residents' trust fund accounts. The facility managed seventeen (17) resident accounts. Findings include: Record review with the Nursing Home Administrator and Business Office Manager on 9/24/09 revealed that the residents' trust fund account balance was $11,478.00. Further review revealed bank statements with average ending balances ranging between 12,300.04 to 10,308.17 for the months of May, June, July, and August 2009. The facility's surety bond was in the amount of $10,000.00. In an interview with the Nursing Home Administrator on 9/24/09 at 8:30 a.m., he acknowledged that the surety bond amount was insufficient. | 2014-04-01 | ||
| 10579 | 10579 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 363 | E | W1TL11 | Based on observation, record review and staff interview the facility failed to follow menus for two (2) meals during the survey. This had the potential to affect most residents consuming food (total = 132). Findings include: Review of the menus provided by the facility revealed pancakes or waffles were to be served for breakfast 9/23/09. Observation of the breakfast meal revealed neither were served to residents, they received toast instead. During an interview with the Dietary Manager (DM) on 9/23/09 at 10:20 a.m. she stated the facility did not serve pancakes or waffles because one (1) or two (2) years ago residents complained the items were served cold and/or hard. Review of the four (4) week cycle menu provided by the facility revealed a variety of starch-based food items were listed contributing to the menu variety. These items included muffins, biscuits, french toast, pancakes, Danish, waffles and cinnamon rolls. Interview with the DM at 2:20 p.m. revealed the facility did not serve any of these products but always served toast instead. The menu also called for lettuce and tomato to be served as part of the dinner meal on 9/23/09. Interview with the DM on 9/23/09 at 8:30 a.m. and 10:30 a.m. revealed they were not serving lettuce but only diced tomatoes. She stated residents can choke on lettuce and that it was also a food waste issue. Review of the grievance file and resident council minutes since 10/2008 revealed no notation about pancakes, waffles or lettuce. | 2014-04-01 | ||
| 10580 | 10580 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 371 | F | W1TL11 | Based on observation, record review and staff interview the facility failed to store, prepare and serve food under sanitary conditions for all residents consuming food (total = 132). Findings include: Observation during initial tour of the kitchen on 9/22/09 at 9:35 a.m. revealed the wall around the stainless steel counter near the dishmachine was soiled with a black substance in the grout and on the wall and continued under the counter. This wall area also had a build up of substances that were dried and sticky. Three (3) used dishcloths were observed on the bottom shelf of a cart next to clean serving trays. Observation of the right reach-in cooler revealed two (2) fat-free milks with a use-by date of 9/20/09. The walk-in cooler had two (2) containers of buttermilk with use-by dates of 9/04/09 and 9/16/09. Also in this walk-in cooler were prepared ground sausage, pureed sausage and pureed eggs dated 9/23/09. Interview with the Dietary Manager (DM) at this time revealed these items were prepared 9/22/09 to be served for breakfast on 9/23/09. She stated these items were prepared ahead of time instead of on the day of service because staff often came in late in the mornings. Observation on 9/23/09 at 7:25 a.m. revealed dietary staff "AA" operating the three (3) compartment sink. She was washing and sanitizing items in full sinks of water. However, she was rinsing items under running water without submerging in a full sink of rinse water as required. Interview with the DM at this time revealed she agreed the correct procedure was not being followed. Observation at 9:50 a.m. revealed a bucket with several dishcloths immersed in water. The DM stated the facility used chlorine in the bucket as a sanitizer but she twice attempted to test the sanitizer level with the wrong chemical strips. When she used the correct chlorine test strip, chlorine did not register as present in the solution. Observation at 10:00 a.m. revealed packaged turkey in a pan of water on a preparation counter. The DM stated it was being thawed. Obs… | 2014-04-01 | ||
| 10581 | 10581 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 221 | D | W1TL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to apply a restraint as ordered for one (1) resident (#12) on a sample of twenty four (24) residents. Findings include: Review of the clinical record for resident #12 revealed a physician's orders [REDACTED]. Observation of this resident on 9/22/09 at 11:50 a.m. and 12:35 p.m. and 9/23/09 at 7:30 a.m. and 11:15 a.m. revealed the resident was in his wheelchair with a full lap table and wearing the left hand mitten. Interview with the Director of Nursing (DON) on 9/23/09 at 11:00 a.m. revealed the resident has the mitten because he continually touches his gastrostomy tube and pulled it out 7/16/09. She also stated he does wear an abdominal binder at all times in the wheelchair. There was no indication why the resident was also wearing the left hand mitten while in his wheelchair, since this device was ordered for use in the bed. The DON added at that time, that with the abdominal binder and a full lap tray the resident would have difficulty accessing the gastrostomy tube while in the wheelchair. She confirmed that the mitten should not be applied. | 2014-04-01 | ||
| 10582 | 10582 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 314 | D | W1TL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, it was determined that for three (3) of the twenty-four (24) sampled residents, #1, #6 and #19, the facility failed to prevent pressure ulcers from forming for residents not previously having pressure ulcers and failed to treat pressure ulcers appropriately to promote healing and prevent new ulcers from forming. Findings include: Review of the clinical record for resident #1 revealed a Minimum Data Set ((MDS) dated [DATE] that indicated the resident had intact skin, with no breakdown. Section M5 of this document also indicated that staff was not using any protective or preventive skin care. However, review of the Master Care Plan revealed that the resident was assessed as being at risk for pressure ulcers. A progress note by the Nurse Practitioner and attending physician, dated 09/17/09 described a Stage II ulcer behind her left ear. Observation of this pressure ulcer on 09/22/09 at 2:15 a.m. revealed that the resident was wearing eye glasses and had plastic tubing around her ears for receiving supplemental oxygen. There was also a dressing in place behind her left ear. Interview with the Director of Nurses on 09/23/09 at 7:45 a.m. indicated that she was unaware of any preventive measures that had been put into place to prevent this pressure ulcer from forming. Record review for resident #6 revealed the resident a care plan dated 12/31/08 that indicated the resident had a potential for skin breakdown. A Nurse's Note dated 9/11/09 indicated the resident had received a skin shear to the right buttock. This was described as a Stage II pressure area measuring 0.2 centimeter in diameter. The Treatment Record for September 2009 described this Stage II wound on the right buttock as a skin shear. During an observation of the resident receiving incontinent care on 9/22/09 at 2:30 p.m., the Stage II pressure sore on the right buttock was not covered by a dressing, but the skin was intact. The re… | 2014-04-01 | ||
| 10583 | 10583 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 323 | D | W1TL11 | Based on observation and staff interview, the facility failed to maintain an environment that remained free of accidents hazards as is possible. This was evidenced by the failure to ensure safe storage of drugs and therapeutic agents, to prevent access by cognitively impaired residents for one of five (1 of 5) medication carts. Findings include: Observation on 9/22/09 at 3:35 p.m. revealed that the medication cart on the A Hall was unlocked. All drawers (except the narcotic box) were able to be opened. No staff was in attendance, or in the vicinity. The Nurse's Station was approximately 50-60 feet away. Licensed Practical Nurse (LPN) "GG" was observed approaching the cart from the Nurse's Station. In an interview with LPN "GG" on 9/22/09 at 3:40 p.m. she acknowledged that the medication cart should be locked when leaving it unattended. | 2014-04-01 | ||
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 10335 | 10335 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2011-03-21 | 323 | G | 1 | 0 | S4HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, Incident/Accident Report review, and staff interview, it was determined that the facility failed to ensure that one (1) resident (#1) received the necessary supervision, and Hoyer lift transfer, as specified by the Care Plan to minimize the risk of a fall for one (1) resident (#1), and failed to use floor mats as specified by the Care Plan to serve as a fall precaution for one (1) resident (#4), from a survey sample of six (6) residents who had been assessed as being at risk for falls. Resident #1 subsequently fell and sustained a fracture of the right leg. Findings include: 1. Clinical record review for Resident #1 revealed a record Face Sheet which documented that the resident had [DIAGNOSES REDACTED]. A Care Plan entry of 02/24/2010 identified the resident to be at risk for falls, with Approaches to address this risk which included to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the licensed nurse had been called to the resident's room by a nursing assistant and observed the resident to be sitting on the floor in the room. This Note documented that the resident had fallen while being changed, and that the resident complained of right knee pain, with swelling noted to the right knee and thigh. A Nurse's Notes entry of 02/01/2011 at 3:00 p.m. documented that the physician was notified of the resident's condition, and that an order was received to send the resident to the hospital for evaluation. A Nurse's Notes entry of 02/01/2011 at 3:40 p.m. documented that Emergency Medical Services had arrived to transport the resident to the hospital, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had been admitted to the hospital with [REDACTED]. A 02/01/2011 facility Incident/Accident Report which referenced Resident #1's fall documented that Nursing Assistant In Training "AA" had been providing incontinen… | 2014-07-01 |
