cms_GA
Data source: Big Local News · About: big-local-datasette
10,655 rows sorted by zip
This data as json, copyable, CSV (advanced)
| Link | rowid | facility_name | facility_id | address | city | state | zip ▼ | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1116 | 1116 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 812 | E | 0 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of policies titled Labeling and Dating Inservice, Labeling & Dating/Expired Foods/Covering Foods and Dating, Open Foods in Ziplock Bags, Environment, Manual Warewashing, and Warewashing, the facility failed to properly label food products; failed to maintain appropriate temperatures on the serving line for a cold food item; failed to properly air dry dome lids and maintain them in good condition; failed to maintain a clean food processor and microwave oven; failed to maintain an ice machine lid in good condition; and failed to ensure a waste receptacle next to the hand wash station had a lid. This had the potential to affect 138 residents receiving an oral diet. Findings include: During an interview and observation on [DATE] at 9:48 a.m. with the Dietary Manager (DM) he verified the following observations. Ice machine lid, upper right corner is broken exposing orange colored internal insulation. Dome lids were stacked one on top of another with visible moisture between the dome lids and in poor condition with a whitish discoloration on the underside of the lids. An observation of the inside of the microwave revealed dried reddish-brown food splattering on the ceiling and sides. During an interview and observation on [DATE] at 9:51 a.m. with the DM of the pantry, there was with an open package of spiral pasta and spaghetti, with unreadable open dates and no 'use by' dates. The DM reported the labels should include what the item is and have a 'use by' date on the label. During an interview and observation on [DATE] at 9:55 a.m. with the DM of the walk-in refrigerator there were three unlabeled open packages of cheese dated ,[DATE] with no 'use by' date. An unlabeled open package of shredded cabbage dated ,[DATE] with no 'use by' date. An open package of ham dated [DATE] with no 'use by' date. During an observation and interview on [DATE] at 11:51 a.m. with Cook AA she reported 23 resi… | 2020-09-01 |
| 1117 | 1117 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2018-08-16 | 578 | D | 0 | 1 | ZDF911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility failed to properly follow the process regarding the code status according to advance directive documentation, for three residents (R)#52, R#91, and R#104) of 29 residents reviewed for advance directive documentation by failing to ensure the residents had been examined and lacked sufficient understanding or capacity to make significant responsible decisions regarding medical treatment. Findings include: 1. Review of the Quarterly Minimum Data Set (MDS) completed 6/6/18, in the medical record of R#52 revealed an original admitted to the facility on [DATE] with a readmission date of [DATE] with a [DIAGNOSES REDACTED]. MDS indicated R#52 is cognitively impaired with poor memory. Review of the physician's orders [REDACTED].#52 revealed an order for [REDACTED].>Further review of the medical record for R#52 revealed a document titled, Do Not Resuscitate Order and dated 1/2011. The form has been signed by the primary physician on 8/24/17 and the next of kin of R#52 on 8/23/17. There was no power of attorney document in the medical record of R#52. Review of the care plan for R#52 revealed there was no care plan regarding advance care planning with a focus on the code status for R#52. There was no statement from the physician that stated he had assessed R#52 and made the determination that R#52 was not able to make medical decisions for himself. 2. Review of the Admission MDS, dated [DATE], in the medical record of R#91 revealed an original admitted to the facility on [DATE], with a readmission date of [DATE] with [DIAGNOSES REDACTED]. MDS indicated R#91 is cognitively impaired with poor memory. Review of the physician's orders [REDACTED]. Review of the medical record for R#91 revealed a document titled Georgia Advance Directive for Health Care which was signed by the resident on 5/19/11. The document indicated in section #3, My health care agent will make health care deci… | 2020-09-01 |
| 1118 | 1118 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2018-08-16 | 641 | D | 0 | 1 | ZDF911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure each resident had an accurate assessment that was reflective of the current status of that resident for one sampled resident (R)#8 of three residents who were receiving Hospice care. The total sample was 29. Findings include: Review of the Quarterly Minimum Data Set (MDS) in the medical record of R#8 dated 5/6/18, revealed an admitted to the facility of 1/27/17. The Annual MDS dated [DATE] identified the following [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] identified the following Diagnosis: [REDACTED]. The MDS dated [DATE] does not [MEDICAL CONDITIONS] arthritis as a [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] identified R#8 to receive special services of Hospice care. Review of the Quarterly MDS dated [DATE] does not identify R#8 to receive special services of Hospice care. Review of the physician's orders [REDACTED]. Review of the care plan for R#8 revealed a focus initiated on 1/27/17 and created on 1/30/17, which stated R#8 has a terminal prognosis r/t (related to) Malignant [DIAGNOSES REDACTED] and is on Hospice Services Measurable goals listed to maintain comfort, dignity and autonomy with a target date of 8/20/18. Interventions include ADL (activities of daily living) care, respect resident wishes, provide support to family and friends, monitor for pain and administer pain meds, psychiatric consult if needed, work with hospice team to ensure needs are met. Resident #8 is currently receiving services from Hospice. Interview with the MDS Coordinator on 8/15/18 at 1:45 pm in her office confirmed R#8 does have a [DIAGNOSES REDACTED]. She stated R#8 is a Hospice patient and has been since she was admitted on [DATE]. She confirmed the quarterly MDS dated [DATE] does not accurately assess the current status of R#8 as having a [DIAGNOSES REDACTED]. The MDS Coordinator stated this information was inaccurate and would need a correction. | 2020-09-01 |
| 1119 | 1119 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2018-08-16 | 656 | D | 0 | 1 | ZDF911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for two residents (R)#52 and R#104) of 29 sampled residents reviewed for care plan development and implementation. Findings include: 1. Review of the Quarterly Minimum Data Set (MDS) completed 6/6/18, in the medical record of R#52 revealed an original admitted to the facility on [DATE] with a readmission date of [DATE] with a [DIAGNOSES REDACTED]. MDS indicated resident #52 is cognitively impaired with poor memory. Review of the physician's orders [REDACTED].#52 revealed an order for [REDACTED].>Review of the care plan for R#52 revealed there is no care plan regarding advance care planning with a focus on the code status for R#52. 2. Review of the Quarterly MDS dated [DATE], in the medical record of R#104 revealed an original admitted to the facility on [DATE] and a readmitted on [DATE] with [DIAGNOSES REDACTED]. MDS for R#104 indicated R#104 is cognitively impaired with poor memory. Review of the nursing progress notes dated 4/22/18, for R#104 revealed documentation he had an incident in which he was attempting to leave the facility and when employees were trying to redirect him, he ripped away the emergency bar from the exit door and chased employees down the hall, threatening to hit them. There was also documentation that 911 was called and R#104 was taken to the emergency department for a mental evaluation. R#104 returned to the facility that evening. Nursing documentation indicated staff continues to monitor R#104 for behaviors and the resident receives psychiatric services. Review of the care plan for R#104 revealed there was no care plan that identified the resident had behavior, no identified focus that addresses the behaviors for R#104, no goals and no interventions instructing facility staff with approaches on what to do if R#104 has behaviors. Interview with the Care Plan Coordinator on 8/15/18 at 1:45 p.m. in… | 2020-09-01 |
| 1120 | 1120 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2018-08-16 | 657 | D | 0 | 1 | ZDF911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to revise the fall care plan interventions for one resident (R) (R#98) to reflect the use of bed and chair alarms of 29 sampled residents. Findings include: Observations made on 8/15/18 at 2:50 p.m. on the facility's secured unit revealed R#98 was seated in a wheelchair directly across from the nurses' station. Two licensed nurses were seated at the nurses' station providing direct observation of the resident. R#98 was observed to be dressed in clean appropriate clothing, including socks and shoes. The resident was without any signs of obvious injury and was engaged in incoherent, rambling conversation with another resident also seated in a nearby wheelchair. Further observation of R#98's wheelchair revealed the seat had a Dycem cushion to help prevent the resident from slipping out of the seat. A chair alarm was also attached to the wheelchair. Upon request, Licensed Practical Nurse (LPN) LL activated the chair alarm demonstrating it was functioning properly. Record review of R#98's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed an original admission date of [DATE] with a readmission date of [DATE]. Under Section C0500 - Cognitive Patterns, R#98 was assessed as having scored a six on his Brief Interview of Mental Status (BIMS) indicating a severe cognitive deficit. Under Section I4900 - Active [DIAGNOSES REDACTED]. Under section J1900 - Health Conditions R#98 was assessed as having one fall with no injury, and one fall with an injury since his last MDS assessment dated [DATE]. Under Section P0200 Alarms and Restraints, the resident was identified as having both bed and chair alarms used on a daily basis. Record review of R#98's care plan for falls prevention developed 8/29/17 revealed no new interventions had been added or updated since 10/11/17. A few of the observed fall prevention measures that were listed on the resident'… | 2020-09-01 |
| 1121 | 1121 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2018-08-16 | 692 | D | 0 | 1 | ZDF911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure that nutritional recommendations were implemented for one resident (R) R#78 with 10% weight loss within 41 days from a sampled three residents. This omission had the potential of resulting R#78 experiencing nutrition-related health problems. The findings include: Record review revealed R#78 was admitted to the facility on [DATE]. The resident was diagnosed with [REDACTED]. Review of the resident's admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident is rarely/never understood and unable to obtain a Brief Interview for Mental Status (BIMS) score. The resident was assessed as requiring extensive assistance for bed mobility, transfers, eating and toileting. The resident was assessed with [REDACTED]. Review of the resident's vital signs revealed that R#78 was weighed on 6/21/18 at 168 pounds; on 7/14/18 at 162.6 pounds; and on 8/1/18 at 151.7 pounds. The review revealed that Resident #78 experienced a significant weight loss greater than 10% in 41 days. Further review of the resident's record revealed the dietary progress notes dated 8/6/18, the Registered Dietician (RD) recommended the resident to receive: multi-vitamin, Magic Cup (two times a day with lunch and dinner) and Liquid Protein (30 ml BID for 20 days). Review the resident's clinical record revealed a care plan problem for Altered Nutrition/ Weigh fluctuations was revised 7/6/18 by the Registerd Dietician. Additional review of the care plan revealed the RD updated resident's care plan to reflect signifcant weight loss on 8/6/18. The update also included the RD's recommendations for mutli-vitamins, Magic cup, and Liquid Protein. Review of the Medication Administration Record [REDACTED]. The nurse on duty confirmed that the RD's recommended medications were not on the Physician order [REDACTED]. On 8/14/18 at 11:20 a.m., the resident was observed in his room. An attempt to interview the … | 2020-09-01 |
| 1122 | 1122 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2018-08-16 | 838 | F | 0 | 1 | ZDF911 | Based on record review and interview the facility failed to conduct and document a facility wide assessment to determine what resources were necessary to provide care for residents living in the facility competently during day to day operations and emergencies. Total sample was 29. Findings include: On 8/13/18 at 9:00 a.m., during the entrance conference with the Administrator in the conference room, surveyor requested a copy of the Facility Assessment. On 8/14/18 at 3:00 p.m. in the conference room, the Facility Assessment was again requested from the Administrator when reviewing a list of documents previously requested by surveyors and not yet received from the facility. The Administrator stated they had bits and pieces of information in a binder but had not put it into the assessment tool. On 8/15/18 during an interview with the Administrator in her office at 12:30 p.m., she stated the assessment tool had been started but was not complete. She presented an assessment tool for review that was incomplete. Review of the incomplete Facility Assessment presented for review from the Administrator revealed Section II Staffing, Training, Services & Personnel (A) Function, Mobility & Physical Disabilities, (B) Acuity-Diseases, Conditions, & Treatments, (C) Cognitive, Mental & Behavioral Status, (D) Cultural, Ethnic, &Religious Factors; Section III Physical Environment, Technology &Equipment (A) Function, Mobility & Physical Disabilities, (B) Acuity-Diseases, Condition &Treatment, (C) Cognitive, Mental & Behavioral Status, (D) Cultural Ethnic &Religious Factors; Section IV-All Hazards Risk Assessment; Section V-Assessment Contributors and Supporting Documents were all blank. The facility had not completed an assessment tool and therefore was unable to develop a Facility Assessment. The facility was not able to use that assessment to determine staffing needs, dietary preferences, activity preferences and other resident needs that would be identified by the assessment had it been completed and in place. | 2020-09-01 |
| 1123 | 1123 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 225 | D | 0 | 1 | I6YR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure all alleged violations involving abuse and/or injuries of unknown source were reported immediately to the State Survey Agency (SSA) for two of three residents reviewed for abuse (Resident (R)#42 and R#95), from 39 sampled residents. The facility failed to provide evidence R#95's injury of unknown origin was thoroughly investigated. The facility failed to prevent the potential for further abuse after R#42 alleged he was abused by a staff member. Findings include: Review of the facility's policy titled, Detection and Prevention of Resident Abuse and Neglect (undated) indicated it did not address the regulatory requirement for reporting allegations of abuse, neglect, and injuries of unknown origin to the SSA within 2 hours (cross reference to F226). 1. Review of R#42's clinical record revealed he was a long-term resident with [DIAGNOSES REDACTED]. Per the resident's most recent quarterly Minimum Data Set ((MDS) dated [DATE], the resident was cognitively intact (Section C- Cognitive Patterns), as evidenced by a Brief Interview for Mental Status (BIMS) score of 14/15. Per Section G- Functional Status R#42 required extensive assistance of staff with toileting and section H - Bladder and Bowel documented he was always incontinent of urine. Review of facility investigation records revealed on 8/5/17, during the 3:00-11:00 p.m. shift, R#42 reported a Certified Nursing Assistant (CNA) put urine soaked shirt in his face and berated him. Review of facility investigation records revealed this allegation, which the facility categorized as abuse, was not reported to the SSA until 8/7/17. Review of witness statements for this investigation confirmed facility staff were aware of the allegation on 8/5/17, as Licensed Practical Nurse (LPN) CG documented Between the hours of 2130 and 2230 (9:30-10:30 p.m.) R#42 requested to see her because a CNA was upset with him because his urine got onto his … | 2020-09-01 |
| 1124 | 1124 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 226 | E | 0 | 1 | I6YR11 | Based on record review, interview, and review of the facility's Abuse Prevention policy, the facility failed to develop policies and procedures in specific detail to assure allegations of abuse, neglect, injuries of unknown source, misappropriation, and/or exploitation were reported to the State Survey Agency (SSA) within required time frames. The reporting portion of the policy was not developed in sufficient detail to assure compliance with federal regulations regarding reporting for suspicion of a crime. The failure to assure the reporting component was developed impacted two (Resident (R) #42 and R#95) of three residents reviewed for abuse. Findings include: Review of the current Abuse Prevention policy, dated 9/13/16 provided by the Administrator on 8/14/17 revealed the reporting component of the policy failed to include specific information about the required time frames for reporting allegations. The prevention component noted that allegations were to be reported immediately to State Agencies, but failed to define the term immediately or provide the specific timeframes required by regulation (within no more than two hours for allegations of abuse or reports of serious bodily injury, and within no more than 24 hours for all other allegations). The policy failed to denote the specific State Agencies to whom the report was to be made and also did not address reporting suspicions of a crime. Review of this policy revealed it, also, was not developed to include current requirements about reporting abuse and neglect. Review of the policy revealed The report of the Initial Investigation will be telephoned or faxed to the State Complaint Investigation and Referral Unit within 24-hours of the incident. The policy did not address the (YEAR) changes to federal regulation which defined that allegations of abuse, as well as any allegation with serious bodily injury, were to be reported in no more than two hours. The policy also did not address the (YEAR) regulatory changes which required policies and procedures to incl… | 2020-09-01 |
| 1125 | 1125 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 241 | E | 0 | 1 | I6YR11 | Based on observations, interviews, and review of the Resident Dignity and Social Services Policies - Dignity policies, the facility failed to provide meal service to three residents (R#16, R#147, and R#179) of 39 sampled residents. The census was 147. Findings include: Review of the facility policy Resident Dignity, dated (MONTH) 2106, revealed: Policy - The facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The Procedures of the resident dignity policy revealed, 2. Facility staff will encourage and assist resident's as necessary with daily activities of daily living in a manner to promote psychosocial well-being and the resident's highest level of independence. The Social Services Policies - Dignity revealed, 'Dignity' means that in their interactions with the resident, staff carries out activities which assist the resident to maintain and enhance his/her self-esteem and self-worth. One of the examples listed under dignity revealed, Promoting resident independence and dignity in dining (such as avoidance of day-to-day use of plastic cutlery and paper/plastic dishware, bibs instead of napkins, dining room conducive to pleasant dining). On 8/14/17 observations were made of the lunch meal on the secured dementia unit (Unit 3, Hall 400). The scheduled meal service times for Unit 3 identified the first meal tray cart was to be delivered at 12:30 p.m., the second cart was to be delivered at 12:40 p.m. and the third cart was to be delivered at 12:45 p.m. The first cart was delivered to the unit at 12:35 p.m. After passing trays to the residents eating in their rooms, three trays remained on the cart and the cart was brought to the dining room at 12:52 p.m. The trays were not distributed to the three residents identified on the tray tickets who were seated in the dining room at that time. R#179 was in the dining room at 12:35 p.m., she repeatedly asked for something to drink and eat. He… | 2020-09-01 |
| 1126 | 1126 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 242 | D | 0 | 1 | I6YR11 | Based on observation, record review, and interview, the facility failed to honor food choices for four of 39 sampled residents (R#124, R#112, R#63, and R#130). Residents made selections between the regular and alternate meal; however, they did not receive the foods they chose. Residents were not offered milk for the noon meal as one of their beverage selections even though it was supposed to be served per the menu. Findings include: 1. Review of the menu for lunch on 8/14/17 showed the regular selection consisted of sliced ham, scalloped potatoes, glazed carrots, corn bread, apple cinnamon cake, and milk. Review of the tray cards showed the alternate selection consisted of barbeque chicken, baked beans, and coleslaw. 2. Meal observations made on 8/14/17 for the lunch meal in the main dining room: a. At 12:25 p.m. R#124 was observed with a meal consisting of the alternate meal of two chicken wings, baked beans, coleslaw, corn bread and a piece of cake. The resident stated, I wanted ham, potatoes, and carrots (the main meal). This happens (not getting what selected) almost daily. The resident's tray card was on the table and she pointed to it showing she selected the regular meal and not the alternate. At 12:48 p.m. the resident got up and left the dining room. She ate less than 25% of the chicken, beans, coleslaw, and cake. At no time during the meal was she offered the regular selection. b. At 12:32 p.m. R#112 was studying her tray card while her meal sat on the table in front of her. She stated she had ordered ham, scalloped potatoes, and carrots for lunch. She was served three chicken wings, baked beans, and coleslaw. She showed the surveyor her tray card which indicated she selected the regular meal and not the alternate. The resident stated, This is terrible. I did not order this. It happens all the time (getting food she did not choose). No one comes around to check on us. When the resident's plate was checked at 1:03 p.m. after she had vacated the dining room, she had consumed less than 25% of her meal. At … | 2020-09-01 |
| 1127 | 1127 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 248 | E | 0 | 1 | I6YR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review of Activities Policies - Conducting Activities, the facility failed to provide for an ongoing program of activities designed to meet the needs for two of three cognitively impaired residents (R#61 and R#78) of 39 sampled residents. Activities were not provided in sufficient numbers/types, were not held as scheduled on the dementia unit, and there were no activities on weekends or in the evenings. Findings include: Review of the (MONTH) 2007 facility policy titled, Activities Policies - Conducting Activities revealed its purpose was to provide a well-organized and safe activity program for all residents. The policy did not address 1:1 activities, specialized activity needs of residents with dementia, or weekend and evening activities. Observations on 8/14/17 at 12:20 p.m., 1:15 p.m., 2:12 p.m., 3:10 p.m., 3:35 p.m., 4:35 p.m., and 4:46 p.m.; on 8/15/17 at 9:55 a.m. and 4:42 p.m., and on 8/16/17 at 8:51 a.m., 9:25 a.m., 10:32 a.m., 10:47 a.m., 11:12 a.m. 11:40 a.m., 12:00 - 1:30 p.m., and 3:00 p.m. revealed R#78 and R#61 were in bed in their shared room. There were no activities observed to be provided during any of the above observations for these two residents. A television set was present in the resident's room; however, it was not turned on during any of the above listed observations. There was no radio or other equipment noted in the room to provide R#78 and R#61 with auditory or sensory stimulation. 1. Review of R#78's clinical record revealed the following pertinent Diagnoses: [REDACTED]. Review of her most recent annual comprehensive Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/12/17, revealed staff assessed the resident to have severe cognitive impairment, verbal behaviors, as totally dependent on staff for care, and was bedfast. Section F: Preferences for Customary Routine and Activities documented her activity preferences included liste… | 2020-09-01 |
| 1128 | 1128 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 253 | E | 0 | 1 | I6YR11 | Based on observations, interview and record review, the facility failed to ensure the building was adequately clean and maintained in three of four resident units (100, 200, and 400 rooms) and in common areas. The census was 147 residents. Findings include: 1. Environment observations/tour a. 100 Hall Room 101B - on 8/16/17 at 9:49 a.m. and during the environmental tour, on 8/17/17 between 9:45 a.m. and 11:06 a.m., five red splatters or spills were observed low on the bedroom wall and several more on the floor adjacent to the bathroom. During the environmental tour with the Maintenance Director (MD), Maintenance Staff, and Director of Housekeeping (DH) on 8/17/17 between 9:45 a.m. to 11:06 a.m. the same splatters were observed. The MD stated housekeeping staff was responsible to clean the splatters off the walls and floors. Flooring in the hallway - on 8/16/17 at 10:08 a.m. and during the environmental tour, on 8/17/17 between 9:45 a.m. and 11:06 a.m., cracks were observed on all the linoleum floor tiles (linoleum) extending across the hallway at the start of the lower numbered section of the 100 hall. In addition, in the higher numbered sections, across from the oxygen storage room, seven tiles were cracked in a row down the hallway creating a slight edge between the higher and lower part of the tiles. Twelve more tiles were cracked length wise down the hallway outside rooms 109 through room 111. The MD was interviewed during the environmental tour on 8/17/17 between 9:45 a.m. to 11:06 a.m. and stated it was a foundation issue which affected the flooring. He stated there had been a large tree causing the flooring to buckle and tiles to crack on the 100 hall. The MD stated the tree was removed about six months ago, and he was still watching for additional settling. The MD stated the facility planned to build an addition onto the 100 hall and all the flooring in the hallway would be replaced at that time. The MD stated the facility was in the planning phase of this project and it had not yet been approved by gover… | 2020-09-01 |
| 1129 | 1129 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 258 | E | 0 | 1 | I6YR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure sound levels were maintained within acceptable levels for 5 of 39 sampled residents (R#140, R#152, R#124, R#35, and R#40) and residents who attended the resident council meeting. Staff made too much noise in the hallways and equipment was not maintained to minimize sound levels affecting residents' ability to sleep and rest. Findings include: 1. Observations a. 100 Hall - On 8/14/17 at 5:03 p.m., the floor polisher across from the conference room made a very loud noise as a staff member went up and down the hallway polishing the linoleum floor. Surveyors who were in the conference room at the time were unable to carry on a conversation. b. 200 Hall - On 8/16/17 at 10:29 a.m. a housekeeping staff wheeled 2 barrels down the hall (a 55-gallon round barrel and a square one). Noise from the wheels on the round barrel were very loud. The surveyor was unable to carry on a conversation with another surveyor as the staff member pushed the barrels down the hall. This occurred outside room [ROOM NUMBER]. c. 300 Hall - On 8/16/17 at 10:35 a.m. the Assistant Dietary Manager was pushing a dietary department cart (with sandwiches and drinks) down the hall. The wheels squeaked, creating a very loud noise as the cart was pushed from one end to the other end of the hall. Several minutes later, as the Assistant Dietary Manager was pushing the cart back, she stated to the surveyor, It (the cart) is very loud. It is the wheels. We can send it to maintenance and they can fix it. It is like this (loud and squeaky) a lot. The noise from the cart could be heard from one end of the 300 hall to the other end. The door into the locked unit from the 300 hall was loud and squeaky as a staff member came in on 8/16/17 at 10:58 a.m. and again several minutes later as two additional staff members exited the secure unit into the 300 hall. 2. Interviews a. Four residents expressed concerns with th… | 2020-09-01 |
| 1130 | 1130 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 275 | D | 0 | 1 | I6YR11 | Based on record review and interview, the facility failed to assure that an annual assessment was completed in required timeframe's for two residents (R#61 and R#78.) of 39 sampled residents. Specially, the facility staff failed to complete and sign the annual Minimum Data Set (MDS) within 14 days of the Assessment Reference Date (ARD.) Findings include: Review of R#78's the clinical record revealed an annual MDS with an ARD of 6/12/17. Further review of this assessment revealed that Section V (Care Area Assessment) and Section Z (Assessment Administration), attesting that the assessment was complete, was not signed until 6/29/17, the 17th day after the ARD. Review of R#61's clinical record revealed an annual MDS with an ARD of 4/6/17. Further review of this assessment revealed that Section V (Care Area Assessment) and Section Z, attesting that the assessment was complete, was not signed until 4/24/17, the 18th day after the ARD. Interview on 8/16/17 at 4:20 p.m. with MDS Coordinators (MDS BB), who was a Licensed Practical Nurse, revealed she was one of the facility's three. She confirmed both R#61 and R##78's annual assessments were not completed in the required timeframe, and should have been finished within 14 days of the ARD. She stated the MDS department was supposed to have three staff but the department had been short staffed as people just up and left. She related that for a period, she was the only staff completing MDS, and as a result, Some MDSs were late. | 2020-09-01 |
| 1131 | 1131 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 279 | D | 0 | 1 | I6YR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of the Careplans and Care Plans policies, the facility failed to revise the care plan to reflect the resident's current status for one of 39 sampled residents (R#78). Specifically, the facility failed to update/revise the care plan regarding a newly developed pressure ulcer and the use of side rails for accidents. Findings include: Review of the facility policy titled, Careplans (sic) revised (MONTH) (YEAR) revealed, Areas of concern or potential concern will be addressed with measurable goals and specific person-centered approaches to promote achievement of the goal(s). An additional policy titled, Care Plans (revised (MONTH) 2010 and provided by the Administrator as current) revealed, Upon change of condition, complete the Change in Condition report and update the care plan. Review of R#78's clinical record revealed the following pertinent Diagnoses: [REDACTED]. Review of her most recent annual comprehensive Minimum Data Set ((MDS) dated [DATE], revealed Section C-Cognitive Patterns identified R#78 had both short and long-term memory problems and was severely impaired regarding daily decision making. Section G-Functional Status revealed she required total assistance for bed mobility, bathing, eating, toilet use, dressing, and personal hygiene. R#78 was bedfast. Section H-Bladder and Bowel identified she was always incontinent of bladder and bowel. Section J1800 documented R#78 had not had any falls since her last assessment. Section M-Skin Conditions documented she was at risk for pressure ulcers, but did not have any pressure ulcers. Section N-Medications revealed the resident did not receive any [MEDICAL CONDITION] medications. Pressure Ulcer: Review of an Initial and Weekly Healing Pressure Record form dated 8/1/17 revealed, on 7/22/17, the resident was identified with an unstageable pressure ulcer to the left buttock that was 3x3 centimeters in size. Review of the care pla… | 2020-09-01 |
| 1132 | 1132 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 314 | D | 0 | 1 | I6YR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policies titled, Wound Management Program, Policy and Procedures for the Prevention and treatment of [REDACTED].#78). The delay in assessing and providing physician-ordered treatments for a newly acquired pressure ulcer, had the potential to delay healing of the wound. Findings include: Review of the (MONTH) 2010 facility policy titled, Wound Management Program revealed, A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. The policy indicated, A Facility Pressure Ulcer Report is completed weekly. Review of the undated Policy and Procedures for the Prevention and treatment of [REDACTED]. to provide appropriate treatment modalities for wounds according to industry standards of care. The policy indicated, If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer, the following procedure is to be implemented . Initiate Initial and Weekly Pressure Ulcer Healing while (sic) will include: type of wound, location, date, stage (pressure ulcers only) . length, width, and depth, wound base description and if present drainage, odor, undermining, tunneling and/or pain. Review of the facility's Pressure Ulcer Prevention and Treatment Interventions Guidelines, dated 2013, revealed, Provide pressure ulcer topical treatment as ordered. Review of R#78's electronic clinical record revealed she was receiving hospice care and had [DIAGNOSES REDACTED]. Review of her most recent annual comprehensive Minimum Data Set ((MDS) dated [DATE], revealed Section C-Cognitive Patterns identified R#78 had both short and long-term memory problems and was severely impaired regarding daily decision-making. Section G-Functional Status revealed she required total assistance for bed mobility, bathing, eating, toilet use, dressing and personal hygiene. Resident #7… | 2020-09-01 |
| 1133 | 1133 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 323 | D | 0 | 1 | I6YR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, professional reference, interview, review of the Resident Assessments policy, and record review, the facility failed to provide an environment free of accident hazards for two (Resident (R)#61 and R#78) of three residents reviewed for accidents, from 39 sampled residents. Specifically, side rails were not firmly attached to the bed when a specialty hospice mattresses was used, resulting in gaps which could potentially cause injuries. Findings include: According to the website: https://www.fda.gov/downloads/medicaldevices/productsandmedicalprocedures/generalhospitaldevicesandsupplies/hospitalbeds/ucm 8.pdf the Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings, The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as . confusion and pain . The risk may also increase due to technical issues such as the mis-sizing of mattresses, bed rails with winged edges, loose bed rails, or design elements such as wide spaces between vertical bars in the rails themselves . Evaluation is needed to assess the relative risk of using the bed rail compared with not using it for an individual patient. Interview on 8/17/17 at 11:45 a.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed the only policy they could provide related to side rails was the (MONTH) (YEAR) Resident Assessments policy that read for staff to complete a side rails assessment as indicated. Review of this policy revealed it did not indicate when or how side rails were to be used, how the staff would determine what configuration, or size rails a resident required, based on their individual needs, and did not identify the need for ongoing monitoring related to safe use of this equipment. 1. Review of R#78's clinical record revealed she was receiving hospice care and had [DIAGNOSES REDACTED].#78 had both sho… | 2020-09-01 |
| 1134 | 1134 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 364 | E | 0 | 1 | I6YR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the contracted food service provider company recipes, the facility failed to follow recipes for preparation of pureed food items for 14 residents who had physician orders [REDACTED]. The facility census was 147. Findings include: 1. Unit 3 During the initial lunch dining observation on 8/14/17 on Unit 3, the secured dementia unit, began at 12:30 p.m. The first food cart was scheduled to arrive on the unit at 12:20 p.m. The first cart was delivered to the unit at 12:35 p.m. After staff were observed passing trays to the residents eating in their rooms, three trays remained on the cart and the cart was brought to the dining room at 12:52 p.m. The trays were not distributed to the three residents identified on the tray tickets who were seated in the dining room at that time. The insulated plate covers were ajar and it was unlikely palatable temperatures were maintained. The second meal cart was delivered to the unit at 1:03 p.m. It was scheduled to be delivered at 12:40 p.m. Trays were delivered to the remaining residents who ate in their rooms. The cart was then brought to the dining room. Three residents at the same table were served their meal trays at that time, however, the remaining trays were not distributed to the residents. Staff standing by the trays shuffled the trays around on the cart trying to group the trays together for residents seated at the same table. However, all of the trays needed for the residents in the dining room still had not been delivered to the unit. The insulated plate covers were ajar on the plates and it was unlikely palatable temperatures were maintained. At 1:12 p.m. on 8/14/17 Licensed Practical Nurse (LPN) GG confirmed only three of the 19 residents in the dining room had been served lunch. LPN GG explained staff were waiting until trays for all people seated together at one table arrived prior to serving any resident seated at that table. LPN G… | 2020-09-01 |
| 1135 | 1135 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 368 | E | 0 | 1 | I6YR11 | Based on observation, record review and interview, the facility failed to ensure meals were served at meal times comparable to normal mealtimes in the community. The deficient practice affected 50 residents who ate in the secured unit and nine residents who ate during the second seating in the main dining room out of a total of 147 residents; residents were observed eating lunch as late as 2:25 p.m. Meal service was haphazard for residents eating in the secured unit with a lack of organization of trays, resulting in residents' trays sitting for extended time frames before being served. Findings include: 1. Review of a CQI (Continuous Quality Improvement) Tool for Dietary Services report dated 5/30/17 indicated a concern with dining room meal service as follows: The D/R (dining room) service did not seem to flow smoothly. The dessert was held hostage till after the meal and some left the D/R before getting their dessert or (sic) it was served .Unit 3 D/R - resident's (sic) were not served their trays together by table leaving some resident eating and other waiting and then trying to get the other resident's tray and or food . (Sic) 2. Review of Food Committee Minutes dated 6/11/17 indicated a resident's comment, Evening meals are sitting too long before being served to residents. 3. Review of an all staff Inservice Sign In Sheet dated 6/22/17 showed 93 staff members attended. One of the topics, Delivery of Trays indicated there was a concern with the delivery and timing of meals as follows: Completion of tray pass is taking longer due to trays being sent out to the floor out of order. Is there anyway (sic) trays can be set up on the tray rack in order of the rooms? 4. Planned meal times Review of the Meal Services Times form indicated planned meal times for lunch for the Unit 3 carts, Unit 2 carts, short hall and second seating in the main dining room were: -Unit 3 first cart - 12:30 p.m. -Unit 3 second cart - 12:40 p.m. -Unit 3 third cart - 12:45 p.m. -Unit 2 right cart - 12:50 p.m. -Unit 2 left cart - 1:00 p.m. … | 2020-09-01 |
| 1136 | 1136 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 371 | F | 0 | 1 | I6YR11 | Based on observation, interview, and record review, the facility failed to develop and implement a system to ensure the kitchen was maintained in a clean and sanitary condition for food storage and preparation. This failure had the potential to affect all 147 residents in the facility. Findings include: The initial tour of the facility's kitchen was conducted on 8/14/17 from 8:40 a.m. until 10:13 a.m. Observations during this time included: Kitchen Floor: -Debris was observed under the deep fryer which appeared to be coagulated grease with food particles, including pieces of what appeared to be potatoes. -A pipe behind the stove had been sawed off and capped. It was approximately 4 inches in diameter, and approximately 4 inches high. It was heavily soiled with what appeared to be dried food particles, grease, and dirt on the outer and inner surfaces. The area around the base of the pipe appeared wet. -There was a hole in the floor (where another pipe had been capped off), approximately 4 inches in diameter, near the two-compartment food preparation sink area and stove which was approximately 3/4 of an inch below the level of the floor tiles. There was standing water in the hole which appeared to have food particles and grease floating in the water. The Dietary Manager stated it used to have a cover over it. -There was a missing piece of metal threshold, approximately 8 inches long, between the red floor tiles and the larger linoleum squares near the steam table. The area where the threshold was missing was wet and there was debris, which appeared to be food particles, dirt, and grease. -There was debris which appeared to be food items, dust, and dirt under the work stations for food preparation. The rubber floor mats (which were made with holes in them) in front of the stove and three-compartment sink had a build-up of visible food debris in the holes. The kitchen floor was sticky and greasy. A container of powdered thickener was on the shelf under the food preparation table where pureed food items were prepared.… | 2020-09-01 |