| 10336 | 10336 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2011-03-21 | 495 | G | 1 | 0 | S4HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Incident/Accident Report review, and staff interview, the facility failed to ensure that a nursing assistant had demonstrated competency and had been determined competent in the provision of care before allowing the nursing assistant in training to transfer and provide incontinence care for one (1) resident (#1) from a survey sample of six (6) residents. This failure resulted in actual harm ([MEDICAL CONDITION] leg) for Resident #1. Findings include: Cross refer to F323 for more information regarding Resident #1. Clinical record review for Resident #1 revealed a Care Plan entry of 02/24/2010 which identified the resident to be at risk for falls and included the use of a Hoyer lift for all transfers, as well as to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the licensed nurse had been called to the resident's room and observed the resident sitting on the floor in the room, after having fallen while being changed. This Note documented that the resident complained of right knee pain, with swelling noted to the right knee and thigh, and that an order was received to send the resident to the hospital for evaluation. A Nurse's Notes entry of 02/01/2011 at 3:40 p.m. documented that the resident was transported to the hospital, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had a [DIAGNOSES REDACTED]. A 02/01/2011 facility Incident/Accident Report which referenced Resident #1's fall documented that Nursing Assistant In Training "AA" had been providing incontinence care to Resident #1 at the sink, but the resident was unable to hold on and Nursing Assistant "AA" thus slid the resident to the floor. This resulted in the resident sustaining a [MEDICAL CONDITION] distal femur. In a written statement dated 02/01/2011, Nursing Assistant In Training "AA" documented that when Resident #1 needed a changed brief, she assisted … | 2014-07-01 |
| 10337 | 10337 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2011-03-21 | 282 | G | 1 | 0 | S4HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, Incident/Accident Report review, and staff interview, it was determined that the facility failed to ensure that one (1) resident (#1) received supervision and Hoyer lift transfer, as specified by the Care Plan, and failed to use floor mats as specified by the Care Plan for one (1) resident (#4), from a survey sample of six (6) residents. Resident #1 fell and sustained a [MEDICAL CONDITION] leg. Findings include: 1. Cross refer to F323, Example 1, for more information regarding Resident #1. Clinical record review for Resident #1 revealed a Care Plan entry of 02/24/2010 which identified the resident to be at risk for falls, with Approaches which included the use of a Hoyer lift for all transfers and to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the nurse observed the resident on the floor in the room after having fallen while being changed. The resident complained of right knee pain, and swelling was noted to the right knee and thigh. A Nurse's Notes entry of 02/01/2011 at 3:00 p.m. documented that the physician was notified and ordered a hospital transfer, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had been admitted to the hospital with [REDACTED]. A 02/01/2011 facility Incident/Accident Report documented that Nursing Assistant In Training "AA" had been providing incontinence care to Resident #1 at the sink and then slid the resident to the floor. The resident sustained [REDACTED]. During an interview with Nursing Assistant In Training "AA" conducted on 03/02/2011 at 4:10 p.m., the nursing assistant stated she had been working by herself when providing care to Resident #1. In a written statement provided by the Director of Nursing (DON), the DON documented that Resident #1 had been transferred by Nursing Assistant "AA" without the use of a mechanical lift (as specified in the Care Plan), and … | 2014-07-01 |
| 10338 | 10338 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2011-02-01 | 328 | D | 1 | 0 | 4N3N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor the oxygen saturation level, in accordance with the physician's order, for one (1) resident (#1) of five (5) sampled residents. Findings include: Record review for Resident #1 revealed that the January 2011 Physician's Orders sheet, dated as having been reviewed on 12/27/2010, referenced physician's orders to administer oxygen 2.0 liters per minute per nasal cannula as needed for [MEDICAL CONDITION], and to monitor the resident's oxygen saturation to keep the oxygen saturation at 90 percent. The resident's January 2011 PRN Medication Administration Record [REDACTED]. However, further record review, to include review of the line on this PRN Medication Administration Record [REDACTED]. During an interview conducted on 02/01/2011 at 2:50 p.m., the Assistant Administrator acknowledged that the resident's oxygen saturation levels had not been recorded and there was no way to determine the resident's oxygen levels. | 2014-07-01 |
| 10339 | 10339 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2011-03-09 | 225 | D | 1 | 0 | DUNW11 | Based on review of a facility Complaint Form and staff interview, it was determined that the facility failed to report allegations of neglect to the State survey and certification agency for one (1) resident ("A") from a survey sample of ten (10) residents. Findings include: Review of a facility Complaint Form of 01/29/2011 revealed a family member of Resident "A" documented that she had visited the resident at 3:30 p.m. and noticed that the resident was wearing a brief that was soaked and was timed at 5:35 a.m. The family member also documented that the resident was wearing a gown that she had worn for two (2) days, and had been wearing the same socks since the Wednesday before. This Complaint Form documented that the unit manager was notified of these allegations on 01/29/2011. Documentation on the back of this Complaint Form indicated that the unit manager had counseled the staff member and removed the staff member from the resident assignment. On the back of the employee Corrective Counseling Statement, the unit manager included negligence as a reason for the disciplinary action. However, further record review revealed no evidence to indicate that the allegations of neglect referenced above had been reported to the State survey and certification agency. During an interview with the unit manager conducted on 03/09/2011 at 4:10 p.m., this staff member stated that she did not report these allegations of negligence to the State survey and certification agency. During an interview with Nurse "AA" conducted on 03/09/2011 at 4:20 p.m., Nurse "AA", who was responsible for reporting allegations of abuse and neglect to the State survey and certification agency, stated that she had not been made aware of these allegations of neglect, nor had she reported this to the State agency. | 2014-07-01 |
| 10340 | 10340 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2011-03-09 | 315 | D | 1 | 0 | DUNW11 | Based on observation, it was determined that the facility failed to provide the appropriate care to prevent urinary tract infections for one (1) resident (#4), of two (2) residents observed for incontinence care, from a survey sample of ten (10) residents. Findings include: During an observation of incontinence care for Resident #4 conducted at 4:00 p.m. on 03/09/2011, Certified Nursing Assistant "ZZ" failed to change gloves after wiping feces off the resident and before turning the resident on his/her back and wiping the perineal area with the same soiled gloves. | 2014-07-01 |
| 10341 | 10341 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2011-03-09 | 327 | D | 1 | 0 | DUNW11 | **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 ensure that adequate hydration was provided for two (2) residents (#1 and #2), who had a history of [REDACTED]. Findings include: 1. Record review for Resident #1 revealed a Care Plan entry of 04/06/2010 which identified the resident to be at risk for urinary tract infections, and referenced as an Approach to encourage fluids by mouth throughout the day. A hospital History and Physical for a 12/21/2009 hospital admission documented that the resident had discharge [DIAGNOSES REDACTED]. Observation of Resident #1 on 03/09/2011 at 1:10 p.m. revealed that the resident was seated in a geri-chair in the hallway outside of her room, and in the resident's room, the water pitcher was observed to be empty. Additional observations of the resident at 2:40 p.m. and 4:40 p.m. on 03/09/2011 revealed that the resident was in her room with the water pitcher still being empty and out of reach, on the window ledge. During an interview with Licensed Staff "SS" on 03/09/2011 at 5:10 p.m., this staff member stated that certified nursing assistants who were responsible for residents on each shift were responsible for checking the water pitcher for each of their assigned residents at the beginning and ending of their shifts. 2. Record review for Resident #2 revealed an 08/28/2010 Care Plan problem of the resident being at risk for fluid volume deficit due to receiving a daily diuretic, with an Approach to encourage fluids by mouth. Additionally, a current physician's orders [REDACTED]. A laboratory report dated 02/17/2010 identified that the resident had an elevated blood urea nitrogen level of 46 (reference range, between 6 to 24), and on the laboratory sheet, the physician wrote orders which included to increase water. However, observations of the resident at 2:50 p.m. and 4:50 p.m. on 03/09/2011 revealed that the resident was on her bed with no thickened water … | 2014-07-01 |
| 10342 | 10342 | RIVERDALE CENTER | 115144 | 315 UPPER RIVERDALE ROAD | RIVERDALE | GA | 30274 | 2009-02-04 | 165 | D | 1 | 1 | UBZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow their grievance process related to missing dentures for one (1) resident ("Q") on a sample of twenty-six (26) residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for resident "Q" revealed the resident had dentures. A Nursing Admission Assessment and Interdisciplinary Progress Note dated 12/01/08 also revealed the resident had upper and lower dentures on admission. On 02/02/09 at 12:52 p.m., the resident's morning care had been completed, and the resident was sitting in a Gerichair in their room. However, no dentures were observed in the resident's mouth at that time. On 02/03/09 at 12:13 p.m., Certified Nursing Assistant (CNA) "OO" located the bottom denture plate only in a cup in the resident's bedside table. On 02/03/09 at 12:18 p.m., the Social Services Director (SSD) stated that she thought a family member had asked her about a week-and-a-half ago about the resident's dentures and where they were. The SSD said it was on a Saturday and she was not able to come into the facility. She stated she called the resident's Power of Attorney (POA) the following Monday and left a message, and called the POA again this past Friday when asked by the family member again about the dentures, but was not able to reach the POA. The SSD said that she had no documentation of this, and at 5:35 p.m. added that in the event of missing items, the Grievance Policy and Procedure should be followed. On 02/04/09 at 8:00 a.m., Licensed Practical Nurse (LPN) Unit Manager "II" stated she did not know at what point the resident's upper dentures were lost. She added she thought a family member and/or SSD had asked about them, but could not remember when. At 10:00 a.m., the SSD stated she was able to reach the POA who verified that the resident had upper and lower dentures when admitted , and that they did not take the dentures home. Review of the facility's Res… | 2014-07-01 |
| 10343 | 10343 | KENTWOOD NURSING FACILITY | 115147 | 1227 WEST WHEELER PARKWAY | AUGUSTA | GA | 30909 | 2009-09-02 | 323 | G | 1 | 0 | 4GZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility document review, hospital document review, and staff interview, it was determined that the facility failed to ensure that adequate supervision was provided to one (1) resident, who required supervision related to wandering, on the survey sample of eighteen (18) residents. The resident subsequently exited the building and experienced a fall, resulting in fracture. Findings include: Record review for Resident #1 revealed a Minimum Data Set (MDS) assessment dated [DATE] which indicated that the resident had short-term and long-term memory problems, had moderately impaired decision making-capacity, and required the supervision of staff with locomotion on the unit. During an interview with the Director of Nursing (DON) conducted on 09/02/2009 at 1:30 p.m., the DON stated that the resident was up in the wheelchair daily and propelled himself/herself in the wheelchair by scooting with one foot throughout the halls. The resident's Care Plan dated 03/17/2009 listed as a problem that the resident had a history of [REDACTED]. Approaches listed on the Care Plan included to ensure that the alarm was on the exit door, to monitor the resident if around exit doors, and to monitor for potential signs of elopement. A Nurse's Note dated 08/28/2009 at 9:15 a.m. documented that nursing staff were summoned to provide assistance to the resident after a fall. This Note documented that Resident #1 was observed to be on the ground six (6) to eight (8) feet from the Richmond Wing door, two (2) feet away from the curb. The Note documented that the resident was laying with the face on the ground, turned slightly on the right side, with a swollen left eye and bleeding from both nostrils. This Note further documented that the resident's status was assessed and Emergency Medical Services (EMS) was contacted. A Nurse's Note of 08/28/2009 at 9:25 a.m. documented that EMS staff had arrived and that the resident was transported to the hospital. … | 2014-07-01 |
| 10344 | 10344 | KENTWOOD NURSING FACILITY | 115147 | 1227 WEST WHEELER PARKWAY | AUGUSTA | GA | 30909 | 2011-01-04 | 323 | G | 1 | 0 | 6FEF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility Incident/Accident Report review, and staff interview, it was determined that the facility failed to ensure that one (1) resident (#1) who utilized a Hoyer Lift for transfers, on the survey sample of ten (10) residents, received adequate supervision to prevent a fall. Resident #1 fell from the Hoyer Lift and sustained actual harm by receiving a fracture of the tibia/fibula. Findings include: Record review for Resident #1 revealed a Minimum Data Set (MDS) assessment of 08/13/2010 which indicated that the resident was totally dependent on staff for transfers, and had [DIAGNOSES REDACTED]. The resident's current Care Plan indicated that the resident was to be mechanically lifted with the use of a Hoyer Lift. A Nurse's Note of 12/16/2010 at 5:00 p.m. documented that Resident #1 had been lifted via a Hoyer Lift from the chair to the bed when the Hoyer Lift pad flipped and the resident fell to the floor. This Note documented that the resident was assessed to have a raised bluish area on the left lower leg, and documented that when contacted, the physician gave an order to transfer the resident to the hospital for evaluation. A Nurse's Note of 12/16/2010 at 6:39 p.m. documented the resident's hospital transfer. A Nurse's Note of 12/17/2010 at 4:30 p.m. documented that the resident had returned to the facility from the hospital after having been diagnosed with [REDACTED]. The 12/16/2010 facility Incident/Accident Report which referenced Resident #1's fall documented that the resident had fallen forward from the Hoyer pad onto the floor. A 12/16/2010 written statement of Certified Nursing Assistant (CNA) "DD" documented that as she and another CNA were putting Resident #1 to bed, they positioned the resident onto the Hoyer net and lifted the resident slightly off the shower chair, and the resident then suddenly fell forward. During an interview with the Administrator conducted on 01/04/2011 at 12:15 p.m., the Administra… | 2014-07-01 |
| 10345 | 10345 | AMARA HEALTH CARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2010-02-01 | 456 | D | 1 | 0 | KVUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to maintain patient care equipment in safe operating condition, related to one (1) of two (2) mechanical lifts utilized in the facility. Findings include: Record review for Resident #5 revealed a Minimum Data Set assessment of 02/02/2010 which indicated that the resident had a history of [REDACTED]. During an observation of a transfer of Resident #5 on 02/01/2010 at 11:00 a.m., two (2) certified nursing assistants (CNAs) were transferring the resident from the wheelchair to the bed via a mechanical lift. The resident was lifted up and over the bed via the lift, but then the lift malfunctioned. The lift would not respond to lower the resident onto the bed, and the resident was suspended in the lift sling above the bed. The CNAs alerted supervisors and maintenance staff, and two (2) replacement batteries were installed, but the lift continued to fail to respond, still leaving the resident suspended over the bed. Eventually, two (2) maintenance staff members evenly caused the lift to lower the resident onto the bed. The resident remained suspended in the lift over the bed for approximately 15 minutes before finally being placed in the bed via the lift. During an interview on 02/01/2010 at the time of the observation referenced above, three (3) CNAs stated that the lift had not been working correctly for weeks, and that this had been reported. | 2014-07-01 |
| 10346 | 10346 | AMARA HEALTH CARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2010-02-01 | 309 | D | 1 | 0 | KVUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide a wound treatment, as ordered by the physician, to one (1) resident (#3) on the survey sample of six (6) residents. Findings include: Record review for Resident #3 revealed that the January 2010 Treatment Record documented that the resident had [DIAGNOSES REDACTED]. A 01/07/2010 Wound Healing Center Physician order [REDACTED]. However, the January 2010 Treatment Record referenced above documented that on the dates of 01/08/2010, 01/09/2010, 01/10/2010, 01/11/2010, 01/12/2010, 01/13/2010, 01/14/2010, 01/16/2010, 01/17/2010, 01/18/2010, 01/19/2010, 01/20/2010, 01/21/2010, 01/23/2010, 01/24/2010, 01/25/2010, and 01/26/2010, the treatment had been done only once per day, on the 3:00 p.m. - 11:00 p.m. shift. During an interview with Nurse "AA" conducted on 01/27/2010 at 1:30 p.m., this nurse stated that it appeared that when the Wound Clinic changed the foot treatment order on 01/07/2010 from a previously existing order, the new treatment order did not get changed on the Treatment Record, and further acknowledged that treatments had been done only once daily. | 2014-07-01 |