| 1137 | 1137 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 441 | E | 0 | 1 | I6YR11 | Based on observation and interview, the facility failed to handle laundry in a manner to prevent cross-contamination. Specifically, soiled and clean laundry were comingled in an outdoor area unprotected from the elements. The census was 147. Findings include: Observation on 8/17/17 at 10:08 a.m. revealed laundry was processed in a separate building behind the main facility. The doors to both the clean and soiled laundry areas were propped open. The entrance to the soiled laundry area was through a screened-in porch and observation revealed soiled laundry was stored on the porch outside the building. The tour of this area revealed it included a large uncovered cloth bin, half-filled with soiled clothing. A plastic barrel filled with soiled linen was also stored in this area, the cover to the bin had a large open hole for staff to fill the container without touching the cover. Multiple pillows were on a table touching the screening on the back wall of the porch. In the area between the soiled linen tub, barrel, and shelf with pillows, was another large tub containing clean, neatly folded blankets. The cloth bins used to transport clean laundry were stained or worn, and contained paper and plastic waste. During an interview on 8/17/17 at 10:17 a.m. with contract Laundry/Dietary Aide (DA) DD said barrels and bins kept outside on the screened porch were never covered because this was considered part of the soiled area. She stated the pillows observed on the table (as well as additional pillows in plastic bags) were also soiled. She stated the pillows either came from hospitals or another nursing home that was evacuated approximately 3 months earlier due to a bad storm. She confirmed the pillows were all waiting to be thrown away, and she did not know why the pillows had not been immediately disposed of if they were soiled and could not be cleaned/reused. DA DD said because the soiled laundry was stored on the screened porch, Stuff sitting out in this area can get wet when there is rain or a storm. She confirmed the un… | 2020-09-01 |
| 1138 | 1138 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2017-08-17 | 469 | E | 0 | 1 | I6YR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to ensure adequate pest control services were provided to address the presence of cockroaches, flies, spiders and gnats for residents residing on three out of four wings (100 unit, 300 unit, and 400 unit) and in the kitchen. Staff failed to report the presence of bugs/insects to the maintenance department; interventions to eradicate insects were not timely. The census was 147. Findings include: 1. Environmental Observations/Tour a. 100 Unit -Room 115 - On 8/14/17 at 2:08 p.m., several gnats were observed flying above Resident (R)#218's bedside tray. -Room 115 - On 8/14/17 at 2:35 p.m. a gnat was flying between R#219 and the surveyor during the resident interview. b. 300 Unit -Observations were conducted in the Unit 3 dining room beginning at 12:50 p.m. on 8/14/17. R#17 received her lunch tray at 1:04 p.m. CNA ZZZ assisted R#17 by removing the plate cover and by opening the drinks on R#17's tray, then walked away. At 1:06 p.m., three flies were observed to land on R#17's food. During the next five minutes, flies landed and re-landed on R#17's food six times. R#17 did not respond to the presence of the flies and did not receive staff assistance or support to address the flies. The Dietary Manager (DM) was interviewed at 10:30 a.m. on 8/16/17 and confirmed flies were a problem in the kitchen. The DM confirmed, with food deliveries and dietary personnel coming in and out of the back door to perform tasks such as taking out trash, it was very difficult to keep the flies out of the kitchen, especially in the summer. -During the environmental tour with the Maintenance Director (MD) on 8/17/17 between 9:45 a.m. and 11:06 a.m. a fly was observed flying in the 300 Hallway, halfway down the hall. c. 400 Unit -During the environmental tour with the MD on 8/17/17 between 9:45 a.m. - 11:06 a.m., a gnat was observed flying in the hallway adjacent to the dining room. -400 Hall near the … | 2020-09-01 |
| 4082 | 4082 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2016-07-14 | 253 | D | 0 | 1 | RO4J11 | Based on observation and staff interview, the facility failed to ensure that there was a clean and comfortable environment as evidenced by cracked bathroom countertop laminate; splintered door; stained walls and ceilings; broken toilet paper holder; and ventilation vent cover and privacy curtain track that were not firmly affixed to the ceiling. These environmental concerns were observed in fourteen (14) resident rooms and bathrooms on three (3) of four (4) halls. Findings include: During observations of the environment on 07/11/16 beginning at 10:50 a.m., the front vertical surface of the laminate on the bathroom countertops were noted to be cracked and/or chipped for the following Rooms: 100, 103, 105, 107, 109, 115, 226, 228, and 229. In addition, the wooden frame of the bathroom cabinet on the underside of the laminate was partially exposed near the wall by the bathroom door, and had a rough surface. The above observations were verified during a walk-through with the Maintenance Director on 07/11/16 at 11:13 a.m., who stated the laminate may have been damaged by wheelchairs or geri-chairs. During further observations of the environment, the following concerns were noted: Room 405: 07/12/16 at 9:04 a.m. There was a brown circular stain between the ceiling vent and sprinkler head in the bathroom. The paint on the bathroom wall above the mirror at the ceiling appeared to be bulging away from the wall. The toilet paper holder was missing it's horizontal bar, so the cardboard center of the roll of toilet paper roll had been placed through one of the two toilet paper holder wall brackets. There were brown splatters on the ceiling by the privacy curtain track toward the end of the bed by the window. Room 212: 07/12/16 10:53 a.m. The lower inner edge of the bathroom door was chipped. Room 229: 07/12/16 at 11:00 a.m. The vent cover in the bathroom was not fastened securely to the ceiling. Room 218-A: 07/12/16 at 11:05 a.m. There were four small brown stains on the ceiling over the bed. Room 222-A: 07/12/16 at 11:19 a.… | 2020-04-01 |
| 4083 | 4083 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2016-07-14 | 441 | E | 0 | 1 | RO4J11 | Based on record review of facility infection control data, in-service records and practice guidelines, and staff interview, the facility failed to provide documentation that infection control data that revealed increases in urinary tract infections (UTI) were analyzed for potential causes, and interventions implemented to reduce the incidence of UTI's for three (3) of nine (9) months reviewed. The current facility census was one- hundred and forty-five (145) residents. Findings include: Review of the facility's Infection Control notebook revealed that a monthly analysis was done of the numbers and types of infections per nursing unit, and an overall infection rate calculated. Further review of these Monthly Infection Control Reports revealed the following: September (YEAR): 10 facility-acquired UTI's on two of three units. October (YEAR): 17 facility-acquired UTI's on three of three units, with 9 of these on Unit 2. November (YEAR): 7 facility-acquired UTI's on two of three units. December (YEAR): 10 facility-acquired UTI's on three of three units, with 6 UTI's on Unit 3. Upon further review of the Monthly Infection Control Reports revealed that there was no assessment or plan to address the UTI rates. This was confirmed during an interview with the Registered Nurse (RN) Staff Development Coordinator (SDC), who stated that she had been managing the infection control program since (MONTH) of (YEAR), and would do in-services and/or perineal care checkoffs if she noted that the incidence of UTI's for a particular month were high. On 07/14/16 at 2:31 p.m., the RN SDC provided nine in-service records from (MONTH) to (MONTH) (YEAR) on infection control issues, but stated during interview that she was not able to find any in-service records that addressed infection control and/or UTI's prior to this. During an interview with the RN SDC on 07/14/16 at 4:39 p.m., she stated that she could find only one infection control in-service that addressed UTI's between (MONTH) and December. Review of this in-service sign-in form re… | 2020-04-01 |
| 5412 | 5412 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 241 | D | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure all residents were treated in a manner that maintained the residents' dignity and enhanced the residents' self-worth. This deficient practice had the potential to affect five residents (R73, R185, R234, R167, and R109) in a Stage II sample of 36 and two unsampled residents. Findings include: 1. During lunch service on 3/30/15 on Unit One, Licensed Practical Nurse (LPN39) was at the open door an unsampled resident and she stated the unsampled resident was a feeder. Both residents were in the room and looking at the nurse as she used this term to describe a resident who required staff assistance with meals. 2. At 4:01 p.m. on 3/30/15 in the secured unit, an unsampled resident was seated in a geri-chair with her dress bunched up around her waist and her incontinent brief was clearly visible from the common hallway. At 4:06 p.m., LPN28 stopped at the doorway of the unsampled resident's room and spoke for several minutes to another person. At 4:36 p.m. the unsampled resident remained in her geri-chair, and was clearly visible from the common hallway. The resident was dress was still bunched up around her waist and her incontinent brief was still visible to anyone who passed by her room. 3. Observation of wound care for R73 on 4/1/15 at 11:10 a.m. revealed the resident's door was closed, the curtains pulled because the sacral (buttocks) wound was exposed. When a Certified Nursing Assistant (CNA) knocked on the door, the treatment nurse called out,wound care. However, the CNA entered the room without permission and inquired about a subject unrelated to R73, thereby denying R73 the right to privacy, dignity and respect, while receiving wound care. During an interview with the Director of Nursing (DON) and the Staff Development Coordinator (SDC) on 4/2/15 at 6:10 p.m. confirmed that the staff interactions in regard to resident dignity, were inappropriate. 2. Observation of on 3/30/15 at… | 2018-09-01 |
| 5413 | 5413 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 244 | E | 0 | 1 | NBZI11 | Based on interview and documentation review, the facility failed to respond to multiple concerns voiced by residents during the Resident Council aka (also known as) Speak-Out meeting. There was no evidence of response to seven of 21 concerns voiced by the Resident Council for (MONTH) 2014 - (MONTH) (YEAR). Findings include: Interview on 4/1/15 at 1:19 p.m. with R1 revealed she believed the facility did not respond adequately to the concerns voiced during the Resident Council meeting. She said the appropriate staff was not always present to provide an explanation of the resolution related to the concerns voiced during the previous meeting(s). Interview on 4/1/15 at 1:32 p.m. with Social Service employee (SS146) revealed if there was a complaint or concern voiced during the Resident Council meeting, a Grievance/Complaint Form was to be filled out. The form was to be provided to the applicable department manager who was then to address the concern. The Administrator was to review the completed form for appropriate resolution. The Resident Council concerns were to be entered into the Grievance/Complaint log and were to be reported monthly during the facility quality assurance (QA) meeting. Review of the concerns reported during Resident Council meetings against the Grievance/Complaint Log for the corresponding dates revealed a Grievance/Complaint Form was not completed for particular departments as follows: Dietary - (MONTH) 2014: juice watered down, food not thoroughly cooked, food served late, menu not consistent with what was served, preferred choice meal not served - (MONTH) 2014: undesirable spices used on food, ice tea served hot - (MONTH) 2014: food worse, run out of food and condiments, juice sour/watered down, food not warm, burnt food, too much repetition, not notified when change in menu, do not receive requested alternate, poor presentation Laundry - (MONTH) 2014: turnover time too long, missing items Housekeeping - (MONTH) 2014: not cleaning floors properly - (MONTH) (YEAR): not cleaning floors properly,… | 2018-09-01 |
| 5414 | 5414 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 253 | E | 0 | 1 | NBZI11 | Based on observation and interview the facility failed to ensure that housekeeping and maintenance services were provided to ensure a clean environment and furnishings in good repair. This had the potential to affect 28 out of approximately 80 resident rooms in the facility. Findings include: On 3/30/15 and 3/31/15 during observation of the rooms for 40 Stage 1 sample residents, 28 resident rooms were found to have walls, floors, dressers, doors or other areas in need of repair. On 4/2/15 from 3:45 p.m. to 4:55 p.m., a tour was conducted with the Maintenance Director, Housekeeping Supervisor and Environmental Manager to observe to the physical environment in the following rooms (Rooms 212B, 216B, 221A, 221B, 222A, 223A, 225A, 227A, 302A, 302B, 305A, 305B, 403B, and 418A). The tour revealed: Room 212: bottom drawer of dresser was difficult to open and missing a piece of wood. Paint was peeling around the ceiling light in the bathroom. Room 216: dresser drawer had scratched wood. The wall was dented. The side of the resident's bed had scratched and chipped wood. Room 222: bathroom wall was scratched. There were black marks on the bottom of the wall. The door to the entrance of the room was scratched. Room 223: walls had black scratch marks. Orange marks were located on the ceiling. Bathroom door had scratch marks. Wood was loose on the side of the over-the-bed table/tray. Room 225: bathroom walls had black scratch marks. Dresser drawers were smaller than the spaces for the drawers. Room 227: dresser drawer had scratched, chipped wood and missing wood pieces. Door to the room and bathroom had scratched and chipped wood. Room 302: dresser drawer had chipped wood. The plywood located on the edge of the counter to the sink in the bathroom was chipped. Air conditioning vent in the bathroom had dust. Room 305: wall between the dresser and bathroom had black scratch marks. The baseboard was scratched and had chipped wood. Room 403: floor was not flush to the baseboard on the wall, leaving an open space under the baseboard… | 2018-09-01 |
| 5415 | 5415 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 278 | D | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to develop accurate comprehensive assessments for three (R46, R125 and R167), residents in the Stage 2 sample of 36. Findings include: 1. Observation of R46 on 3/30/15 at 2:08 p.m. revealed that she did not have any teeth on her top jaw and she was missing most of her teeth on her bottom jaw. The resident's tongue was lying on her gums between the missing teeth on her bottom jaw. An interview with the Speech Therapist on 4/2/15 at approximately 9:30 a.m. confirmed that R46 had been placed on a pureed diet many months prior due to missing teeth, difficulties chewing, and some swallowing problems. Review of the Diet Type Report dated 3/31/15 confirmed that R46 had a physician's orders [REDACTED]. Review of the initial nursing assessment dated [DATE] revealed that R46 had some missing teeth and she had both chewing and swallowing issues. Observation of R46 on 4/2/15 from 8 a.m. until 9:30 a.m. revealed that she was seated outside of the dining room in a Geri chair and she coughed continuously. Review of the Minimum Data Sets (MDS) assessments revealed that the facility failed to accurately code R46's difficulties with chewing and or swallowing. Review of the quarterly MDS dated [DATE] and Section L - Oral and Dental Status revealed that the facility had not coded R46 as having difficulties chewing. Review of the quarterly MDS assessment dated [DATE], the discharge MDS assessment dated [DATE] and the entry tracking record dated 3/19/15, revealed that the facility did not code R46 as having difficulties chewing. An interview with the MDS coordinator on 4/2/25 at approximately 9:45 a.m. confirmed that she had completed R46's MDS assessments and she had miss-coded Section L. The MDS coordinator stated that the MDS assessments were inaccurate. 2. On 3/30/15 at 4:16 p.m., observation revealed R125 seated in a geri-chair in the resident's room. R125 wore an upper denture, but did no… | 2018-09-01 |
| 5416 | 5416 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 282 | D | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assure services were provided in accordance with the plan of care for one of five residents (R16) reviewed for accidents in the Stage 2 sample of 36. Findings include: Review of the clinical record of R16 revealed [DIAGNOSES REDACTED]. Review of incident reports revealed the resident had a history of [REDACTED]. Review of the care plans for R16 revealed that on 3/9/15, the facility revised the care plan for a problem of is/has potential to demonstrate physical behaviors and verbal abuse towards other r/t (relative to) Dementia, [MEDICAL CONDITION]. Review of this care plan revealed that its approaches included: When resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress. On 4/2/15 at 1:53 p.m., R16 was observed in the secured unit in a wheelchair using the handrail to pull himself along the hallway. An unsampled female resident was behind R16 and propelled her wheelchair into the back of R16's wheelchair. Observation revealed the two wheelchairs were wedged together, and could not be separated by the residents. R16 began screaming profanities and flailing his/her arms around in an attempt to strike the female resident. Although R16's care plan called for staff to intervene before an escalation of agitation, and to guide the resident away from the source of distress, observation revealed this did not occur until surveyor intervention. Three staff were present in the area and witnessed R16 screaming profanities, attempting to strike the other resident, and unable to remove himself from the situation. However, none of these staff came from behind the nurses' station where they were standing for 96 seconds, until assistance/intervention was requested by the survey team. An interview was conducted immediately after Licensed Practical Nurse (LPN) 39 disentangled the two resident's wheelchairs and removed the residents from the situ… | 2018-09-01 |
| 5417 | 5417 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 312 | D | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADL), including nail care for one of three Stage 2 sampled residents (R167) reviewed for ADLs. Findings include: 1. Observation on 3/31/15 at 11:23 a.m. of R167 revealed many of her fingernails had a dark yellow discoloration and were thick with rough edges. Interview with R167 at that time revealed her fingernails have a fungus on them. She reported, The nurse is supposed to put cream on them, but she was told to do it myself. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed R167 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that her cognitive abilities were intact. The Bathing ADL was coded for R167 as Total Dependence on one staff person for that activity. Review of the care plan for R167, printed from the electronic clinical record on 4/2/15, revealed a Focus of ADL Self-Care Performance Deficit with an intervention for Bathing that was Initiated: 09/09/2014. According to the care plan, the Certified Nursing Assistants (CNA) was responsible to Check nail length and clean on bath day as necessary. Report any changes or necessity for trimming to the nurse. Review of the Visual Bedside Kardex that was accessible on the Point of Care (P[NAME]) computer kiosks for the CNAs revealed the same instructions. Review of the (MONTH) (YEAR) P[NAME] Response History for Skin Assessment with Shower revealed the CNAs provided assistance with R167's shower three days a week on Monday, Wednesday, and Friday. Despite the assistance provided on those days, interview on 4/1/15 at 5:04 p.m. with CNA93, who identified herself as consistently assigned to R167 four days a week on the evening shift, revealed that CNA93 had not identified or reported R167's discolored and thickened fingernails. Review of the Progress Notes regarding R167 revealed the condition of the resident's nails was do… | 2018-09-01 |