| 10347 | 10347 | AMARA HEALTH CARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2009-10-08 | 309 | J | 1 | 0 | YP7611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received laboratory testing, and timely drug therapy, as ordered related to the administration of the anticoagulant drugs [MEDICATION NAME] and Aspirin. This resulted in serious harm to Resident #3, who was subsequently hospitalized with bruises, bleeding gums, and a [DIAGNOSES REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed on 09/28/2009 and continues. Findings include: Record review for Resident #3 revealed an 08/24/2009 Minimum Data Set assessment which documented that the resident was admitted to the facility on [DATE]. Admission physician's orders [REDACTED].) by mouth daily, [MEDICATION NAME] 75 mgs. by mouth daily, and aspirin 81 mgs. by mouth daily. The resident's September 2009 Medication Record documented that the resident received these drugs daily during the month of September, as ordered, and documented that the resident had [DIAGNOSES REDACTED]. A physician's admission order of 08/13/2009 specified that the laboratory tests Pro-[MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) be done on 08/17/2009, and then every two weeks thereafter. Therefore, in addition to the PT/INR laboratory test due on 08/17/2009, PT/INR tests were due on 08/31/2009 and 09/14/2009. The initial PT/INR results on 08/17/2009 indicated a PT of 19.10 (reference range, 10.0-13.0) and an INR of 2.3 (reference range, 2.0-3.0), with a hemoglobin of 12.1 (reference range 12.5-16.0). However, further record review revealed no evidence to indicate that the ordered PT/INRs were drawn on 08/31/2009 or on 09/14/2009. During an interview conducted on 10/07/2009 at 3:00 p.m., Laboratory Supervisor "CC" acknowledged that PT/INR laboratory tests … | 2014-07-01 |
| 10348 | 10348 | AMARA HEALTH CARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2009-10-08 | 502 | J | 1 | 0 | YP7611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received laboratory testing as ordered related to the administration of the anticoagulant drugs [MEDICATION NAME] and Aspirin. This resulted in serious harm to Resident #3, who was subsequently hospitalized , diagnosed with [REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed on 09/28/2009 and continues. Findings include: Record review for Resident #3 revealed admission physician's orders [REDACTED].) by mouth daily, [MEDICATION NAME] 75 mgs. by mouth daily, and aspirin 81 mgs. by mouth daily. A physician's admission order of 08/13/2009 specified that the laboratory tests Pro-[MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) be done on 08/17/2009, and then every two weeks thereafter. A laboratory Patient Requisition of 08/14/2009 also indicated that PT/INR tests were to be done starting on 08/17/2009, and then every two weeks. Further record review revealed that the initial PT/INR laboratory tests were done on 08/17/2009, however, there was no evidence to indicate that the PT/INRs were drawn on 08/31/2009 or on 09/14/2009, as ordered and requisitioned. During an interview conducted on 10/07/2009 at 3:00 p.m., Laboratory Supervisor "CC" acknowledged that PT/INR laboratory tests had not been done on 08/31/2009 and 09/14/2009, as ordered. A Nurse's Note of 09/24/2009 at 7:00 p.m. documented that bruising was observed to the resident's inner right thigh, bilateral underarms, left outer thigh, and left side, and that when the physician was notified of the bruises, the physician ordered PT/INR laboratory tests. The Physician's Telephone Orders sheet of 09/24/2009, timed at 7:54 p.m., ordered a "Stat" PT/INR. However, record re… | 2014-07-01 |
| 10349 | 10349 | AMARA HEALTH CARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2009-10-08 | 281 | J | 1 | 0 | YP7611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received services in accordance with professional standards of practice. This resulted in serious harm to Resident #3, who was subsequently hospitalized with bruises, bleeding gums, and a [DIAGNOSES REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed on 09/28/2009 and continues. Findings include: Article 43-26-1, The Georgia Registered Professional Nurse Practice Act, Chapter Two - Standards of Nursing Practice, Part 2.2.2., Standards Related to Registered Nurse Responsibility for Nursing Practice Implementation, specifies that the registered nurse will implement treatments and therapy, including medication administration. Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received laboratory testing, and timely drug therapy, as ordered. This resident received the anticoagulant drugs [MEDICATION NAME] and Aspirin. This failure to provide services in accordance with professional standards of practice resulted in Resident #3 being hospitalized with bruises, bleeding gums, and a [DIAGNOSES REDACTED]. Cross refer to F309 and F502 for more information regarding Resident #3. | 2014-07-01 |
| 10350 | 10350 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 309 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow physician's orders related to a bed/chair alarm and blood pressure parameters for two (2) residents (#5 and # 16) from a sample of twenty four (24) residents. Findings include: 1. Observation of resident #5 on 8/24/09 at 8:35 a.m. with Rehabilitation tech "YY" revealed the resident in bed with a sensor alarm on the bed and wheelchair. Observation of incontinence care provided by Certified Nursing Assistant (CNA) "XX" on 08/24/09 at 12:35 p.m. revealed that the bed alarm started sounding. The CNA turned it off and continued care. Review of the clinical record for resident #5 revealed a physician's order dated 8/18/09 to discontinue the bed/chair alarm. Continued review revealed an Interdisciplinary Progress Note dated 08/18/09 indicating that the bed/chair alarm had been discontinued. During interview, record review and observation with Unit Manager (UM) "ZZ" on 08/25/09 at 4:00 P.M., she acknowledged that the bed/chair alarm had not been discontinued as ordered by the physician. 2. Review of the clinical record for resident #16 revealed a [DIAGNOSES REDACTED]. Review of the June, July, and August, 2009 Medication Administration Records (MAR) revealed that the resident received the [MEDICATION NAME] fourteen (14) times when the SBP was less than 120. Interview on 08/26/09 at 11:10 a.m. with, Licensed Practical Nurse (LPN) Unit Manager "CC" revealed that the [MEDICATION NAME] was documented as given on the days it should have been held. | 2014-07-01 |
| 10351 | 10351 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 244 | D | 0 | 1 | 2MEL11 | Based on review of the Resident Council meeting minutes and residents and staff interview, the facility failed to actively work to resolve continued grievances related to timely response to call lights. Findings include: During a group interview on 08/25/09 at 10:00 a.m., eleven (11) of thirteen (13) residents in attendance revealed that they had ongoing problems with timely responses to call lights and that they had voiced these concerns to the facility during Resident Council meetings on more than one occasion. Eleven (11) residents revealed that although the average response time to a call light was about 15 minutes; response time could take 45 minutes or more and was l an ongoing problem. The group members revealed that the greatest concern was not with the initial response to the call light but with the Certified Nursing Assistants (CNA) entering the residents' rooms, turning off the call light, and informing the resident that the CNA would inform the assigned CNA to return to assist the resident. However,on these recalled occasions no one would return. The residents indicated that either ultimately no one followed up with them or that, after long waits, the residents turned the light on again and repeated the process. During an interview with random resident "B", assessed as cognitively intact, on 08/26/09 at 9:00 a.m., he/she revealed that the call light concern had come up more than a few times at the Resident Council meetings and could not recall any specific response from the facility to address the problem about lights being turned off without assistance and follow up care. During an interview with the Activities Director on 08/26/09 at 1:30 p.m., she revealed that she attended and took minutes at each meeting for the residents. She revealed that she recalled that the subject of call light response had come up several times over the last six months during the Resident Council meetings. She cited examples of complaints about a call light on the floor for one resident's roommate and complaints on more th… | 2014-07-01 |
| 10352 | 10352 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 322 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that the appropriate amount of flush/water was administered per Gastrostomy Tube as ordered by the physician for one (1) randomly observed resident during Medication Pass. Findings include: During and observation of Medication Pass on 08/25/09 at 9:01 a.m., Registered Nurse (RN) "JJ", flushed a gastrostomy tube ([DEVICE]) with 120 milliliters (ml) of water after having checked for residual and placement of the tube. Interview on 8/25/09 at 9:01 a.m. with RN "JJ" revealed that she had flushed the tube with 120ml of water. Review of the physician's orders [REDACTED]. Interview at 10:00 a.m. on 08/25/09 with RN "JJ" revealed that she needed to give the resident 230ml more water for hydration purposes. | 2014-07-01 |