| 5418 | 5418 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 361 | F | 0 | 1 | NBZI11 | Based on observation, interview and record review, the facility failed to ensure that the Registered Dietitian (RD) worked collaboratively with the kitchen staff and was utilized in planning, managing and implementing dietary service activities in order to assure that the kitchen staff utilized safe and sanitary techniques. This had the potential to affect all 125 of the residents who ate their meals in this facility. Findings include: 1. Observation of the kitchen during two days of the survey, on 3/30/15 during the initial tour and again on 4/1/15 from 9:45a.m. until 2:30 p.m. revealed that the kitchen staff had failed to utilize safe and sanitary techniques when they failed to: 1) Discard potentially contaminated health shakes, 2) maintain potentially hazardous foods at the appropriate temperature (below 41 degrees Fahrenheit (F) or above 135 degrees F), 3) separate soiled equipment from clean dishware, 4) cover food securely in the dry storage area, and 5) air dry the Robot Coupe (blender) before each use. (Refer to F371.) 2. Observation of the food production and meal service revealed the facility failed to ensure that the kitchen staff utilized standardized recipes and followed the preplanned written menus when they prepared the residents' lunch meal. (Refer to F363.) 3. Observation of the meal service, interviews with residents and taste tests revealed the facility failed to prepare and serve food that was attractive, palatable, and pleasing to the residents. (Refer to F364.) 4. Observation of the kitchen revealed that the facility failed to maintain the kitchen environment in a safe and functional fashion. (Refer to F465.) 5. Observation, interview and record review revealed the facility failed to employ sufficient staff to ensure that their food production was managed effectively and that the staff was trained and competent to perform their duties and responsibilities. (Refer to F361.) 6. Observation of the meal service on 4/1/15 at 11:30 a.m. revealed that the cook and the Food Service Director (FSD) we… | 2018-09-01 |
| 5419 | 5419 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 363 | F | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that the kitchen staff utilized standardized recipes and followed the preplanned written menus when they prepared the residents' lunch meal. This deficient practice had the potential to affect all of the 125 residents who ate their meals in this nursing facility. Findings include: Observation of the kitchen on 4/1/15 from 9:45 a.m. through 2:30 p.m. revealed that the cook, D3 did not follow the facility's policies and procedures relative to following the preplanned written menus and the standardized recipes. Review of the Diet Type Report dated 3/31/15 revealed that the facility had 125 residents who ate their meals at this facility. Of those 125 residents there were 55 residents who had a physician's orders [REDACTED]. The 55 residents included 31 residents who had a physician's orders [REDACTED]. Review of the Week-At-A-Glance . Week 1 revealed that the facility was to prepare the following foods for lunch on Wednesday, 4/1/15: Fried Chicken Smothered Steak Cornbread Braised Cabbage Whole Kernel Corn Macaroni & Cheese Noodles Mandarin Oranges Observation of the steam table at 12:15 just before the lunch tray line began, revealed that the cook, D3, did not prepare the mechanically altered foods per the menu. D3 did not prepare mechanical soft or pureed fried chicken, mechanical soft or pureed smothered steak, pureed noodles, pureed cream style corn, or pureed mandarin oranges. After interviews with the staff, most of the foods listed above, were prepared. Observation of the meal preparation revealed that D3 had floured the raw chicken for those residents who were on a regular diet, but for those residents on a mechanically altered diet, D3 boiled chicken cubes and then ground and pureed that for the residents who were ordered a mechanical soft or pureed diet. Review of the recipe titled; Corporate Recipe .Entrees - chicken revealed that staff was to grind the fr… | 2018-09-01 |
| 5420 | 5420 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 364 | F | 0 | 1 | NBZI11 | Based on interview, observation, record review and taste tests, the facility failed to prepare and serve food that was attractive, palatable, and at a temperature that was pleasing to the residents. This deficient practice had the potential to affect all of the 125 residents who ate their meals at this nursing facility. Findings include: During the Stage 1 interviews, many of the residents complained about the taste and the quality of the food served at this facility. An interview with R222 on 3/30/15 at 12:14 p.m. revealed that she was unhappy with the food. The resident stated, I hate to complain but I do not eat the food here. I very seldom eat because the food is not good. I have told the facility that I would just prefer soup and crackers but they still send me the same food that I do not like. An interview with R26 on 3/30/15 at 1:34 p.m. revealed that she did not like the food at this facility. The resident stated, The food is terrible. The black eyed peas are as hard as a rock. They are not following the menu. Many times I just get a chicken patty and pudding. An interview with R48 at 3/30/15 at 1:40 p.m. revealed that she did not like the food at this facility. The resident stated, I always have to ask for something else to eat because the food does not look good or taste good. An interview with R62 on 3/30/15 at 2:17 p.m. revealed that he did not like the food at this facility. The resident stated, I think that all of us think the food could be better. An interview with R198 on 3/30/15 at 3:36 pm revealed that she thought the food was, Usually too cold to eat. Observation of the main dining room on 3/31/15 at approximately 7:30 a.m. revealed that the food being served did not appear appetizing. The fried eggs were prepared ahead of time and they were discolored and appeared rubbery, the oatmeal was runny and discolored, and the bacon was lying in grease. Observation of the food preparation on 4/1/15 from 9:45 a.m. until 2:30 p.m. revealed that the facility failed to maintain and serve food at appropriat… | 2018-09-01 |
| 5421 | 5421 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 365 | F | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to prepare and serve food that was designed to meet each resident's individual needs. This deficient practice had the potential to affect 55 residents who had a physician's orders [REDACTED]. Findings include: Review of the Diet Type Report dated 3/31/15 revealed that the facility had 125 residents who ate their meals at this facility. Of those 125 residents there were 55 residents who had a physician's orders [REDACTED]. The 55 residents included 31 residents who had a physician's orders [REDACTED]. Per the Academy of Nutrition and Dietetics pureed foods for dysphagia (swallowing problems) should be homogenous and cohesive and Pudding - Like. Mechanical soft and pureed foods are prepared to ensure that each resident who experienced chewing and/or swallowing problems could consume their food safely and prevent coughing, choking, and aspiration pneumonia. Observation of the breakfast meal on 3/31/15 at 7:30 a.m. revealed that the pureed oatmeal was lumpy, thin in texture and not holding its shape. Observation of the steam table on 4/1/15 at 12:15 p.m. just before the lunch tray line began, revealed that the cook, D3, did not prepare the mechanically altered foods per the menu. D3 did not prepare mechanical soft or pureed fried chicken, mechanical soft or pureed smothered steak, pureed noodles, pureed cream style corn, or pureed mandarin oranges. The facility did not prepare the pureed noodles, pureed mandarin oranges, and the mechanical soft smothered steak until surveyor intervention. On 4/1/15 at 2:30 p.m. a test tray was obtained from the kitchen. The test tray was prepared at the end of the meal service by the kitchen staff and it contained mechanically altered foods, which were tasted for texture. The test tray contained: Pureed chicken, pureed cabbage, pureed bread, cream corn, and ground breaded chicken patties. The food was tasted for texture by three surveyors. Per… | 2018-09-01 |
| 5422 | 5422 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 371 | F | 0 | 1 | NBZI11 | Based on observation, record review and interview, the facility failed to ensure food safety when they did not; 1) Discard potentially contaminated health shakes, 2) maintain potentially hazardous foods at the appropriate temperature (below 41 degrees Fahrenheit (F) or above 135 degrees F), 3) separate soiled equipment from clean dishware, 4) cover food securely in the dry storage area, and 5) air dry the Robot Coupe (blender) before each use. This deficient practice had the potential to affect all of the 125 residents who ate their meals in this nursing facility. Findings include: 1. Observation of the kitchen and the refrigerated unit (walk-in) on 3/30/15 at 9:00 a.m. revealed approximately two cases of undated defrosted health shakes that were placed on the metal ready to use shelving. Observation of the 4 ounce (oz) health shakes revealed a statement from the manufacturer, which was placed under the spout, that read: discard after 14 days of defrost. Observation of the panty on Unit One on 3/30/15 at 9:30 a.m. revealed approximately 25 defrosted health shakes that did not contain a label or a use by date. Review of the Dietary - Supplements list dated 3/31/15 revealed that the facility had 10 residents who received a daily health shake, including Residents #48, #51, #99, #147, and six un-sampled residents. An interview with the Food Service Director (FSD) on 3/30/15 at 10:00 a.m. confirmed that the facility utilized health shakes for those residents who were nutritionally compromised. The FSD added that the health shakes were physician ordered and it was necessary to discard the defrosted shakes after the 14 day defrost period. When interviewed about why the defrosted health shakes in the walk-in and in the pantry on Unit One did not contain a date or a label, the FSD stated she was uncertain. 2. Observation of the kitchen on 4/1/15 from 9:45 a.m. until 2:30 p.m. revealed that the facility did not demonstrate safe and sanitary techniques while preparing the residents' lunch meal. The following observations we… | 2018-09-01 |
| 5423 | 5423 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 412 | D | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify dental and oral health concerns and obtain dental services for one of three Stage 2 sampled residents (R167) reviewed for dental and oral health concerns. Findings include: During interview on 3/31/15 at 11:33 a.m. with R167, the resident replied Yes each time when asked three separate questions to determine if the resident had any mouth or facial pain with no relief, chewing or eating problems, or tooth problems. The resident reported she had her natural teeth but had problems with some of them. She opened her mouth and pointed out the fourth tooth from the back on the upper right that was loose and another one in the back on the upper left that was decayed. She said the tooth on the upper left needed a crown. During the interview, R167 rubbed the right side of her jaw by her ear. She said she had an earache and was getting antibiotic drops for it. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed R167 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that her cognitive abilities were intact. Follow-up interview with R167 on 4/2/15 at 11:50 a.m. confirmed that she had trouble with (the loose) tooth all year, but she put (getting dental care) off because of the cost. She explained she needed to get it done because she felt a lump on the side of my face. She also reported she had a lump on the left side of her face as well because of her tooth that needed a crown. R167 cupped her hand on her left jawline close to her ear. Review of a Dentist's Progress Notes dated 11/7/14 revealed a Missing/Broken diagram that indicated R167 had upper and bottom teeth. The following teeth on the upper jawline were marked as problematic: tooth 1 at the back on the left, tooth 5 forward from the back on the left, and the last four teeth 13 - 16 at the back on the right. The diagram also displayed the last three teeth on the left and r… | 2018-09-01 |
| 5424 | 5424 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 441 | E | 0 | 1 | NBZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility documentation, the facility failed to ensure standard infection control practices. Direct care staff wore long fingernails, and/or long unrestrained hair that posed infection control concerns. Failure to develop, institute, and maintain an effective infection control program has the potential to affect all one hundred twenty-six residents residing in the facility. Findings include: 1. On 3/30/15 between 12:24 p.m. and 12:55 p.m., meal service on Unit One revealed the following: a. At 12:24 p.m., Licensed Practical Nurse (LPN39) delivered a tray to room [ROOM NUMBER]A and provided meal set up for the resident. LPN39 had long hair that was pulled back in a low ponytail, with the exception of an approximately 2 inch wide swatch of hair that hung down the left side of her face. The hair reached the middle of her chest and each time she leaned forward to remove the covers from the food on the tray, her hair swung forward and brushed against the resident's face and over the food tray. b. At 12:26 p.m., LPN39 was observed delivering trays throughout Unit One while unconsciously twirling her lock of hair with her fingers after using hand sanitizer and before delivering trays to multiple rooms. c. At 12:38 p.m., LPN15 was observed serving and setting up trays on Unit One during lunch on 3/30/15 and was seen to have acrylic fingernails greater than 1/4 inch past her fingertips. d. At 12:45 p.m., Certified Nursing Assistant (CNA101) was observed as she fed the resident in room [ROOM NUMBER]. CNA101 had long unrestrained hair that was chest length and wore long acrylic fingernails. e. At 12.54 p.m., CNA102 was observed in room [ROOM NUMBER] as she assisted a resident in B bed with lunch. CNA102 had long acrylic fingernails greater than 1/2 inch past the end of her fingertips. Observations throughout the facility during the survey (3/30/15-4/3/15) also revealed additional direct care staff with long, … | 2018-09-01 |
| 5425 | 5425 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2015-04-03 | 465 | F | 0 | 1 | NBZI11 | Based on observation, interview and record review, the facility failed to maintain the kitchen environment in a safe and functional fashion. This deficient practice had the potential to affect all of the residents who resided in this facility. Findings include: Observation of the kitchen on 3/30/15 at 9:00 a.m. revealed that the tile floor in the dish room and throughout the food preparation area was cracked, discolored and missing tiles. The floor in the dish room was missing many tiles and the concrete underlayment was exposed. The area missing tiles measured approximately 3 feet by 4 feet. There were large holes and crevices in the underlying concrete that were filled with discolored water. There was approximately 1/2 to 3/4 inches of water covering the entire dish room floor. Observation of the cook's preparation area revealed that the tiles were cracked, there was a black build up in the corners and around the drains and there were two uncovered floor drains that were covered with food debris and a black tar like material. Observation of the kitchen floor on 3/30/15 at 9:00 a.m. and again on 4/1/15 at 9:45 a.m. until 2:30 p.m., revealed that there were two large grease traps under the kitchen sinks. The grease traps were leaking water and debris all over the floor in the food production area. The floor was covered with water that had pooled in the center in the food production area. The pooled water was approximately one inch deep and staff was observed walking through the greasy pooled water during the entire time they prepared and served the resident's lunch meal. An interview with the Food Service Director (FSD) and the Regional Director of Food Service confirmed that the kitchen floor was maintained in poor condition. They added that they were unaware of the two uncovered floor drains, what they were used for, or why they were covered with debris. Observation of the back door that separated the kitchen from the outside garbage area revealed that it was missing paint, missing metal pieces, and it did not … | 2018-09-01 |
| 6733 | 6733 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2013-07-25 | 431 | D | 0 | 1 | 0FNL11 | Based on observation, record review, staff interviews and review of facility policy, the facility failed to ensure that expired medications were removed from one (1) of three (3) medication rooms. Findings include: Observation of medications stored in the medication room on the 400 hall on 7/25/13 at 10:35 a.m. with Registered Nurse (RN) AA revealed the following expired medications: [REDACTED] 1. There was one (1) opened bottle of Magnesium Oxide four hundred milligrams (400mg), one hundred twenty (120) tablets that had an expiration date of 1/13. Interview with staff Licensed Practical Nurse (LPN) BB on 7/25/13 at 12:02 p.m. revealed there are two (2) residents who currently receive Magnesium Oxide, resident #108 and resident #61. Record review revealed resident #108 received Magnesium Oxide 400mg daily; the medication was ordered 5/2/11. Resident #61 received Magnesium Oxide 400mg twice daily; the medication was ordered 5/6/13. 2. There was one (1) opened bottle of Zinc Sulfate two hundred twenty milligrams (220 mg), one hundred (100) tablets that had an expiration date of 6/13. Interview with staff LPN CC 7/25/13 at 11:21 a.m. revealed no current residents receive Zinc Sulfate. 3. There were thirteen (13) packets of Juven Specialized Nutrition Powder that had an expiration date of 1 Jun 2013. Interview with staff LPN DD on 7/25/13 at 11:35 a.m. revealed there were no residents on the 400 hall who currently receive the Juven supplement. 4. There were three (3) bottles of Flu Vaccine for the 2012-2013 flu season, one (1) opened and two (2) unopened, that had an expiration date of 5/2013. Interview with RN AA on 7/25/13 at 11:33 a.m. revealed no flu vaccines had been given since the end of March 2013. 5. There was a box of Phenadoz twenty five milligrams (25 mg) suppositories (Promethazine) for resident #29 that had an expiration date of 3/2013. The box or twelve (12) suppositories had eight (8) remaining in the box. Interview with staff LPN CC on 7/25/13 at 11:35 a.m. revealed the resident was not currently rec… | 2017-10-01 |
| 8001 | 8001 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2012-01-26 | 441 | D | 0 | 1 | ECVV11 | Based on observation, staff and resident interview, and review of the facility policy for storing aerosol equipment, the facility failed to properly store nebulizers for one (2) random resident on one (1) of three (3) halls (200 Hall). Findings include: Observation, during initial tour, on 01-23-12 beginning at 9:30 a.m. revealed a Mabis Minicomp Nebulizer sitting on the bedside table to the left bed 216B. The Nebulizer was sitting directly on the table top, not on a protective barrier or covered and the Nebulizer mask, lying on the Nebulizer, also uncovered. The residents last treatment had been administered at 6:00 a.m. Review of facility policy for storing aerosol equipment revealed that a clean cloth should be placed under and on top of the compressor when not in use. Interview with the Director of Nursing (DON) on 1/25/12 at 3:50 p.m., revealed that the Nebulizers were to be covered with a cloth after use. Telephone interview on 2/6/12 at 10:30 a.m. with the DON revealed that the resident received Nebulizer treatments four times a day at 6:00 a.m., 12 noon, 6:00 p.m. and 12 midnight. | 2016-07-01 |
| 8002 | 8002 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2012-01-26 | 463 | D | 0 | 1 | ECVV11 | Based on observations,staff interviews and review of the facility guidelines for call lights, the facility failed to ensure that the call light system functioned appropriately in six (6) of one hundred and fifty nine (159) resident rooms on one (1) of three (3) halls (400 hall) Findings include: Observations of the resident call light system on the 400 hall on 1/23/12 beginning at 11:30 a.m revealed the following: Room 407B- the call light was attached to the side of the bed and plugged into the wall but the push button was missing from the call light making it impossible to signal for assistance;.Room 408B- the call light was attached to the side of the bed and plugged into the wall but the light failed to light up or sound in the room or at the nurses station; Room 403B-the call light failed to light up or sound in the room or at the nurses station; Rooms 416A and B, and 420A-the call lights failed to light up or sound at the nursing station. Review of the Facility Practice Guidelines for Call Lights revealed that any defective call ligh should be reported to the charge nurse and that maintenance department immediately. Interview with the Maintenance Director on 01-23-12 at 3:00 p.m. and checks of the call lights confirmed that the call lights were not working and need to be fixed. Continued interview revealed that the call lights are checked once a month and that they are fixed when they are found not to be working at that time. | 2016-07-01 |
| 9540 | 9540 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2010-07-08 | 371 | F | 0 | 1 | F1CC11 | Based on observation and staff interview the facility failed to maintain food items at temperatures necessary to prevent food borne illnesses. This affected all residents on oral alimentation (census = 156). Findings include: 1. Observation in the main dining room on 7/7/10 at 12:10 p.m. revealed bologna and cheese sandwiches, ham and cheese sandwiches and chef salads containing diced ham sitting on a cart rather than on ice or in a refrigerator. These items were available as alternate food choices for residents in independent dining during the 12:00 noon to 12:30 p.m. Approximately thirty (30) residents were seated in the dining room. A digital thermometer, used to check the temperatures of the sandwiches and salads, revealed that the food items were at 68 degrees Fahrenheit. Interview with the Registered Dietitian (R.D.) on 7/7/10 at 12:10 p.m. revealed that these food items were being held at a temperature that could create a high risk for harmful microorganism growth. 2. During observation in the main kitchen on 7/7/10 at 12:30 p.m., the temperatures of food items being served to residents at the lunch meal were checked with a digital thermometer. Several pieces of cornflakes-coated oven baked chicken had temperatures ranging from 116 to 126 degrees Fahrenheit. Interview with the facility's Food Service Director (FSD) on 7/7/10 at 12:30 p.m. revealed that this was below the minimum temperature of 135 degrees Fahrenheit required for holding food on the steam table. | 2015-06-01 |
| 2702 | 2702 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2018-01-04 | 644 | D | 0 | 1 | 8BHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely obtain a Pre -Admission Screening and review (PASSAR) Level ll assessment and coordinate services for one resident, R #37, of 17 residents in the sample. Findings include: R #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of resident record revealed resident #37 is not receiving any antipsychotic medications however, the resident is being monitored for behaviors. Per Treatment Administration Records (TARs), resident has not exhibited behaviors for 3 months. On 1/2/18 at 11:44 a.m. during record review, the facility was unable to locate any PASSAR information in R#37 medical record. An interview with, Social Services Director (SSD), presented evidence of Department of Medical Assistance-6 Form (DMA-6) dated 11/4/14. On 1/3/18 at 2:16 p.m. an interview with Minimum Data Set (MDS) Coordinator AA, revealed completed PASSAR level I dated 11/6/14. When asked why a Level II had not been completed, especially since the resident has [DIAGNOSES REDACTED]. Review of resident annual MDS dated [DATE] and quarterly MDS dated [DATE] supports a [DIAGNOSES REDACTED]. On 1/4/18 at 8:16 a.m. a 2nd request for completed version on PASSAR level ll was made to SSD and to MDS Coordinator A[NAME] On 1/4/18 at 09:28 a.m. an interview with the SSD, revealed the PASSAR process is a coordinated effort. Per SSD, the Admissions Coordinator handles setting up the reevaluation review if the resident needs another evaluation beyond PASSAR Level l. When asked where was the PASSAR Level ll for this resident, SSD stated the resident was admitted in 2014. They have not been able to locate it. On 1/4/18 at 9:43 a.m. Conversation with the Admission Director (AD), offered a copy of an email sent 1/4/17 at 7:30 a.m. to another entity, requesting a copy of the PASSAR Level ll paper work. Per AD the paperwork would be sent as soon as possible (ASAP). On 1/4/18 at 12:04 p.m. AD offered another emai… | 2020-09-01 |
| 2703 | 2703 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2018-01-04 | 698 | D | 0 | 1 | 8BHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to follow the [MEDICAL TREATMENT] care plan, check and record blood pressure and pulse, monitor the right chest perm-cath and left arm fistula sites before and after [MEDICAL TREATMENT], and communicate with the [MEDICAL TREATMENT] center for one resident (R) 216. According to the facilities Resident Census and Conditions of Residents (CMS Form 672) there are five [MEDICAL TREATMENT] residents. The sample size was 17. Findings are as followed: R #216 is a [AGE] year old female admitted to facility on 12/14/17 with admitting [DIAGNOSES REDACTED]. A record review of R #216's Entry Assessment Minimum Data Set ((MDS) dated [DATE] revealed no Brief Interview for Mental Status or Care Area Assessment. A record review of R#216's Interim Care Plan created on 12/15/17 revealed blood pressure and pulse before and after [MEDICAL TREATMENT] and monitor shut as indicated. A record review of the (MONTH) (YEAR) and (MONTH) (YEAR) Nurse's Notes(NN) for R#216 revealed missing documentation that supports the facility's nursing staff monitored the right chest perm-cath access for signs of infection or bleeding and monitored the left arm fistula for bruits and thrills and signs of infection and bleeding. A record review of R# 216's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records (MAR) revealed missing documentation that supports the facility's nursing staff monitored the right chest perm-cath access for signs of infection or bleeding and monitored the left arm fistula for bruits and thrills and signs of infection and bleeding. A record review of the facility's policy titled [MEDICAL TREATMENT] Care Pre and Post [MEDICAL TREATMENT] last reviewed (MONTH) (YEAR) revealed staff are expected to take and record patient/resident blood pressure and pulse before and after [MEDICAL TREATMENT], observe shunt access prior to patient/resident transport to [MEDICAL TREATMENT] and post-[MEDICAL… | 2020-09-01 |
| 2704 | 2704 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2019-01-10 | 761 | F | 0 | 1 | 3GX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to label medications, according to requirements, in three of three medication carts. Findings include: A review of the facility policy, Medication Administration: General Guidelines, dated with effective date of 4/1/1998 and a reviewed and revised date of 4/6/2018 revealed, item 4. medications are administered at the time they are prepared; item 10. indicates medications are administered within 60 minutes before or after scheduled times; item 18. indicates, prior to administration, the information on the Medication Administration Record [REDACTED]. indicates the nurse may not alter the medication label. A review of the facility policy, Medication Storage in the Healthcare Centers, dated 4/1/1998 and a revision date of 9/15/2017 revealed, item 1. the pharmacy dispenses medications in containers that meet legal requirements and transfer from one container to another is done only by a pharmacist. On 1/9/19 at 8:36 a.m., during the medication cart check for the 100-hall with Licensed Practical Nurse (LPN) AA, revealed two unlabeled pills were observed in the cart, in an unlabeled clear plastic medication cup, at the back of drawer number two. The two pills were not in any kind of blister-pack or packaging. One medication was a white capsule and one medication was a small, white round pill. LPN AA reported she did not know where the medications came from nor how long the medications may have been in the cart. LPN AA reported she does not ever pull the drawers out that far to see the back of the drawer. At this time, the Director of Nursing (DON) was summoned and she was shown the unlabeled medications in the cart. The DON reported the medications should have been discarded and not left in the cart. The DON reported the pharmacy had checked the carts the previous day. Observation and interview on 1/9/19 at 9:50 a.m. with LPN BB during routine medication administration of the 2… | 2020-09-01 |
| 2705 | 2705 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2016-12-22 | 157 | D | 0 | 1 | UD3W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of elevated blood sugars greater than 400, for one resident (R) (R#21) out of 19 sampled residents. Refer F309 Findings include: Record review for R#21 revealed a Physician order [REDACTED]. Per the prescribed sliding scale for insulin, administer 9 units of insulin for blood gluscose of 400-439. Review of the Medication Administration Record (MAR) for R#21 documented the following blood sugar results with no explanation or evidence of physician notification documented on the front or back of the MAR: August 19, (YEAR), 11:00 a.m. blood sugar 453, 0 units insulin administered August 22, (YEAR), 11:00 a.m. blood sugar 420 August 25, (YEAR), 11:00 a.m. blood sugar 475, 9 units insulin administered August 29, (YEAR), 11:00 a.m. blood sugar 449, 9 units insulin administered September 15, (YEAR), 9:00 p.m. blood sugar 417 September 16, (YEAR), 9:00 p.m. blood sugar 405 September 19, (YEAR), 9:00 p.m. blood sugar 402 September 22, (YEAR), 9:00 p.m. blood sugar 435 September 23, (YEAR), 11:00 a.m. blood sugar 550, 9 units insulin administered. Review of the Nurses Notes from August, (YEAR) through September, (YEAR) revealed no documentation of physician notification for elevated blood glucose on (MONTH) 19, 22, 25, 29 or (MONTH) 15, 16, 19, 22, 23 of (YEAR). Additionally, there was no evidence/documentation that insulin had been administered (MONTH) 19, (YEAR), nor was there evidence/documentation of a physician order [REDACTED]. Further review of the MAR and Nurses Notes for (MONTH) and September, (YEAR) did not indicate any adverse outcome to R#21 related to the above elevated blood sugars or insulin coverage. Interview with the Licensed Practical Nurse (LPN) AA on 12/22/2016 at 2:48 p.m. revealed that if a resident's blood sugar is out of parameters she would notify the physician and document that information in the nurses notes, on the 24 hour report and would docu… | 2020-09-01 |
| 2706 | 2706 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2016-12-22 | 241 | G | 0 | 1 | UD3W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure that the privacy curtain was pulled closed for one of 19 sampled residents (R) (R#107), while he waited for assistance with incontinent care. Specifically, R#107 was left exposed, uncovered and wearing a soiled adult brief while two Certified Nursing Assistants (CNA) and a family member were in the room assisting his roommate. The facility's failure resulted in psychological harm for R#107 as evidenced by observing the resident repeatedly looking over his shoulder with a frowned expression on his face and during an interview with R#107 on 12/20/16 at 2:42 p.m. in which the resident expressed that he was embarrassed to have his bottom exposed to strangers. Findings include: Record review for R#107 revealed admission to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of six, indicating severe cognitive impairment. The resident usually understands, misses some part/intent of message but comprehends most conversation. R#107 requires extensive assistance for bed mobility, transfers and toileting. The resident is always incontinent of bowel and has a urinary catheter. Review of the Admission Interim Care Plans Form dated 12/8/16 documented the resident has severe contractures, has urinary catheter related to pressure ulcers in that area, requires assistance with toileting, requires cueing to turn and reposition, and does not resist care. Observation on 12/20/16 at 02:44 p.m. of R#107 revealed the resident lying on his bed (bed B) on his left side with his back turned towards bed [NAME] The privacy curtains for both beds A and B were completely open. R#107 didn't have any pants on and was wearing a soiled brief. A top sheet was pulled half way down to the resident's middle thighs. Two Certified Nursing Assistants (CNA) and a family member were providing as… | 2020-09-01 |
| 2707 | 2707 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2016-12-22 | 309 | D | 0 | 1 | UD3W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders [REDACTED].#21). Findings include: Review of the policy titled Medication Administration: Insulin Sliding Scales revised on 6/18/15 documented to check the prescriber's order and to calculate the correct amount of insulin to be administered using scale ordered by the physician. Record review for R#21 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. Active [DIAGNOSES REDACTED]. Record review for R#21 revealed the following Physician order [REDACTED]. Record Results. Administer sliding scale subcutaneously. For blood sugar greater than 250: 251-279 = 4 units 280-319 = 5 units 320-359 = 6 units 360-399 = 7 units 400-439 = 9 units For blood sugar less than 60 or greater than 400, notify the medical doctor (MD). The Medication Administration Record (MAR) documented: August 19, (YEAR), 11:00 a.m. blood sugar 453, 0 units insulin administered August 25, (YEAR), 11:00 a.m. blood sugar 475, 9 units insulin administered August 29, (YEAR), 11:00 a.m. blood sugar 449, 9 units insulin administered September 23, (YEAR), 11:00 a.m. blood sugar 550, 9 units insulin administered Review of the Physician order [REDACTED]. Further review of the MAR and Nurses Notes for (MONTH) and September, (YEAR) did not indicate any adverse outcome to R#21 related to the above elevated blood sugars or insulin coverage. Interview with Licensed Practical Nurse (LPN) AA on 12/22/2016 at 2:48 p.m. revealed that the protocol for administering sliding scale insulin is to check the blood sugar and administer insulin per the sliding scale. LPN AA confirmed that if the blood sugar was over 400, she would notify the physician. She stated that if the blood sugar was out of the parameter for the sliding scale, she would notify the physician to obtain a new one time order… | 2020-09-01 |
| 2708 | 2708 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2016-12-22 | 371 | E | 0 | 1 | UD3W11 | Based on observation, record review and interviews, the facility failed to ensure the temperature, of the low temperature dishwasher, was at least 120 degrees Fahrenheit (F) in accordance with the manufacturer's recommendations for proper sanitation, during a wash/rinse cycle. The facility's failure to maintain the proper temperature required for sanitation, increased the risk of potential foodborne illness of 63 residents that received an oral diet. The facility census was 67. Findings include: Review of the undated guideline printed from the Ecolab website, in which the facility uses as practice, titled By[NAME]L. Petran PhD- Vice President, Food, Safety & Public Health documented: In every restaurant, one ingredient cannot be overlooked: Clean dishes and utensils. It can expose your customers to dangerous foodborne illness. Best practices to warewashing, the following basics are recommended: Check the gauges and compare their readings with the minimum temperatures, chemical concentrations and pressure measurements listed on the data plate. Low-temperature, or chemical sanitizing machines, also show minimum rinse and wash temperatures- typically 120 degress F for both, on the data plate. Observation of the low temperature dishwasher in the kitchen on 12/19/16 at 11:00 a.m. revealed the temperature thermostat on the front bottom. The temperature read 90 degrees F during the wash cycle of several dishes and utensils. Further observation revealed a sticker on the front of the temperature dial that stated the minimum temperature setting should be at least 120 degrees F. The Dietary Manager (DM) was called to observe the dishwasher temperature at this time. The Dietary Aide (DA) ran the dishwasher through four (4) cycles, however, the maximum temperature reached each time was 90 degrees F. The sanitizer was at 150 parts per million (ppm). The DM confirmed the temperature did not go above 90 degrees F and stated at the time of the observation that this was not an acceptable temperature and that the dishes would need … | 2020-09-01 |
| 6413 | 6413 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2014-07-02 | 279 | D | 0 | 1 | 6JZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews the facility failed to develop a care plan for one (1) resident (# 6) who was readmitted to the facility with an indwelling urinary catheter from a sample of twenty-five (25) residents. Findings include: Observation of resident # 6 on 06/30/14 at 1:10 p.m., in the main dining room, revealed a urinary catheter bag covered in a privacy bag attached to the wheelchair. Observation of resident # 6 on 07/01/14 at 10:35 a.m. revealed the resident in bed, for wound care treatment, with both treatment nurses at the bedside. Continued observation revealed a urinary catheter bag attached to the side of the bed covered in a privacy bag. Review of the clinical record for resident #6 revealed that the resident was readmitted to the facility in March, 2014, after hospitalization , with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed as requiring extensive assistance of one(1) person with bed mobility and toileting, total assistance of two (2) people with transferring, and was assessed with [REDACTED]. Review of the comprehensive care plan dated 02/04/14 and updated 06/21/14 revealed that the resident had an alteration in elimination; was incontinent of bowel and bladder; and at risk for pressure areas, and urinary tract infections [MEDICAL CONDITION]. There was no evidence that a care plan for an indwelling urinary catheter had been developed for this resident. Interview with the Licensed Practical Nurse (LPN) Case Mix Director on 07/01/14 at 4:15 p. m. revealed that resident # 6 was readmitted to the facility in March with an indwelling urinary catheter, and she should have addressed the resident's catheter on the comprehensive care plan. The LPN acknowledged that she was responsible for updating the care plan after a resident is readmitted to the facility and she did not. | 2018-01-01 |
| 6414 | 6414 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2014-07-02 | 371 | F | 0 | 1 | 6JZX11 | Based on observation and staff interview the facility failed to properly demonstrate use of the three compartment sink to prevent the potential for food borne illness. Findings include: Observation on 07/01/14 at 11:20 a.m. revealed a dietary worker using the 3 compartment sink to wash the bowl, lid, and blade for the food processor. The dietary worker washed the kitchen equipment in soapy water, rinsed, then dipped the items in the sanitizer solution and put on the rack to dry. The dietary worker did not submerge the kitchen equipment for 1 minute as posted above the 3 compartment sink. Interview on 07/01/14 at 11:25 a.m. with the Dietary Manager revealed that she provided an in-service on the use of the 3 compartment sink a few months ago. Continued interview revealed that she was able to verbalize that kitchen equipment that is cleaned in the 3 compartment sink needs to be submerged for 1 minute in the sanitizer solution. Interview on 07/01/14 at 11:28 a.m. with the dietary worker revealed that she did not know that she needed to submerge kitchen equipment that is sanitized in the 3 compartment sink sanitizer solution. | 2018-01-01 |
| 7638 | 7638 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-11-07 | 256 | D | 0 | 1 | 9RB511 | Based on observations and resident and staff interviews, the facility failed to maintain proper lighting for one (1) resident (#D) from a total sample of twenty-seven (27) residents. Findings include: Observations on 11/7/13 at 9:00 a.m. in rooms A-1, A-4, A-13, B-8, and B-10 revealed the lighting to be inadequate to perform basic nursing procedures. Continued observations revealed that the artificial light available in each resident room was a round ceiling fixture in the center of the ceiling and a light over each resident's bed. The ceiling light used incandescent bulbs and lights the center of the room, leaving dark corners in the room and the individual resident lights over the beds are metal shaded, cone shaped lights. These resident lights used incandescent bulbs and provided directional lighting only. Continued observation revealed that these cone shaped individual lights appear mounted, so that they can be pivoted and change direction; however, when the light is turned on, the metal shade is too hot to touch. Interview with resident D on 11/7/13 at 9:00 a.m., revealed that her light was not bright enough for her to read her Bible. Interview with the Maintenance Director on 11/7/13 at 10:30 a.m., revealed that the bulbs used in the resident rooms are soft white incandescent bulbs. | 2017-02-01 |