| 10353 | 10353 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 441 | D | 0 | 1 | 2MEL11 | Based on observation and staff interview the facility failed to maintain an environment free of the likelihood of infection for one (1) randomly observed resident during Medication Pass. Findings include: Observation during Medication Pass on 08/25/09 at 10:30 a.m. revealed Registered Nurse (RN) "JJ" administering medication to the resident by spoon. After administering a spoonful of pills to the resident the placed the cup of pills with the spoon inside onto the unclean, uncovered bedside table, so that she could give the resident some water. As she began to pick the cup up with the spoon in it, an orange capsule fell out onto the unclean bedside table. "JJ" scooped it up with the spoon, put it back into the cup with the other pills and continued to administer them to the resident. Interview with Licensed Practical Nurse (LPN), Unit Manager "CC" on 08/25/09 at 10:35 a.m. revealed that since it was a orange capsule and easily identifiable it should have been discarded and replaced. It should not have been administered to the resident after it fell on an unclean surface. | 2014-07-01 |
| 10354 | 10354 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 315 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, failed to perform incontinence care in a manner to prevent urinary tract infection [MEDICAL CONDITION] for one (1) resident ( #9) from a sample size of twenty-four (24) residents. Findings include: Observation of incontinence care for resident #9 on 08/25/09 at:28 a.m. provided by Certified Nursing Assistant (CNA) "GG" assisted by Licensed Practical Nurse (LPN) "FF" revealed the CNA used the same disposable wipe a total of seventeen (17) [MEDICAL CONDITION] up and down the right inner thigh and then wiped the middle labia without changing the wipe. The CNA obtained a new wipe and wiped twenty-four (24) [MEDICAL CONDITION] on the left inner thigh and then cleaned the inner vaginal area without rearranging or obtaining a new wipe. The resident was repositioned on his/her left side and after the CNA obtained a new wipe,she wiped repeatedly over the back area and around the open wound area on the gluteal fold using the same wipe. During an interview with CNA "GG" on 08/25/09 at 10:15 a.m. she revealed that she had recently attended inservices on incontinence care. Review of the facility 's policy and inservices on perineal care revealed that for females the labia should be gently separated using downward [MEDICAL CONDITION] from the pubic to rectal area using alternate sites of the cloth with each downward stroke. | 2014-07-01 |
| 10355 | 10355 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 156 | C | 0 | 1 | 2MEL11 | Based on record review and staff interview, the facility failed to ensure that liability and appeal notices for medicare non-coverage were provided for fifteen (15) of seventeen (17) resident records reviewed. This included thirteen (13) randomly-reviewed residents and two (2) residents (#6 and #10) from twenty four (24) sampled residents. Findings include: Review of residents discharged from Medicare services revealed seventeen (17) residents were identified by the facility as no longer meeting the criteria for skilled medicare services, all of whom were still in the facility. Continued review revealed only two (2) Notices of Medicare Provider Non-Coverage forms were located. Interview on 08/26/09 at 11:20 a.m. with the Administrator revealed that she was aware there was a problem with liability notices. Of the seventeen (17) residents discharged from Medicare services in the last three (30 months, only two (2) residents received non-coverage notices. Review of these two Notices revealed that there was no date as to when they had been sent, and no description of the services that were no longer covered. | 2014-07-01 |
| 10356 | 10356 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 502 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that laboratory specimens were drawn as ordered by the physician for one (1) resident (#9) of twenty -four (24) sampled residents. Findings include: Record review of resident #9 revealed [DIAGNOSES REDACTED]. Review of the physicians' orders revealed an order dated 07/25/09 for a [MEDICATION NAME] Time with International Ratio (PT with INR) every Monday and Thursday. Record review revealed no evidence that this laboratory test had been completed on Monday, 08/10/09 or Thursday, 08/13/09. During an interview with the Unit Manager Licensed Practical Nurse (LPN) "CC" on 08/24/09 at 3:45 p.m. she revealed, after checking her records and with the laboratory, that the [MEDICATION NAME] with INRs were not done as ordered. | 2014-07-01 |
| 10357 | 10357 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2009-08-26 | 279 | D | 0 | 1 | 2MEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a plan of care for the use of [MEDICATION NAME] (a blood thinning medication) for one (1) resident (#4) of the twenty-four (24) sampled residents. Findings include: Review of the clinical record for resident #4 revealed a [DIAGNOSES REDACTED]. Further review of the clinical record revealed no evidence that a plan of care had been developed for the use of [MEDICATION NAME]. Interview with the Minimum Data Set (MDS) Coordinator on 8/24/09 at 1:56 p.m. revealed that there was no plan of care for [MEDICATION NAME] and indicated that there should have been one developed. | 2014-07-01 |
| 10358 | 10358 | MANOR CARE REHABILITATION CENTER - MARIETTA | 115283 | 4360 JOHNSON FERRY PLACE | MARIETTA | GA | 30068 | 2009-04-03 | 315 | E | 1 | 0 | ENNJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide incontinence care in a manner to prevent the spread of urinary tract infections for four (4) residents (#s 1, 2, 3 and 4), who were incontinent and were dependent on staff for toileting, on the survey sample of seven (7) residents. Findings include: 1. Record review for Resident #1 revealed a 03/18/2009 Minimum Data Set (MDS) assessment which indicated that the resident was incontinent of bowel and bladder and was totally dependent on staff for toilet use. During an observation of incontinence care provided to Resident #1 on 04/02/2009 at 7:10 p.m. by Certified Nursing Assistant (CNA) "AA", the CNA placed on gloves and proceeded to clean the resident's rectal area, but failed to clean the resident's front perinea area. The CNA continued to provide care to the resident wearing the soiled gloves used to clean the rectal area, placing a clean diaper and gown on the resident. 2. Record review for Resident #2 revealed a 03/06/2009 MDS assessment which indicated that the resident was incontinent of bowel and bladder and was totally dependent on staff for toilet use. During an observation of incontinence care provided to Resident #2 on 04/02/2009 at 7:25 p.m. by CNA "AA", the CNA placed on gloves prior to providing care, and cleaned the front perinea with a back-to-front wipe. Then, wearing the same gloves used to provide incontinence care, the CNA placed a clean diaper and gown on the resident and pulled the sheets up around the resident. 3. Record review for Resident #3 revealed a 01/06/2009 MDS assessment which indicated that the resident was frequently incontinent of bowel and bladder and required the extensive assistance of staff for toilet use. During an observation of CNA "BB" providing incontinence care to Resident #3 on 04/02/2009 at 7:45 p.m., after cleaning stool from the resident, the CNA placed cream on the resident's buttocks and rectal area, and t… | 2014-07-01 |
| 10359 | 10359 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2010-04-12 | 309 | D | 1 | 0 | 4GY711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer a medication as ordered by the physician to one (1) resident (#3) on the survey sample of seven (7) residents. Findings include: Record review for Resident #3 revealed a physician's orders [REDACTED]. The February 2010 Medication Record (MR) documented that the [MEDICATION NAME] 125 milligram-per-dose therapy was initiated for the 10:00 p.m. dose on 02/04/2010. However, further record review, to include review of the February MR, revealed no evidence to indicate that the resident received the prescribed [MEDICATION NAME] on 02/12/2010, 02/13/2010 and 02/14/2010. During an interview conducted on 04/12/2010 at 3:00 p.m., the Administrator acknowledged that there was no evidence to indicate that the resident received the prescribed [MEDICATION NAME] on 02/12/2010, 02/13/2010 and 02/14/2010. | 2014-07-01 |
| 10360 | 10360 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-04-06 | 323 | G | 1 | 0 | 5ZN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility document review, the facility failed to ensure that two (2) residents (#s 1 and 3), on the survey sample of eight (8) residents, received adequate supervision during transfer and/or the provision of care. This resulted in Resident #3 experiencing a right-leg fracture, thus representing actual harm to the resident. Findings include: 1. Record review for Resident #3 revealed a 02/10/2009 Minimum Data Set (MDS) assessment which indicated that the resident was totally dependent on staff for transfers. A Care Plan entry of 02/12/2009 specified the use of two (2) staff for transfers at all times. A Nurse's Note of 03/28/2009 at 10:00 a.m. documented that the resident was observed with swelling and pain of the right knee, and documented extreme heat on the knee. This Note documented that the physician was called and gave an order to transfer the resident to the hospital emergency room for evaluation. A Nurse's Note of 03/28/2009 at 10:25 a.m. documented that the transport service had arrived and transported the resident to the hospital. A subsequent Nurse's Note of 03/28/2009 at 2:30 p.m. documented that the resident had returned to the facility from the hospital with a splint on the right leg and a [DIAGNOSES REDACTED]. Review of the facility's investigation into this resident's injury revealed a 03/31/2009 written statement by Certified Nursing Assistant (CNA) "BB". In this statement, CNA "BB" documented that on 03/28/2009, she had transferred Resident #3 with the Hoyer lift without any assistance, and that during the transfer, the resident had hit his/her leg against the bed when the CNA was attempting to turn the resident around and place him/her in the Geri-Chair. The CNA further documented that when she laid the resident down, she noted swelling to the resident's right leg. 2. Record review for Resident #1 revealed a 01/09/2009 MDS assessment which indicated that the resident was totally de… | 2014-07-01 |