| 7639 | 7639 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-11-07 | 279 | D | 0 | 1 | 9RB511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care for the use of antipsychotic medication for one (1) resident (#71) from a sample of twenty-seven (27) residents. Findings include: Review of the clinical record for resident #71 revealed the resident was admitted to the facility in October, 2008 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident received an antipsychotic for the seven (7) days of the assessment period. Continued review of the Care Area Assessment Summary revealed that the [MEDICAL CONDITION] Drug Use triggered as a concern, with the decision made to care plan. Review of the current physician's orders [REDACTED]. Review of the care plans revealed no evidence that a care plan for the use of an antipsychotic medication had been developed. Interview with the Case Mix Director on 11/07/13 at 10:25 a.m., revealed that a care plan should be developed any time a resident is receiving an antipsychotic medication. Continued interview revealed that resident #71 was receiving an antipsychotic drug during the MDS assessment period, and that a care plan had not been developed to address the medication. Further interview at 10:45 a.m., revealed that she had reviewed the resident's previous care plans, and did not see a care plan related to antipsychotic use. | 2017-02-01 |
| 7640 | 7640 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-11-07 | 325 | D | 0 | 1 | 9RB511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide a therapeutic diet and correct consistency liquids for one (1) resident (# 62) from a sample of twenty-seven (27) residents. Findings include: Review of the clinical record for resident #62 revealed a physician's orders [REDACTED]. Continued review revealed an order dated 11/05/13 for a Low Potassium, no added salt, mechanical soft diet with nectar thickened liquids. Review of the resident's meal ticket for the dinner meal on 11/05/13 revealed no evidence of a Renal diet and/or a low potassium diet. Continued review of the facility's menu for the evening of 11/5/13 revealed that resident's receiving the Low Sodium and Low Potassium diet (renal) were to receive noodles instead of potatoes and the dessert was fruit, but no oranges. Observation on 11/5/13 at 4:45 p.m. of the dinner meal for resident #62 revealed that the resident was to have potatoes and approximately ten (10) ounces (oz) of orange juice in addition to other foods. Interview on 11/5/13 at 4:50 p.m. with the Registered Dietician and Dietary Manager revealed that a Renal Diet would not contain potatoes nor that much orange juice. Interview on 11/5/13 at 5:00 p.m. with the Registered Dietician confirmed that the resident was not receiving the Renal diet as ordered. Observation on 11/5/13 at 4:55 p.m. with the Registered Dietician revealed the resident to have a pitcher 3/4 full of water in her room, that was not thickened. The pitcher had a straw in the top and the resident was capable of reaching and drinking independently. Review of the printed physician's orders [REDACTED]. Interview on 11/6/13 at 1:05 p.m. with Certified Nursing Assistant (CNA) AA revealed that water pitchers are cleaned three times weekly by dietary and are returned as a bundle. The CNAs distribute the water pitchers to the residents. Interview on 11/6/13 at 10:30 a.m. with CNA BB revealed that if a a resident is on thicken… | 2017-02-01 |
| 7641 | 7641 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-11-07 | 332 | E | 0 | 1 | 9RB511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the medication error rate was less than 5%. A total of twenty-eight (28) med opportunities were observed, and there were three (3) errors made by two (2) of four (4) nurses for two (2) of four (4) residents on two (2) of three (3) halls, for a total error rate of 10.71%. Findings include: 1. Observation on 11/05/13 at 10:10 a.m. revealed Licensed Practical Nurse (LPN) EE giving morning meds to resident #44, which included two (2) inhaler medications. The nurse gave two (2) puffs of the [MEDICATION NAME] inhaler, followed by one (1) puff from a Proair inhaler. Reconciliation of the medication given with the physician's orders [REDACTED]. Interview on 11/05/13 at 2:18 p.m. with LPN EE revealed that she could not remember if she had given the Aspirin, but verified that she had not initialed it as given on the Medication Administration Record [REDACTED]. 2. Observation on 11/05/13 at 3:45 p.m. revealed LPN FF performing a fingerstick blood sugar (FSBS) measurement for resident #8, which was 204. The LPN stated that the resident received a dose of Insulin per a sliding scale for the elevated blood sugar, as well as a routinely-scheduled dose of 28 units of [MEDICATION NAME] 70/30 Insulin, and pointed this out on the MAR. Continued observation revealed that at 3:55 p.m., LPN FF drew up 30 units of [MEDICATION NAME] 70/30 Insulin, which she stated was both for the sliding scale coverage as well as the routine Insulin dosage. The LPN proceded into the resident's room to administer this medication when she was stopped by the surveyor. She was asked if the sliding scale Insulin was supposed to be [MEDICATION NAME] 70/30 or [MEDICATION NAME] R, and verified she should have drawn up 2 units of [MEDICATION NAME] R for the sliding scale amount, instead of giving 2 extra units of the [MEDICATION NAME] 70/30. Review of the physician's orders [REDACTED]. | 2017-02-01 |
| 7642 | 7642 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-11-07 | 371 | E | 0 | 1 | 9RB511 | Based on observations and staff interviews the facility failed to serve food in the main dining room in a sanitary manner for one (1) of two (2) meals observed. Residents receiving oral alimentation -sixty nine (69) Findings include: Observation of lunch served on 11/04/13 at 12:35 p.m., in the main dining room revealed twenty four (24) residents seated with three or four (3 - 4) residents to a table. Towels were used as clothing protectors. Continued observation revealed two (2) Certified Nursing Assistants (CNAs) serving trays from the kitchen. After assisting with tray set up, the CNAs took the tray back into the kitchen and placed the tray on a cart inside the kitchen. The dietary aide on the tray line picked up the dirty tray, placed it on the counter, get a clean plate, and served another meal. This meal distribution method continued for the whole lunch session with the CNAs bringing back the same dirty trays to be used over again in the kitchen. Continued observation of lunch being served from the kitchen at 12:50 p.m., revealed the Director of Nursing (DON) assisting to pass trays to residents and returning the tray to the kitchen for re-use. Observation of a tray coming out of the kitchen revealed that the tray had pieces of meatloaf, and spilled tea on the tray. Interview with the DON on 11/04/13 at 12:50 p.m., after showing her the tray, revealed that the dirty tray was not acceptable way to serve food to the residents. During interview with the Dietary Manager on 11/07/13 at 11:45 a.m., she stated that during meal service in the dining room, the staff should have been using one tray for delivery of food to a resident, then place that tray in the window of the dishwashing area and obtain a new tray to serve the next resident's plate of food. Upon further interview, she stated that the used tray should not have been brought back into the food area of the kitchen, and that they had enough trays to be able to serve all of the residents this way. | 2017-02-01 |
| 7643 | 7643 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-11-07 | 441 | E | 0 | 1 | 9RB511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policies for Handwashing Techniques and Blood Glucose Equipment and Supplies and staff interview, the facility failed to distribute meals to residents in the dining room and cleanse and store glucometers for three (3) residents (#8, #21, and #29) in a clean and sanitary manner from a census of twenty seven (27) residents. The total census was seventy (70) residents. Findings include: 1. Observation, in the dining room on 11/6/13 at 7:45 a.m. revealed a Certified Nursing assistant (CNA) DD assisting four (4) residents with tray set up for breakfast. This set up included unwrapping eating utensils, spreading jelly on toast, placing spoons or forks in eggs or cereal, assisting one (1) resident with tucking a clothing cover into the shirt collar, touching a resident on the shoulder and locking the wheelchair. Continued observation revealed that the CNA assisted these residents without sanitizing or washing her hands between residents. After completing this task, the CNA crossed the hall, entered a resident's bathroom and washed her hands. Interview with the CNA on 11/6/13 at 7:55 a.m. revealed that there was no method of cleaning her hands available in the dining room. 2. Observation of trays being distributed from the kitchen to the main dining room on 11/04/13 at 1:00 p.m., revealed a CNA standing in the kitchen at the tray line waiting for the resident trays. The CNA coughed into her sleeve, picked up a glass of tea, placed it on the tray and then went into the dining room to serve the trays. Continued observation revealed that the CNA assisted the residents with set up, opening condiments and cutting up their food without washing her hands or using hand sanitizer. Further observation revealed that that none of staff washed hands or used hand sanitizer between residents, or before assiting to feed residents. There were no hand washing or hand sanitizing stations in the dining room. 3. During dining obse… | 2017-02-01 |
| 9612 | 9612 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-04-05 | 221 | D | 0 | 1 | WNM011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to assess the use of full siderails as potential restraint devices for two residents (#75 and #33), and failed to assess the use of a seat belt as a potential restraint device for one (1) resident (#75) from a sample of forty four (44) residents. Findings include: 1. Observations of resident #75 in the bed on 04/01/13 at 3:49 p.m.; 04/02/13 at 7:20 a.m., and 04/03/13 at 7:10 a.m. revealed that one side of their bed was against the wall, and a full siderail was up on the open side of the bed. Observations of resident #75 when in the wheelchair on 04/02/13 at 11:00 a.m. and 12:15 p.m., 04/03/13 at 12:20 p.m., 04/04/13 at 12:50 p.m., and 04/05/13 at 9:10 a.m. revealed that the resident had a seat belt and hand mitts on. During further observations at these times, the resident was noted to move their legs and slide down in the wheelchair, but was not noted to be able to remove the seat belt or exit the chair. During interview with Licensed Practical Nurse (LPN) "CC" on 04/01/13 at 3:15 p.m., she stated that resident #75 had full siderails on both sides of the bed and that one side of the bed was against the wall, that she had seen the resident put their legs over the siderail before, and that he/she was not able to get up safely. Review of the clinical record for resident #75 clinical record revealed that the resident had [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) dated 06/12/12 and Quarterly MDS dated [DATE] revealed that the resident was not assessed for use of restraints. Review of the care plan revealed that a care plan was not developed for use of the siderail, hand mitts, or seat belt. Review of Nurse's Notes revealed the following: 12/02/12 10:05 p.m. Resident very agitated at times, trying to climb out of bed. 12/03/12 3:00 p.m.-11:00 p.m.: Attempting to climb out of bed. 12/06/12 11:05 p.m.: Resident trying to scoot out of bed with feet… | 2015-06-01 |
| 9613 | 9613 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-04-05 | 241 | D | 0 | 1 | WNM011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to ensure that dignity was maintained for five (5) residents (#5, #6, #27, #13 and #15) from a sample of forty-four (44) residents. Findings include: 1. Observation on 4/4/13 at 7:00 a.m. of resident # 6 revealed she was being assisted with breakfast by Certified Nursing Assistance (CNA) "FF". Continued observation revealed "FF" was standing while feeding the resident. Interview on 4/4/13 at 1:46 p.m. with "FF" revealed that she did not know that she was suppose to sit down and feed the resident. She further revealed that the bed was too high for her to reach the resident and that she has always fed the resident # 6 standing up. Continued interview revealed that the last inservice she attended about feeding was about four years ago when she completed her CNA class. 2. Observation on 4/4/13 at 4:30 p.m. of resident #27 during the evening meal revealed CNA "DD" assisting the resident with the meal. Continued observation revealed that the CNA was standing while feeding the resident. Interview on 4/4/13 at 4:45 p.m. with CNA "DD" revealed that she always stands to feed the residents. Continued interview revealed that she had not been told to do it differently. 3. Observation on 4/5/13 at 7:15 a.m. of resident # 5 revealed she was being assisted with breakfast by CNA "EE".Continued observation revealed the CNA was standing while feeding the resident. Interview on 4/5/13 at 10:14 a.m. with Licensed Practical Nurse (LPN) "BB" revealed that the Certified Nursing Assistants were taught that they should sit when feeding residents and although this has been discussed with the CNA's , a formal inservice had not been done. 4. Observations on 4/1/13 at 3:03 p.m., 4/2/13 at 8:45 a.m., 4/3/13 at 2:35 p.m., and 4/4/13 at 3:50 p.m., revealed resident #15 with white socks on their feet. The resident's last name had been written across the top of the socks and was visible to any visitors in the facil… | 2015-06-01 |
| 9614 | 9614 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-04-05 | 253 | E | 0 | 1 | WNM011 | Based on observation and staff interview, the facility failed to maintain a clean and comfortable environment on three (3) of three (3) halls as evidenced by rusted elevated commode seats; broken and/or stained floor tiles; soiled, damaged or unpainted furniture, walls, siderails, linen cart cover, weight scale, and door frame. Findings include: The following concerns were noted during observations of the environment on 04/01/13 beginning at 1:30 p.m. and 04/02/13 beginning at 2:49 p.m. A-Hall: Room A-2: The underside of the raised toilet seat was very rusty. Room A-3-1:The horizontal metal frame of the overbed table had large, dried splatters. Room A-7: The door frame in the bathroom leading into Room 5 on the left side near the floor was corroded. Room A-8-1: The paint on the bottom tier of a small 2-tier black table just inside the hallway door had peeled off in several areas. On 04/01/13 at 5:07 p.m., resident "A" stated the table was there when they were admitted to the room, and wished that they would paint it. Room A-11: The legs of the elevated commode seat in the bathroom were rusty, and the armrests were missing on both sides. Room A-12: The corner walls to the right of the sink in the bathroom approximately eighteen inches off the floor had brown smears. B-Hall: Room B-8-2:There was a dried white material on the siderails on the resident's left side. B-Hall Hallway: A Seca weight scale had debris on the platform, and multiple white splatters on the seat. The front cover to the linen cart in the hall had multiple vertical and horizontal splits. A turquoise-colored chair in the day room at the end of the B-hall had a two-inch split in the vinyl of the seat on the left front corner, and a one-inch split on the seat cushion on the middle right side. C-Hall: The common Shower (on the Medical Records side of the hall): There were two broken tiles surrounding the shower stall drain. There was a dark build-up in the far corners of the shower stall at the floor. The above concerns were verified by the facility'… | 2015-06-01 |
| 9615 | 9615 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-04-05 | 281 | D | 0 | 1 | WNM011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and review of the Georgia Practical Nurses Practice Act, the facility failed to follow standards of practice related to medication administration for one (1) resident (#49) from a sample of forty four (44) residents. Findings include: Observation on 4/2/13 at 4:58 p.m., revealed that Licensed Practical Nurse (LPN) "KK" gave a [MEDICATION NAME] Inhalation Aerosol to resident #49 for administration. The resident took 2 puffs of the [MEDICATION NAME] Inhalation Aerosol. Review of the clinical record for resident # 49 revealed a physician's orders [REDACTED]. The LPN "KK" failed to instruct the resident to only take 1 puff as ordered. Continued review revealed a physician's orders [REDACTED]. The physician ordered licensed nursing staff to administer the Proair Inhalation Aerosol 15 minutes before the [MEDICATION NAME] Inhalation Aerosol and to wait 1 minute between the puffs of the Proair. Observation on 4/2/13 at 4:59 p.m., revealed LPN "KK" gave the Proair Inhalation Aerosol to the resident for administration after the [MEDICATION NAME] Inhalation Aerosol was administered. Furthermore, the resident took the 2 puffs in quick succession without waiting 1 minute between each puff. LPN "KK" failed to administer the Proair Inhalation Aerosol 15 minutes before administering the [MEDICATION NAME] Inhalation Aerosol and failed to instruct the resident to wait one minute between the puffs of the Proair. Interview on 4/5/13 at 1:20 p.m. with the consultant pharmacist revealed that the licensed nursing staff should have administered the Proair Inhalation Aerosol prior to the administration of the [MEDICATION NAME] Inhalation Aerosol. Review of the Georgia Praqctical Nurses Practice Act revealed that the practice of licensed practical nursing means the provision of care for compensation related to the maintenance of health and prevention of illness which shall include; -Chapter 2-Stasndards of Nursing Practice; Section … | 2015-06-01 |
| 9616 | 9616 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-04-05 | 323 | J | 0 | 1 | WNM011 | Based on observation, record review, and staff interview the facility failed to provide a safe smoking environment for six (6) residents (#17, #76, #84, "C", "D" and "E") from a sample of forty-four (44) residents, as evidenced by the use of unsafe ashtrays; lack of a fire extinguisher in close proximity of the smoking area; and unsecured storage of smoking materials. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those six (6) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of September 20, 2012 until April 5, 2013, at which time a plan was implemented by the facility to remove the immediate jeopardy situation. The facility's Administrator and owner were informed of this Immediate Jeopardy on April 3, 2013 at 7:05 p.m. Findings include: 1. Observations on 4/02/13 beginning at 4:00 p.m. revealed signage posted throughout the facility stating not to give residents smoking materials. Interview with the administrator on 4/2/13 at 4:12 p.m. revealed the facility changed its smoking policy in September, 2012 because a resident was burned on 9/20/12, while smoking without a staff member present and required medical attention. Continued interview revealed that prior to this incident, residents were allowed to keep their own smoking materials if they were deemed as safe smokers. Review of the smoking assessment for resident "B", the resident that was burned, dated 7/18/12 revealed that the resident was assessed as able to see clearly to perform the task, able to light a cigarette, smoke a cigarette and extinguish a cigarette safely. Resident "B" had been assessed as a safe smoker, not requiring supervision to smoke and with a Brief Interview of Mental Status score (BIMS) of 9. Interview with resident "B" on 4/3/13 at 11:59 a.m. revealed she was trying to smoke a cigarette and put the lighter too close to her body, and her blouse caught on fire. She revealed she got burned f… | 2015-06-01 |
| 9617 | 9617 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-04-05 | 328 | E | 0 | 1 | WNM011 | **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 the filters on the oxygen concentrators were clean for seven (7) of twelve (12) residents who were administered oxygen and failed to ensure that a nebulizer machine was clean for one resident (#58) from a sample of forty four (44) residents. Findings include: 1. Resident #58 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations on 4/1/13 at 12:06 p.m., 4/2/13 at 2:00 p.m., 4/3/13 at 1:32 p.m. and 4/5/13 at 8:30 am., revealed there were dried smears of a brown substance on the inside compartment of the nebulizer machine located on the resident's bedside table. Interview on 4/5/13 at 8:32 a.m. with Licensed Practical Nurse "HH" revealed that the resident did not currently receive nebulizer treatments and did not remember the last time the resident did receive treatments. Continued interview revealed that the nurses on the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift were responsible for removing the nebulizer machines from resident rooms and placing them in the soiled utility room for cleaning and sanitizing. review of the resident's medical record revealed [REDACTED]. 2. Observations on 4/1/13 at 11:42 a.m., and 3:06 p.m., 4/2/13 at 8:00 a.m., 1:00 p.m. and 3:00 p.m. revealed resident #27 receiving oxygen by nasal cannula at two (2) liters per minute. The filter on the oxygen concentrator was covered in thick gray substance. 3. Observations on 4/4/13 beginning at 7:00 a.m. of residents receiving oxygen revealed the following: Room B-1-The oxygen filter had an accumulation of a dirty gray substance. Room B-8 -The oxygen filter was lying on the floor. Room B-11 -The oxygen filter had an accumulation of a dirty gray substance. Room A-13-The oxygen filter had an accumulation of a dirty gray substance. Room A-14 B-The oxygen filter had an accumulation of a dirty gray substance. Room C-3-The oxygen cannul… | 2015-06-01 |
| 9618 | 9618 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-04-05 | 371 | F | 0 | 1 | WNM011 | **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 chemical concentration in the dish machine was sufficient for sanitization; failed to sanitize the thermometer probe when checking steam table temps; failed to store disposable plastic utensils, Styrofoam cups and plates in a manner to prevent potential contamination; and failed to label and store food properly in the reach-in coolers. Sixty-seven (67) residents in the facility received oral alimentation. Findings include: 1. Observation on 04/03/13 at 1:10 p.m. revealed Dietary employee "NN" washing lunch dishes using a low temperature dish machine. The chemical concentration of the rinse water was checked several times per the manufacturer's directions, but the chlorine strip did not change colors, signifying there was insufficient sanitizer being dispensed. This was verified by the Dietary Manager, who ran the machine three additional times without any reaction noted on the test strip, and verified it was a low temp dish machine and the rinse water temp was only 130 degrees Fahrenheit. Interview with dietary employee "NN" at 1:10 p.m .revealed that the chemical concentration in the dish machine was checked "a lot," but she had not checked it prior to washing the lunch dishes and could not verbalize what the acceptable reading on the test strip should be. 2. Observation on 04/01/13 at 10:45 a.m. revealed four open boxes containing Styrofoam cups, foam plates, and plastic forks and spoons in a closet between the kitchen and porch, which also contained a housekeeping sink and chemicals. The plastic packaging inside the utensils was not closed, leaving the utensils open to air. The open boxes of utensils and cups were approximately three feet off the floor, and there was the potential for splatters when the mop bucket was filled. In addition, the chemical used in the mop bucket was Master Heavy Duty Cleaner and Degreaser, which was connected by a tu… | 2015-06-01 |
| 9619 | 9619 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-04-05 | 441 | F | 0 | 1 | WNM011 | Based on observations, record review and staff interviews, the facility failed to ensure that glucometers were cleaned and sanitized appropriately and that proper hand washing was done after providing wound care for one (1) resident (#82) from a sample of forty four (44) residents. Finding include: 1. Observation on 4/2/13 at 11:50 a.m. of an accucheck done by Licensed Practical Nurse (LPN) "CC" revealed that after completing the accucheck, the nurse removed her gloves, wiped off the accucheck machine with a Super-Sani cloth and placed it in the tray. Continued observation revealed that the nurse immediately removed the accucheck machine from the tray, holding it in her bare hands, pushed the review button to get the results that she had just completed and then placed it back in the tray. Interview on 4/2/13 at 11:55 a.m. with LPN "CC" revealed that all she was suppose to do with the accucheck machine is wipe it off and put it up. She revealed that she did not know that the machine was supposed to be air dried before putting it up; and that she did not know that there was a time frame for the machine to be air dried. Interview on 4/5/13 with "FF" at 8:20 a.m. revealed that the nurses were given an inservice on how to properly clean the accucheck machine after use. She further revealed that the nurse should clean with the saniwipes and lay the machine wet on a barrier to dry for 2 minutes. 2. During observation of medication administration on 4/2/13 at 4:55 p.m., Licensed Practical Nurse "KK" used a glucometer to obtain a blood sugar level for resident #49. After "KK" obtained the blood sugar level, she/he placed the glucometer on top of the medication cart and proceeded to administer the resident's other medications. After the additional medications were administered to the resident, "KK" picked up the glucometer from the top of the medication cart and placed it in a plastic basket in a drawer in the medication cart. However, "KK" failed to clean and sanitize the glucometer after obtaining a blood sugar level for… | 2015-06-01 |
| 9620 | 9620 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2013-04-05 | 514 | C | 0 | 1 | WNM011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain clinical records that were complete, readily accessible, and systematically organized. This had the potential to affect all residents in the facility (census=68 residents). Findings include: On 04/02/13 at 11:27 a.m., Certified Nursing Assistant (CNA) Treatment Aide "PP" was asked to provide the Treatment Records for resident #80, which could not be located in the resident's closed clinical record (the resident was discharged on [DATE]. CNA "PP" was not able to locate the records, and asked the Director of Nurses (DON) to find them. Some of the Treatment Records were provided at 11:57 a.m., however, they did not contain the requested information of the wound measurements and description. During interview with the MDS Coordinator on 04/02/13 at 12:02 p.m., she stated that the DON, who retired the previous week, worked some in medical records, and that she helped with it. Upon further interview she stated that she had been out sick for three months, and that because they were a small facility they didn't have anyone else to organize the medical records. She was asked to see if she could find any wound documentation for resident #80, but was unable to. On 04/03/13 at 9:10 a.m., Licensed Practical Nurse (LPN) "BB" provided the Weekly Pressure Ulcer Records for resident #80, and stated the treatment nurse, who was not scheduled to work that week, came in last night and found the documentation in her office. Upon further interview, LPN "BB" stated the medical records department was "a mess" because they didn't have a room large enough to store everything. She added that at the present time, all overflow or closed records were going into the MDS office and stacked until they had time to organize it. During interview with the MDS Coordinator on 04/05/13 at 8:53 a.m., she stated the Medication Administration Records (MAR) for all residents were removed from the notebooks that … | 2015-06-01 |
| 10315 | 10315 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2011-11-10 | 241 | D | 0 | 1 | F4VJ11 | Based on observation and staff interview, the facility failed to provide care and services to promote dignity for one (1) resident (#37) from a sample of twenty nine (29) residents. Findings include: 1. Observation on 11/7/11 at 8:50 a.m. and 11:30 a.m. of resident # 37 revealed an Indwelling Urinary Catheter bag hanging on the left side of the bed with no privacy bag covering the catheter drainage bag. Observation on 11/8/11 at 11:15 a.m., 11/9/11 at 9:00 a.m. and 12:15 p.m. revealed a urinary drainage bag hanging from bedside facing the door, with urine in the bag, and no privacy cover over the drainage bag. Interview on 11/10/11 at 10:15 a.m. with the Director of Nursing revealed that the facility's policy does not include dignity bags for indwelling urinary catheters and that they were not really necessary especially for residents who were not up and about in the hallways. | 2014-08-01 |
| 10316 | 10316 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2011-11-10 | 314 | D | 0 | 1 | F4VJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews the facility failed to identify a new pressure ulcer for one (1) resident (#37) from a sample of twenty-nine (29) residents. Findings include: Observation of wound care for resident #37 on 11/9/11 at 8:50 a.m. provided by the treatment technician revealed a Stage 4 sacral ulcer with a reddened wound bed and yellow slough. Continued observation revealed an open area to the left of the Stage 4 ulcer with a red wound bed with slough. The wounds, treated as one wound instead of two individual wounds, were cleaned with saline gauze and skin prep applied to the perimeters. Silversorb gel was put on a 2 x 2 gauze and placed over the Stage 4 wound. The other opened area was not covered by the 2x2 gauze. A foam adhesive dressing was applied. Interview with the treatment technician on 11/9/11 at 8:50 a.m. revealed that the resident had two (2) separate wounds; 1 Stage 2 and 1 Stage 4. Continued interview revealed that she did not know the measurements and that the nurses measured the wounds each week. Review of the treatment record revealed no description of either ulcer. Review of the physician orders [REDACTED]. During an interview on 11/9/11 at 11:22 a.m. with the charge nurse, she acknowledged that she observed the sacral wound on 10/25/11 and that there was only one (1) wound that she was measuring. She indicated that she did not see a second ulcer on 10/25/11. Continued interview revealed that this nurse could not stage the wound to the left of the stage 4 sacral wound because she was new to looking at wounds. Licensed Practical Nurse (LPN) "DD" assessed the wound as a Stage 2. Neither of the nurses were aware that the Stage 2 wound was there. Interview on 11/9/11 at 2:30 p.m. with the treatment technician revealed that she did not tell the nurse about the new area on the resident nor had she told her there was an odor coming from the wound. | 2014-08-01 |
| 10317 | 10317 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2011-11-10 | 356 | C | 0 | 1 | F4VJ11 | Based on observation and staff interview, the facility failed to include all required information on posted staffing hours. Finding include: Observation on 11/7/11 at 9:30 a.m.; 11/8/11 at 8:45 a.m.; and 11/10/11 at 11:00 a.m. of the posted staffing sheet revealed no evidence of evening shift staff hours and no evidence of the facility census. During interview on 11/11/11 at 11:00 a.m. the Administrator verified the findings. | 2014-08-01 |
| 10318 | 10318 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2011-11-10 | 441 | D | 0 | 1 | F4VJ11 | Based on review of the facility's infection control policy, glucometer disinfection procedure, observation, and staff interview, the facility failed to ensure that staff followed infection control practices to prevent the spread of infection. Findings include: 1. Observation on 11/8/11 at 8:30 a.m. revealed Certified Nursing Assistant (CNA) "GG" arranging the clean linen cart on C hall. She had packaged wipes and linens lying on the floor and picked them up and returned them to the clean linen cart. 2. Observation on 11/8/11 at 11:00 a.m. revealed CNA "GG" preparing supplies for oral care for resident #35. A clean towel was removed from the clean linen cart, dragged across the hall floor and then used during resident care. 3. Observation and interview on 11/8/11 12:15 p.m. revealed Licensed Practical Nurse "BB" cleaning a glucometer. She used hand sanitizer on a tissue to clean the glucometer and indicated that she let it sit one minute between residents. Interview on 11/10/11 9:40 a.m. with LPN "CC" revealed that the procedure for disinfecting glucometers was to use a Clorox wipe, which is kept at the nurse's station, wipe down the entire glucometer and let it sit one minute between each resident's use. Review of the Clorox container revealed that it disinfects against staphylococcus, escheria coli, listeria, herpes, rotovirus, and influenza. To clean, wipe the surface and let air dry. To sanitize, stay wet for 30 seconds. To disinfect, wipe, keep visibly wet for four minutes. Interview on 11/10/11 at 10:15 a.m. with the Director of Nurses revealed that newly hired CNA's are partnered with an experienced CNA for approximately one week. She further indicated that the CNA's do not have any check off procedure to ensure that they have been adequately trained in infection control processes. Continued interview revealed that the Recommendation for Cleaning and Disinfection of Glucometers - North Carolina Statewide Program for Infection Control and Epidemiology (SPICE) was used as the training tool for nurses on gluco… | 2014-08-01 |
| 10319 | 10319 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2011-11-10 | 164 | D | 0 | 1 | F4VJ11 | Based on observation and staff interview, the facility failed to ensure that privacy was maintained during the provision of care for one (1) resident (#35) from a sample of twenty-nine (29) residents. Findings include; Observation on 11/9/11 at 11:00 a.m. revealed oral care being provided to resident # 35 by Certified Nursing Assistant (CNA) "GG". The door to the room was open, the privacy curtain between the resident's beds was open during care and the residents roommate had visitors as the oral care was being provided. Interview on 11/10/11 at 10:15 a.m. with the Director of Nurses revealed that staff should provide privacy for residents when providing care. | 2014-08-01 |
| 10320 | 10320 | PRUITTHEALTH - COVINGTON | 115588 | 4148 CARROLL STREET | COVINGTON | GA | 30015 | 2011-11-10 | 280 | D | 0 | 1 | F4VJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to update/develop a care plan for behaviors with measurable goals and interventions for one (1) resident (#71) from a sample of twenty-nine (29) residents. Findings include: 1. Review of the nurses notes for resident #71 from 7/27/11-11/5/11 revealed that he occasionally refuses care, is combative, attempts to get out of bed and the geri-chair, pulls at his feeding tube, and tears sheets off the bed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that the resident is physically abusive toward others daily, verbally abusive toward others four to six (4-6) days but less than daily, and other behavior symptoms not directed toward others four to six (4-6) days but not daily. Review of the resident care plan (CP), last updated 10/31/11, revealed no evidence that a care plan had been initiated for behaviors with measurable goals and interventions. Interview with Licensed Practical Nurse (LPN) "DD" on 11/9/11 at 10:30 a.m., revealed that the care plan did not include behaviors and that this resident was exhibiting behaviors. | 2014-08-01 |
| 3674 | 3674 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2018-06-28 | 660 | D | 0 | 1 | EDZ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to develop a discharge plan for one resident (R) (R#32) of 15 sampled residents. Findings include: Review of the clinical records for Resident (R) #32 revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Further review of the clinical records revealed the resident was discharged on [DATE] after a course of wound care which included visits to the wound care clinic. Review of Admission Minimum Data Set (MDS) assessment of 1/10/18 revealed under Section Q, Participation in Assessment and Goal Setting, that the resident had participated in the assessment, but no overall expectation for discharge was documented nor was there an active discharge plan in place. Review of the Social Services notes during the resident's stay revealed there was discussion between the interdisciplinary team and the resident's guardian related to the resident's goal of returning to live in her previous home in an assisted living community. On 3/14/18 Social services documented that discharge planning was in place for the resident with the goal for her to return to the assisted living community within two weeks with the support of Home health. However, a further review of the records revealed no actual discharge plan documented for R#32. During an interview on 6/28/18 at 12:01 p.m. with the individual responsible for providing social services, the Director of Life Enrichment, it was revealed when residents are admitted from the assisted living community, on campus, for short-term skilled nursing, the interdisciplinary team (IDT) meets to plan for that resident's discharge and a plan of care for discharge is supposed to be developed during this meeting. The team then discusses progress to discharge at every care plan meeting. The IDT did meet to plan the discharge for R#32. They were aware that she planned to discharge back to her previous living arrangement on the nearby campus an… | 2020-09-01 |
| 3675 | 3675 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2018-06-28 | 661 | D | 0 | 1 | EDZ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to include the recapitulation of stay information and instructions for post discharge on the discharge summary for one resident (#32) from a sample of 15 residents. Findings include: Review of the clinical records for Resident (R) #32 revealed she was admitted on [DATE] with a [DIAGNOSES REDACTED]. Further review of the clinical records revealed the resident was discharged on [DATE] after a course of wound care which included visits to the wound care clinic. Review of the resident's discharge summary of 4/4/18 revealed that the section Summary of Course of Treatment in Facility documented only that resident was to discharge back to her previous home as per her request and that she would be discharged home with home health and a good potential to reach her goal of wound healing. There was no recapitulation of treatment the resident received while at the facility. The discharge summary also had no post-discharge instructions or plan of care. During an interview with the Director of Nursing (DON) on 6/28/18 at 2:56 p.m. it was revealed that a discharge summary is completed by social services and nursing prior to a resident being discharged . The summary should include a recapitulation of the services the resident received while at the facility and post-discharge instructions. A recapitulation of services received while at the facility was not included on the discharge summary for R#32 because it was felt that the resident planned to return home, not to another provider. | 2020-09-01 |
| 3676 | 3676 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2017-07-09 | 364 | E | 0 | 1 | P8K711 | Based on observation and staff interviews the facility failed ensure puree recipes were available for staff review as well as follow to preserve nutrient content and failed to have a cycle menu available to provide guidance for staff to follow regarding portion sizes for all food items for all meals. This deficient practice had the potential to effect 31 residents receiving an oral diet. Findings include: Observation on 7/8/17 at 11:25 a.m. of the dietary aide BB pureeing the lunch meal for the residents in the skilled nursing facility revealed he placed four, four ounce spoons of chopped ham and four, two ounce spoons of maple raisin sauce in the blender bowl and pureed. He next opened the lid and poured in an unmeasured amount of food thickener from the can and started the blender and pureed again. Dietary aide BB then placed a four ounce serving in four, three compartment plates. The dietary aide then added an unmeasured amount of sliced ham to the blender bowl and poured in an unmeasured amount of maple raisin sauce and pureed. He opened the lid and poured in an unmeasured amount food thickener from the can. The dietary aide then placed a four ounce servings in one three compartment plate and two, four ounce servings on two of the compartment plates. Continued observation of dietary aide BB puree food items for the lunch meal revealed he placed an unknown amount of cooked scalloped potatoes in the blender bowl and pour an unmeasured amount of milk from the gallon container in the blender bowl and pureed. He opened lid and poured more unmeasured amount of milk into the blender bowl. Next dietary aide BB was observed pureeing cooked pea pods. He placed an unmeasured amount of peas pods in the blender bowl and pureed. He then opened the lid and poured an unmeasured amount of food thickener from the can and pureed. Dietary aide BB opened the lid a second time and poured an unmeasured amount of food thickener again from the can. Interview on 7/8/17 at 11:30 a.m. with the Dietary Manager revealed that there are no … | 2020-09-01 |