| 10361 | 10361 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-04-06 | 282 | G | 1 | 0 | 5ZN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility document review, the facility failed to ensure that one (1) resident (#1), on the survey sample of eight (8) residents, was transferred in accordance with the resident's written plan of care. This resulted in Resident #3 experiencing a right-leg fracture, thus representing actual harm to the resident. Findings include: Record review for Resident #3 revealed a Care Plan entry of 02/12/2009 which specified the use of two (2) staff for transfers at all times. A Nurse's Note of 03/28/2009 at 10:00 a.m. documented that the resident was observed with swelling and pain of the right knee, and documented that the physician was called and gave an order to transfer the resident to the hospital. A subsequent Nurse's Note of 03/28/2009 at 2:30 p.m. documented that the resident had returned to the facility from the hospital with a [DIAGNOSES REDACTED]. In a 03/31/2009 written statement by Certified Nursing Assistant (CNA) "BB", this documented that on 03/28/2009, she had transferred Resident #3 with the Hoyer lift without any assistance, and that during the transfer, the resident had hit his/her leg against the bed. The CNA further documented that when she laid the resident down, she noted swelling to the resident's right leg. Cross refer to F323, example 1, for more information regarding Resident #3. | 2014-07-01 |
| 10362 | 10362 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-02-11 | 157 | G | 1 | 0 | O2A612 | Based on record review and staff interview the facility failed to notified the resident's attending physician of blood glucose levels which would require medical intervention. This affected two (2) residents (#10 and #11) from a sample of eighteen (18) residents. The findings include: 1. Record review for resident #10 revealed sliding scale blood glucose monitoring was to be conducted four (4) times daily. The resident's insulin administration was based on this blood glucose monitoring. A review of the resident's Medication Administration Records (MAR) on 2/08/09, 2/09/09, 2/26/09 and 3/05/09 recorded the resident's blood glucose results were below 60. Review of the clinical record revealed the physician had not been notified. An interview with the facility's Director of Nursing (DON) on 3/17/09 at 9:00 a.m. confirmed that the resident's physician was not notified about the low blood sugar results. 2. Record review for resident #11 revealed sliding scale blood glucose monitoring was to be conducted two (2) times per day. The resident's insulin dosage was based on this blood glucose monitoring. A review of the resident's MAR indicated [REDACTED]. An interview with charge nurse LPN "AA" on 3/18/09 at 1:15 p.m. confirmed that physician was not notified about the high blood sugar results. The facility's Diabetic Care Protocol policy directed that the resident's physician be notified if the blood sugar results were less than 60 or more than 400. | 2014-07-01 |
| 10363 | 10363 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-02-11 | 333 | G | 1 | 0 | O2A611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that one (1) resident (#1), in a survey sample of ten (10) residents, was free of a significant medication error, regarding the failure to administer the prescribed dose of [MEDICATION NAME] intended to address the resident's extrapyramidal symptoms resulting from antipsychotic drug therapy. This represented actual harm, as the resident's extrapyramidal symptoms subsequently worsened. Findings include: Record review revealed a Nurse's Note of 09/05/2008 which documented that the resident had been admitted to the facility. A 09/06/2008 physician's orders [REDACTED]. The October and November 2008 Medication Records documented that the resident received doses of [MEDICATION NAME] every six (6) hours as ordered through 11/13/2008. An 11/13/2008 Nurse's Note at 12:25 p.m. documented that a physician's orders [REDACTED]. A Nurse's Note of 11/19/2008 at 11:10 a.m. documented that due to the resident's behavior, the physician had ordered to restart [MEDICATION NAME] 1 milligram every six hours, and to continue the [MEDICATION NAME] therapy. The November Medication Record documented that [MEDICATION NAME] therapy was discontinued on 11/13/2008 and restarted on 11/19/2008 as ordered, and that [MEDICATION NAME] therapy was initiated and administered as ordered from 11/13/2008 through 11/30/2008. The December 2008 Medication Record documented that the [MEDICATION NAME] and [MEDICATION NAME] therapy were administered as ordered from 12/01/2008 through 12/18/2008. Then, a 12/18/2008, 1:10 p.m. Nurse's Note documented that new physician's orders [REDACTED]. The December 2008 Medication Record documented that the [MEDICATION NAME] was changed to be administered on an as-needed basis, and the dose of [MEDICATION NAME] was increased to 75 milligrams twice daily, on 12/18/2008 as ordered, and documented that the resident received these drugs as ordered through 12/31/2008. A Nurse'… | 2014-07-01 |
| 10364 | 10364 | PLACE AT DEANS BRIDGE, THE | 115290 | 3235 DEANS BRIDGE ROAD | AUGUSTA | GA | 30906 | 2009-02-11 | 498 | D | 1 | 0 | O2A611 | Based on review of a facility investigation and hospital record review, one (1) certified nursing assistant (CNA) ("XX"), of six (6) CNAs reviewed, was found to be legally intoxicated while performing duties. Findings include: Review of the Separation Notice for CNA "XX" dated 01/28/2009 revealed that the circumstance of the separation was a gross company violation. The Personnel Action form referencing CNA "XX" documented that during rounds, the charge nurse had smelled alcohol on the CNA and that when the CNA was sent to the hospital for alcohol testing, the CNA failed the test. The Alcohol Testing Form documented a positive result of 0.091 on 01/28/2009. | 2014-07-01 |
| 10365 | 10365 | FAIRBURN HEALTH CARE CTR, INC | 115298 | 178 WEST CAMPBELLTON STREET | FAIRBURN | GA | 30213 | 2009-03-03 | 309 | E | 1 | 0 | TK3H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to do Accuchecks in accordance with physicians' orders for six (6) residents (#s 1, 2, 3, 4, 5 and 6) out of eleven (11) sampled residents. Findings include: 1. Record review for Resident #1 revealed that the Medication Record (MR) documented that the resident had [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The resident also had a current physician's orders [REDACTED]. However, review of the resident's MR for the month of November 2008 revealed no evidence to indicate that Accuchecks were done as ordered and scheduled on 11/08/2008 at 6:30 a.m. and on 11/13/2008 at 4:30 p.m. Review of the November 2008 and December 2008 MR revealed that for the dates of 11/25/2008, 12/01/2008, 12/03/2008 and 12/24/2008, the nurse had initialed the 6:30 a.m. Accuchecks on the MR, circled the initials, and documented in the Nurse's Medication Notes of the MR that the Accuchecks were not done because no strips were available. 2. Record review for Resident #2 revealed that the MR documented that the resident had [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. However, review of the MR for the month of December 2008 revealed no evidence to indicate that Accuchecks were done as ordered and scheduled for the dates of 12/21/2008 and 12/26/2008 at 11:30 a.m., and for 12/10/2008 and 12/16/2008 for at 9:00 p.m. Additional review of this MR revealed that for the dates of 12/02/2008 and 12/24/2008, the nurse had initialed the 6:30 a.m. Accuchecks on the MR, circled the initials, and documented in the Nurse's Medication Notes of the MR that the Accuchecks were not done because no strips were available. 3. Record review for Resident # 3 revealed a current physician's orders [REDACTED]. However, review of the November and December 2008 MRs revealed no evidence to indicate that Accuchecks were done as ordered and scheduled on 11/08/2008 and 12/22… | 2014-07-01 |
| 10366 | 10366 | FIFTH AVENUE HEALTH CARE | 115319 | 505 NORTH FIFTH AVENUE | ROME | GA | 30165 | 2011-02-15 | 333 | D | 1 | 0 | OE0W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to ensure that residents were free of significant medication errors for two (2) residents ("A" and #2) in a survey sample of seven (7) residents. Findings include: 1. Record review for Resident "A" revealed that the January 2011 physician's orders [REDACTED]. Review of a Medication Upon Discharge form for Resident "A" revealed that medications provided to the resident upon discharge from the facility had included [MEDICATION NAME] 1 milligram, [MEDICATION NAME] 10 milligrams and [MEDICATION NAME] 600 milligrams. However, further review of the resident's medical record, including review of the resident's January 2011 physician's orders [REDACTED]. A Grievance/Complaint Report dated 01/09/2011 filed for the family of the resident documented that the resident had been discharged on [DATE], and the family had identified on 01/05/2011 that the resident had been given three (3) of another resident's medications upon discharge, those medications being [MEDICATION NAME] and [MEDICATION NAME]. This Report also documented that Resident "A" had taken three (3) [MEDICATION NAME], two (2) [MEDICATION NAME] and two (2) [MEDICATION NAME], and that these medications had been sent home by accident with the resident. During interview with a family member of Resident "A" conducted on 02/02/2011 at 2:55 p.m., this family member stated that the resident had been discharged from the facility on 01/05/2011. It was stated that the family later discovered, during review of the resident's medications, that medications provided to the resident by the facility at discharge had included three (3) medications that belonged to another resident. It was further stated by the family member that when discussing the incident with the Director of Nursing, she was informed by the Director of Nursing that, based on a medication count of the medication cards, the resident had taken doses of the medic… | 2014-07-01 |
| 10367 | 10367 | FIFTH AVENUE HEALTH CARE | 115319 | 505 NORTH FIFTH AVENUE | ROME | GA | 30165 | 2011-02-15 | 502 | D | 1 | 0 | OE0W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide a potassium level laboratory test in a timely manner, as requested by the nurse practitioner, for one (1) resident (#2) in a survey sample of seven (7) residents. Findings include: Cross refer to F333, Example 2, for more information regarding Resident #2. Record review for Resident #2 revealed a Telephone Orders sheet which referenced a physician's orders [REDACTED]. However, review of the January 2011 Medications sheet revealed that doses of Potassium Chloride 10 milliEquivalents were administered to the resident twice a day, at 9:00 a.m. and 9:00 p.m., on 01/18/2011, 01/19/2011, 01/20/2011, and 01/21/2011, and for the morning dose on 01/22/2011. During interview with the nurse practitioner on 02/02/2011 at 10:45 a.m., this nurse practitioner stated that when she was notified by facility staff during the weekend that the resident's potassium was not discontinued on 01/17/2011, as ordered, she had requested that a potassium level be drawn. However, the nurse practitioner stated she was told by the facility nurse that the nurse could not access the supplies necessary to perform the laboratory test because the supplies were locked up and the nurse supervisor did not have a key, and the hospital would not come to the facility to do the potassium level. Therefore, the nurse practitioner stated that rather than ordering that the potassium level be done as originally requested, the nurse practitioner gave an order to check the potassium level on the following Monday. | 2014-07-01 |
| 10368 | 10368 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 157 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to notify the physician when one resident ("D") who received anticoagulant therapy and was at risk for bleeding, developed unexplained bruising from a sample of thirty-eight (38) residents. Findings include: Record review revealed resident "D" was admitted with multiple health concerns and [DIAGNOSES REDACTED]. The resident was identified by facility assessment and care planned as at risk for bleeding. A Nurse's Admission/Post Hospital Record dated 4/06/12, contained documentation of areas of bruising to the resident's hands. Review of Skilled Daily Nurses Notes dated from 4/06/12 through 5/07/12 continued to document areas of bruising on the resident. During interview with resident "D" on 5/10/12 at 9:09 a.m. she made reference to the bruises that kept reoccurring over her body and she did not know why or what caused them. Review of facility's policy on Resident's Receiving [MEDICATION NAME] Therapy contained instruction that all signs and symptoms of bruising were to be reported to the physician. Review of physician's progress notes indicated no documentation that the MD was aware of the resident's bruising or had been notified of the bruising. Interview with the Director of Nurses on 5/11/12 at 9:42 a.m. revealed the nursing staff should have contacted the physician about the resident's bruises. | 2014-07-01 |
| 10369 | 10369 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 507 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility failed to ensure that laboratory reports were available in the resident's chart and that the physician was notified of the results for three (3) residents (#1, and #103) of thirty-eight (38) sampled residents. Findings include: 1. Resident #1 had a physician's orders [REDACTED]. The previous TSH was done on 2/08/12 with a result of 0.2 (0.35-5.6) which was low with an physician's orders [REDACTED]. An interview on 5/9/12 at 11:45 a.m. with Licensed Practical Nurse (LPN) "JJ" agrees the TSH is not in the chart. LPN "JJ" called the lab and found that the lab had been done on 3/21/12 and had them fax a copy to the facility. The TSH results were 1.71 (0.35-5.6) which are within normal limits. An interview with Licensed Practical Nurse (LPN) on the same day at 2:00 p.m. revealed that the laboratory results needed to be sent to the physician for signature, as the physician had not been notified of the results. 2. Record review for resident #103 revealed that he was receiving [MEDICATION NAME]. Further record review revealed that he had telephone orders for PT/INR tests to be conducted on 2/23/12, 3/01/12 and 3/26/12. These labs results were not in the clinical record and had to be obtained by calling the laboratory used by the facility. Further record review of the clinical record of resident #103 revealed an order for [REDACTED]. A call to the clinical laboratory was made by the facility's Clinical Manager at 10:45 a.m. on 5/09/12. She confirmed that the PT/INR and the BMP tests were performed but the results were not available in the facility and therefore were not in the resident's clinical record. The Clinical Manager also stated in an interview on 5/10/12 at 8:30 a.m. that she did not know if the attending physician had been made aware of the PT/INR or BMP lab results. | 2014-07-01 |
| 10370 | 10370 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 323 | E | 0 | 1 | FDH011 | Based on observation and staff interview the facility failed to keep all resident use and care areas free of accident hazards. Findings include: The second lunch service in the main dining room was observed on 5/09/12 at 1:00 p.m. There was a large amount of food and debris on the floor throughout the room. There was also a large puddle of clear liquid on the floor on the left side of the room from a previous spill. Three (3) ambulatory residents were observed walking in the room during the meal. Several staff members were assisting residents. No one made any attempt to clean up the spilled liquid and food. The Dietary Manager was interviewed on 5/11/12 at 10:10 a.m. and stated the nursing staff is responsible for cleaning food spills between meals. Licensed Practical Nurse (LPN) "JJ" was interviewed on 5/11/12 at 10:45 a.m. and stated she did not notice the spill or food particles. She further stated housekeeping did not clean the dining room between meal services unless requested. | 2014-07-01 |
| 10371 | 10371 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 365 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the facility failed to provide liquids at a consistency appropriate for the needs of it residents. This affected one (1) resident, #112, from a sample of thirty-eight (38) residents. Findings include: A review of the resident #112's physician orders [REDACTED]. There were current orders for nectar thickened and honey thickened consistency liquids. A review of a speech therapy discharge summary dated 11/15/11 revealed a recommendation for honey thick liquids. An observation of beverages in the resident's room on 5/9/12 at 10:00 a.m. revealed that he had 1 carton of honey thickened apple juice and 1 carton of honey thickened water on his over bed table. His personal refrigerator contained 2 cartons of nectar thickened water, 1 carton of nectar thickened lemonade, 2 cartons of nectar thickened apple juice and 1 carton of honey thickened water. In addition, his personal refrigerator contained 3 eight ounce bottles of Ensure Nutrition Shake of regular consistency. An interview with the resident's sister on 5/10/12 at 3:30 p.m. revealed that the family provided the Ensure Nutrition Shake for use in missing food items. The observation of the resident's beverages was confirmed with by the facility's Clinical Manager on 5/10/12 at 10:45 a.m. | 2014-07-01 |
| 10372 | 10372 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 280 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and staff interview the facility failed to develop a care plan with participation of all disciplines determined by the needs of one (1) resident, #112, from a sample of thirty-eight (38) residents. Findings include: Record review for resident #112 revealed that he was admitted to the facility on [DATE] and was under the care of a hospice provider. A review of the resident's care plan revealed no evidence of attendance by representatives of disciplines determined by the resident's needs. The resident had a [DIAGNOSES REDACTED]. He has several restrictions related to his diet and feeding technique, e.g., position to 90 degrees, feed 1/2 tsp bolus, spoon feed all liquids 1/2 tsp., feed to left side of face, remind resident to chin tuck, alternate liquids liquids and solids, ask resident to reswallow, nectar thickened liquids, pureed diet with honey thickened liquids, large portions. Further review of the clinical record revealed that he had been evaluated by a Speech Therapist (ST) from 10/27/11 to 11/15/11 to assess his chewing and swallowing abilities. A review of the ST's discharge summary revealed that recommendations were made as follows: pureed diet, honey-thick liquids, alternation of solids and liquids, rate modifications, bolus size modifications, second dry swallowing, chin tuck upright position for more than 30 minutes after meals. Further record review revealed that he had a current physician's orders [REDACTED]. A review of the residents current care plan revealed that it was updated on 10/27/11 and 11/01/11 to include these interventions. A review of the attendance record for the resident's care plan meetings revealed that the last recorded meeting was on 1/12/12. Further record review revealed that at that meeting the facility had no nursing, dietary, speech therapy, physical therapy, social service or physician representation at the meeting. No other documentation of care plan attendance records were in the clinic… | 2014-07-01 |
| 10373 | 10373 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 156 | E | 0 | 1 | FDH011 | Based on record review and staff interview, the facility failed to fully inform residents and or responsible parties of available options regarding Medicare benefits for three (3) of thirty-eight (38) sampled residents ( #21, #119 and # 123). Findings include: Record review of three (3) resident liability notices (# 21, #119, #123) found that the facility had notified resident and/or responsible party of the facility's intent to discontinue Medicare services within seventy-two (72) hours. However, they failed to provide the resident and his/her legal representative with CMS form Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) which notifies the resident and his/her representative of the estimated cost of these services in order for them to be able to make an informed decision as to whether or not to continue services and pay privately. Interview with the Business Office manager on 5/08/12 at 11:40 a.m. revealed she was not aware that she was supposed to provide residents and responsible parties with this information and that she had not completed this form for any resident. | 2014-07-01 |
| 10374 | 10374 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 164 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to maintain confidentiality of medical records for one resident, # 52 of a sample of thirty-eight (38) residents and for two (2) randomly observed records. This was related to a Medication Administration Record [REDACTED]. Findings include: On 5/08/12 at 8:20 a.m. on A-Hall a medication cart was left unattended with the Medication Administration Record [REDACTED]. The cart and record were unattended from 8:22 a.m. to 8:30 a.m. Licensed Practical Nurse (LPN) "II" was in room [ROOM NUMBER] with the door closed. She returned to the cart at 8:30 a.m. and stated she had left an orientee at the cart. She stated the cart should not have been left unattended with the resident's medication record left open to full view. Additionally, a Laboratory Report dated 5/07/12 was observed on a second cart at the same time at the other end of the A Hall. A nurse was observed to approach the second cart and then leave again. The report was not hidden from view. A second random observation was made on 5/08/12 at 2:29 p.m. The medication cart med on A-Hall had a set of physician's orders [REDACTED]. No staff was observed near the cart. LPN "GG" returned to the cart and stated she should not have left it unattended. The Administrator was interviewed on 5/10/12 at 3:20 p.m. and also stated the residents' records should have been protected from general view. | 2014-07-01 |
| 10375 | 10375 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 166 | E | 0 | 1 | FDH011 | Based on record review, staff and resident interviews, the facility failed to have an effective process in place to report missing items of clothing and to notify resident of status of search for one (1) resident ("C") from a sample of thirty- eight (38). Findings include: Interview with resident "CC" on 5/19/12 at 8:13 a.m. revealed she was missing a pair of pajamas for approximately one (1) week. She further revealed that she had told several staff persons. Record review of facility's Policy on Missing or Lost Resident Items was provided by Licensed Practical Nurse (LPN) "JJ" on 5/10/12 at 8:37 a.m. It contained documentation that a family member or resident was to complete a grievance report as soon as possible. The policy further included Social Services was to start the investigation and enter the missing item on the Missing Item Log. This log was also to note the outcome of the investigation and when the family was notified of dispensation of missing item. Record review of Missing Item Log for 2012 revealed only two entries, both in May 2012. Interview with the Administrator on 5/10/12 at 10:10 a.m. revealed the lost item log was maintained by Social Services. She further revealed that use of the log had just been implemented in May 2012 and that no documentation of lost items had been maintained prior to the log's implementation in May 2012. She was aware this did not meet the procedure outlined in the facility's policy for missing items. | 2014-07-01 |
| 10376 | 10376 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 167 | C | 0 | 1 | FDH011 | Based on observation and staff interview the facility failed to ensure that the most recent survey was available for examination and did not post where the survey results could be found. Findings include: During initial tour on 5/07/12 at 10:00 a.m. the survey results were not easily located nor was a posting of their location. Interview with the Administrator on 5/08/12 at 2:30 p.m. revealed that the survey results were kept inside the front office, which was locked, due to a wandering, confused resident. She agreed there was no signage to indicate where the survey results could be found. | 2014-07-01 |
| 10377 | 10377 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 225 | E | 0 | 1 | FDH011 | Based on record review and staff interview the facility failed to ensure that criminal background checks were conducted for all staff members prior to their employment. This finding was based on one (1) of ten (10) personnel records reviewed. Findings include: A review of a random sample of ten (10) personnel files of recently employed staff members revealed that a Licensed Practical Nurse (LPN) with an employment date of 3/16/12 did not have a criminal background check in his/her personnel record. The facility's Social Worker (SW) was able to print a copy of the background report by accessing the facility's vendor used for this service. The SW confirmed in an interview on 05/09/12 at 1:30 p.m that there was no evidence that the employee's criminal background report was obtained by the facility prior to his/her employment. | 2014-07-01 |
| 10378 | 10378 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 279 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, staff interviews and record review the facility failed to develop a comprehensive care plan for one (1) resident (#102) for resisting care and for incontinence from thirty-eight (38) sampled residents. Findings include: Resident #102 was admitted to this facility on 5/26/11 with multiple [DIAGNOSES REDACTED]. Record review revealed Minimum Data Set (MDS) annual assessment dated [DATE] had triggered urinary incontinence and indicated that it was to be addressed in the resident's care plan. The resident's two (2) quarterly MDS assessments dated 01/30/12 and 4/30/12 both contained documentation that resident #102 was not resistive to care and assessed the resident as continent of urine. Review of the resident's care plan dated 8/02/11 revealed it did not address urinary incontinence or a persistant rejection of care. Review of Nursing Notes dated 12/23/11, 12/28/11, 01/13/12, 01/18/12, 4/26/12, 5/04/12 contained documentation of the resident being resistant to care. Interview with Certified Nurses Assistant (CNA) "TT" on 5/9/12 at 2:00 p.m. revealed the resident often refuses care. She further stated that at least one (1) or two (2) times a day, the resident refused care for bathing or incontinent care. The resident exhibits behaviors of striking out to staff when they provide care. Interview with the MDS Coordinator "BB" on 5/10/12 at 11:35 a.m. revealed resident #102 was not care planned for incontinence and refusal of care. | 2014-07-01 |
| 10379 | 10379 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2012-05-11 | 309 | D | 0 | 1 | FDH011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide care and services in accordance with the residents' current clinical orders. This affected three (3) residents (#71, #103 and #112) from a sample of thirty-eight (38) residents. Findings include: 1. A review of the clinical record of resident #103 revealed that he had a current physician's order for [MEDICAL CONDITION] Embolic Deterrent (TED) hose to be on in the morning and off in the evening. Observation on 5/09/12 at 10:30 a.m. revealed the resident was not wearing TED hose stockings. Interview with the Clinical Manager at that time verified the resident was not wearing TED stockings and that there was a sign on the resident's closet door with instructions on how to apply the TED hose with instructions to put on at 6:00 a.m. and take them off at bedtime. Observation on 5/10/12 at 8:30 a.m. revealed the resident was sitting in a Geri chair near the nursing station without the TED hose on. A review of the resident's clinical record at that time verified no change in the physician orders. 2. A review of the resident #112's physician orders revealed conflicting orders for the consistency of liquids on his diet. There were current orders for nectar thickened and honey thickened consistency liquids. A review of a speech therapy discharge summary dated 11/15/11 revealed a recommendation for honey thick liquids. An observation of beverages in the resident's room on 5/9/12 at 10:00 a.m. revealed that he had 1 carton of honey thickened apple juice and 1 carton of honey thickened water on his over bed table. His personal refrigerator contained 2 cartons of nectar thickened water, 1 carton of nectar thickened lemonade, 2 cartons of nectar thickened apple juice and 1 carton of honey thickened water. The observation of the resident's beverages was confirmed with by the facility's Clinical Manager on 5/10/12 at 10:45 a.m. Further review of the clinical record of resident #112 revea… | 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 );