| 3677 | 3677 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2017-07-09 | 371 | E | 0 | 1 | P8K711 | Based on observation and staff interviews the facility failed to ensure opened food items were labeled and dated in the stand up freezer and dry storage in the satellite kitchen as well as in two of two walk-in refrigerators and one dry food storage rack in the food preparation area in the main kitchen; failed to properly thaw chicken to prevent food borne illness; failed to discard prepared food after seven days; and failed to sanitize food thermometer between food items after taking temperatures. This deficient practice had the potential to effect 31 residents receiving an oral diet. Findings include: Observation on 7/7/17 at 8:40 a.m. during the initial tour of the satellite kitchen revealed the following: 1) Two opened, four quart containers of vanilla ice cream with no open date. 2) One opened, 1.5 quart lactose free vanilla ice cream with no open date. 3) A white eight ounce Styrofoam cup on a shelf in the dry storage area labeled chicken broth with no date. Observation on 7/7/17 at 9:15 a.m. during the initial tour of the main kitchen revealed the following: 1) An opened plastic bag of spaghetti noodles and bag of mostaccioli noodles in a plastic storage bin with no open date. 2) The dry storage rack in the food preparation area had the following items that had been opened with no date: two pound bag sliced almonds, four pound bag of butterscotch chips, nine ounce taco seasoning mix, packet of fruit punch, and one pound bag of powdered sugar. 3) Walk-in refrigerator #1 revealed a five pound of peeled garlic opened with no date, an aliumium pan with sliced turkey breast with a date of 6/27 and a five gallon container containing a brown food item with no label or date. 4) Walk-in refrigerator #2 revealed the following items that had been opened with no date: five pound bag of shredded cheddar cheese and two blocks of sliced cheddar cheese. Interview on 7/7/17 at 9:17 a.m. with the Dietary Manager revealed she confirmed that sliced almonds, butterscotch chips, taco seasoning mix, fruit punch mix, powdered sug… | 2020-09-01 |
| 3678 | 3678 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2017-07-09 | 441 | D | 0 | 1 | P8K711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews, the facility failed to store personal care equipment in a sanitary manner to prevent potential cross-contamination in two of eight bathrooms shared by more than one resident on one of two nursing units. The facility census was 32 residents. Findings include: Observation of resident rooms and bathrooms on 7/7/17 at 10:00 a.m. revealed room [ROOM NUMBER] bathroom was observed to be clean with no odor. Nesting on top of the toilet tank cover were two gray bath basins that were uncovered and unlabeled. The bathroom is shared by two residents who require total assistance with activities of daily living (ADL) and cannot use the bathroom independently. Observation of the bathroom in room [ROOM NUMBER] on 7/1/17 at 10:50 a.m. revealed an unlabeled bedpan sitting in an unlabeled bath basin on top of the toilet tank cover. These items were both uncovered. The bathroom is shared by two residents who are unable to use the bathroom independently. Observation on 7/7/17 at 6:00 p.m. of the bathrooms in room [ROOM NUMBER] and 208 revealed that the two bath basins in room [ROOM NUMBER] were still observed nesting uncovered and unlabeled on top of the toilet tank cover. Observation of the bathroom in room [ROOM NUMBER] on 7/7/17 at 6:02 p.m.revealed that the bedpan was still observed sitting in the bath basin uncovered and unlabeled. All personal care equipment were still observed in the same place observed earlier in the day. Observation of 7/8/17 at 9:30 a.m. of the two bathrooms in 207 and 208 revealed that the personal care items were still observed uncovered and unlabeled in the same place observed on top of the toilet tank cover since entrance to the facility. Interview on 7/8/17 at 3:05 p.m. with Certified Nursing Assistant (CNA) CC revealed that she is responsible for providing ADL care to her assigned residents which consist of a shower on their shower day or bed bath in the room. CNA CC revealed that both reside… | 2020-09-01 |
| 3679 | 3679 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2019-09-12 | 812 | E | 0 | 1 | 9PPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of policies entitled, Food Safety and Sanitation and Receiving and Storing Food and Supplies, the facility failed to discard expired food items and to maintain a clean ice scoop bucket and clean steam table wells. This deficient practice had the potential to affect 29 residents. Findings include: A review of the facility policy titled Food Safety and Sanitation dated 2013, revealed under number 4b - Foods with expiration dates are used prior to the use by date on the package. A review of the facility policy titled Receiving and Storing Food and Supplies dated 2014, revealed under number 4 - Delivered food and supplies are inspected for acceptable quality prior to acceptance and signing off on the delivery invoice. Items not meeting quality standards are rejected, noted on the delivery invoice and reported to the Director of Food Services; (i) - Food items are checked for vermin infestation, damage, acceptable expiration dates and the like. A review of the Cleaning Schedule for D.[NAME]N.H and [NAME] Somers &[NAME]Kitchen dated [DATE], revealed that the steam table and surrounding areas were on a 'Daily' cleaning schedule. The description read drain, clean and polish exterior stainless-steel surfaces, daily as required. An observation of the on-site facility kitchen on [DATE] at 6:15 p.m. revealed the steam table with heavily soiled wells and a can of Thicken-Up with the date ,[DATE] written on the lid and EXP BY 11 [DATE] stamped on the bottom of the can. Further observation revealed divided plates, dinner plates and serving trays stacked one upon the other with visible moisture (wet nested), and dark brown colored debris at the bottom of a blue bucket with two plastic ice scoops and the ice scoop bucket lid inside. Observations of the on-site facility kitchen made on [DATE] at 11:59 a.m., [DATE] at 7:55 a.m. 12:20 p.m., and 4:30 p.m., and [DATE] at 8:30 a.m. revealed the steam table… | 2020-09-01 |
| 5069 | 5069 | SALUDE - THE ART OF RECOVERY | 115723 | 601 NORTH HOLT PARKWAY | SUWANEE | GA | 30024 | 2015-05-14 | 371 | E | 0 | 1 | MMID11 | Based on observation and staff interview the facility failed to properly label and date food items in the walk-in refrigerator and failed to discard expired food items in the walk-in refrigerator and dry storage area. The facility did not have any resident 's receiving alternative nutritional needs. This had the potential to affect all forty-one (41) residents. Findings include: Observation on 05/11/15 at 10:30 a.m. of the walk-in refrigerator revealed the following items on the top shelf: - A one (1) gallon container of French's Worcestershire sauce that was partially used with no date of when it was opened. - Two (2), forty-eight (48) ounce bottles of lemon juice that were were opened with no date to indicate when they were opened. - A one (1) gallon container of Creamy Caesar salad dressing had an date open date of 07/16. - A one (1) gallon container of Sweet and Sour sauce had an open date of 10/30. Continued observation in the walk-in refrigerator was a bag of partially used shredded cheddar cheese with no date of when opened. Further observation revealed that there was a posting on the outside of the walk-in refrigerator titled Food Storage and Shelf Life. It indicated that food items such as salad dressing should be discarded three (3) months after opening and food items such as condiments should be discarded six (6) months after opening. Interview on 05/11/15 at 10:30 a.m. with the Registered Dietitian (RD) she confirmed that the Worcestershire sauce, both bottles of lemon juice, and the bag of shredded cheddar cheese did not have a date of when they were opened. The RD acknowledged that they should have a date of when they were opened. The RD confirmed that the Creamy Caesar dressing had an open date of 7/16, and the Sweet and Sour sauce had an open date of 10/30. She further revealed that she believes that dietary staff used the date the containers were to expire and not when it was opened for usage. The RD acknowledged that staff had dated the items incorrectly. Continued interview revealed that she di… | 2019-02-01 |
| 5584 | 5584 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2015-02-26 | 328 | D | 0 | 1 | 1VZ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the Administering Nebulizer Therapy Policy, the facility failed to maintain respiratory equipment in a sanitary manner for one (1) resident (Z) and failed to follow the facility policy guidelines for administering a Nebulizer treatment for one (1) resident (#17) from a sample of sixteen (16) residents. Findings include: 1. A Continuous Positive Airway Pressure ([MEDICAL CONDITION]) mask for resident Z was observed on 2/24/15 at 11:00 a.m. and 2:00 p.m. face down on the bedside table uncovered. The mask was again observed on 2/25/15 at 8:50 a.m. on the bedside table uncovered and there was no water in the humidifier. During an interview with resident Z on 2/25/15 at 8:30 a.m., the resident reported that she used her [MEDICAL CONDITION] daily. She reported that she put her mask on and took it off each morning and placed her mask on the bedside table. She also reported that she had never cleaned her mask and needed assistance cleaning it. She further reported that the humidifier had been broken and leaked for quite some time and would like to have it repaired. Interview with Licensed Practical Nurse (LPN) AA on 2/25/15 at 9:20 a.m. revealed that the staff had nothing to do with the [MEDICAL CONDITION] and did not clean it or store it. LPN AA further revealed that the facility was aware that the heated humidifier was broken and had spoken with the family last year however there was no follow up and the humidifier remained broken. Interview with the Administrator on 2/25/15 at 9:40 a.m. revealed that she was unaware that the [MEDICAL CONDITION] machine was broken and agreed that although the facility was not responsible for the residents equipment, they should have it cleaned and stored properly. Continued interview revealed that the facility should have followed up with the family to replace the broken heated humidifier and ensure that the [MEDICAL CONDITION] was f… | 2018-08-01 |
| 8272 | 8272 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2012-10-31 | 309 | E | 0 | 1 | EN8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to consistently provide accurate sliding scale insulin coverage for two (2) residents, #2 and #5, from a sample of fifteen (15) residents. Findings include: Record review for resident #2 revealed that he had a [DIAGNOSES REDACTED]. Further record review revealed a current physician's orders [REDACTED]. [MEDICATION NAME]was to be administered according to the following formula: subtract 100 from blood sugar reading and divide that result by 25 to determine the number of units of insulin to be given. A review of the resident's Insulin Flow Sheets for September 2012 revealed that the sliding scale insulin coverage was miscalculated nineteen times out of one hundred and twenty (19/120) occasions. A review of the Insulin Flow Sheets for October 2012 revealed that the resident's sliding scale insulin coverage was miscalculated thirty times out of one hundred and seventeen (30/117) occasions, These findings were confirmed in an interview with the facility's Director of Nursing (DON) in an interview on 10/30/12 at 3:15 p.m. Record review for resident #5 revealed that he had a [DIAGNOSES REDACTED]. Further record review revealed a current physician's orders [REDACTED]. [MEDICATION NAME]was to be administered according to the following formula: if the blood sugar reading was greater than 160 subtract 100 from blood sugar reading and divide that result by 25 to determine the number of units of insulin to be given. A review of the resident's Insulin Flow Sheets for September 2012 revealed that the sliding scale insulin coverage was miscalculated eighteen times out of ninety(18/90) occasions. A review of the Insulin Flow Sheets for October 2012 revealed that the resident's sliding scale insulin coverage was miscalculated sixteen times out of eighty-eight (16/88) occasions, These findings were confirmed in an interview with the facility's Director of Nursing (DON) in an interview on 10/30/12 at… | 2016-05-01 |
| 8273 | 8273 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2012-10-31 | 314 | D | 0 | 1 | EN8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to consistently monitor and document the measurements and appearance of a pressure ulcer to determine the progress towards healing and/or potential complications for one (1) resident (#1). The sample size was fifteen (15) residents. Findings include: Review of a hospital Discharge Summary for resident #1 noted [DIAGNOSES REDACTED]. A Physician's Hospice Care Note dated 12/15/11 noted the resident was at risk for skin breakdown secondary to increasing immobility. Review of a Braden Scale done on 9/11/12 noted that the resident was at high risk for pressure ulcer development. Review of Wound Clinic notes dated 12/12/11 noted that an ankle wound was healing, with measurements of 1.5 centimeters (cm) X 1.4 cm X 0.1 cm. Review of Weekly Pressure Ulcer Records for the pressure ulcer to resident #1's right ankle revealed the following staging and measurements: 9/25/12: Stage 3. 1.5 cm X 1.5 cm X 0.1 cm with bloody serous exudate; there was no notation of eschar to the wound. 9/01/12: Stage 3. 1.0 cm X 1.0 cm X 0.2 cm. 8/02/12: Stage 3. 1.5 cm X 1.0 cm X 0.2 cm. 7/02/12: Stage 3. 1.5 cm X 2.0 cm X 0.5 cm. 6/05/12: Unstageable. 1.5 cm X 1.5 cm X 0.1 cm with tunneling. 5/04/12: Stage 2. Open crater 1.0 cm X 1.0 cm X 0.2 cm. 3/05/12: Stage 2. A scab 1.5 cm X 1.0 cm X 0.1 cm, and an open area 1.0 cm X 2.0 cm X 0.1 cm. 02/03/12: Unstageable. 2.0 cm X 2.5 cm X 0 cm. No documentation of the measurements for the month of October could be found in the clinical records. Review of the most recent Body Audit dated 10/05/12 assessed the resident as having a Stage 2 to the right ankle. During interview with the Director of Nurses (DON) On 10/29/12 at 12:16 p.m., she stated that resident #1 had a Stage 2 pressure ulcer on the right ankle. During interview with Licensed Practical Nurse (LPN) AA on 10/31/12 at 10:45 a.m., she verified there were no measurements of the right ankle wound docum… | 2016-05-01 |
| 10625 | 10625 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2010-07-15 | 371 | F | DUNS11 | Based on observation and staff interview the facility failed to ensure that foods being served to residents in the facility's main dining room were held at a temperature necessary to prevent the likelihood of foodborne illnesses. This affected all residents in the facility (census = 15). Findings include: Observation on 7/13/10 at 12:15 p.m., with dietary employee "EE", in the serving kitchen of the dining room revealed a stainless steel pan full of tossed green salad was sitting unrefrigerated on a cart in the serving area. Continued observation revealed that the pan of salad was sitting in another pan containing ice. A temperature check of the tossed salad, using a digital thermometer, revealed that the temperature was 62 degrees Fahrenheit, well above the safe holding temperature of 41 degrees Fahrenheit. Further observation revealed a small stainless steel pan of chopped ham, being used to make chef salads, sitting on the cart. The pan of chopped ham was being held at room temperature without any means of keeping the ham cold. The temperature of the chopped ham was measured with a digital thermometer at 61 degrees Fahrenheit. | 2014-02-01 | ||
| 2106 | 2106 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 580 | D | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family and staff interview, record review, and policy titled Notification of Changes, the facility failed to promptly notify the family/representative (RP) of one resident (R) A of an open area on her gluteal cleft (the groove between the buttocks) that required a new treatment. The sample size was 34. Findings included: Review of the policy titled, Notification of Changes dated 12/2017 indicated: The purpose of this policy is to ensure the center promptly informs the resident's representative when there is a change requiring notification. Circumstance requiring notification may include: 3. Circumstance that require a need to alter treatment. This may include: a. New treatment. During an interview on 1/22/19 at 11:13 a.m. the family of R A revealed that he had not been notified that the resident has a pressure sore on her buttocks. The family of R A revealed that he is the responsible party for the resident. Review of R A Admission Record revealed the family member is the documented RP. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] documented R A was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Section C- Cognitive Patterns: recorded Brief Interview for Mental Status (BIMS) 13 out of 15 which indicates the resident is cognitively intact. Section M Skin Conditions: M0150. Risk for pressure ulcer. 1. Yes. M0210. Unhealed Pressure Ulcer 0. No. M1040. Other Ulcers, Wounds and Skin Problems: H. Moisture Associated Skin Damage (MASD) not checked on this MDS. Review of a progress note dated 1/20/19 at 7:26 a.m. revealed: Pressure Ulcer reported by CNA at 6:33 a.m. to sacral area, small in size, pt (sic) repositioned for comfort wound nurse notified. No documentation in R A medical record that the family was notified of the changes in the residents' skin. Review Physician Telephone Order dated 1/20/19 revealed: clean open area on gluteal cleft with NS (normal saline) apply hydrogel cover wit… | 2020-09-01 |
| 2107 | 2107 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 600 | D | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family and staff interviews, review of the facility policy Abuse Prevention the facility failed to protect resident (R) A from a Certified Nursing Assistant (CNA) who removed the residents call light and placed it out of the resident reach. The same CNA returned the next day and attempt remove R A call light. The sample size was 34. Findings included: Review of the Minimum Data Set (MDS) admission assessment dated [DATE] documented R A was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Section C- Cognitive Patterns: recorded Brief Interview for Mental Status (BIMS) 13 out of 15 which indicates the resident is cognitively intact. Section G: Functional status: needs extensive assistance in the following areas: bed mobility, transfer, dressing, personal hygiene, and toilet use. An interview was conducted on 01/22/19 at 10:49 a.m. with the resident and the family/responsible party (RP) was present at the time of interview. Resident A revealed that this past weekend she pushed her call light for assistance. The CNA entered the room gave her extra covers and turned the heat up per the resident's request. The resident revealed that later in the night she got to warm and wanted the covers off. The resident revealed that she put her light on and after a waiting while and no one answering the light she pulled the covers down. The same CNA came back into the room untied the call light from the grab bar (supportive device to facilitate position change) and threw it on the floor and left the room. The resident further revealed that after a while the nurse that gives her medicine came in the room; placed her call light within reach and placed the covers on her. The resident revealed that the CNA came back in the room and asked her how did you get the call light back? The resident revealed that the next night the same CNA came in her room and started untying her call light from grab bar. The resident stated that she told the… | 2020-09-01 |
| 2108 | 2108 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 609 | D | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, review of the facility policy Abuse Prevention the facility failed to report allegations of abuse and provide protection to one resident (R) A prior to conducting the investigation of the alleged violation. The sample size was 34. Findings included: Review of an undated policy titled, Abuse Prevention revealed 9. Response and reporting of Abuse, Neglect and exploitation-Anyone in the facility can report suspected abuse to the abuse agency hotline. When Abuse, Neglect and exploitation is suspected, the Licensed Nurse should: Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately. 11. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] documented R A was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Section C- Cognitive Patterns: recorded Brief Interview for Mental Status (BIMS) 13 out of 15 which indicates the resident is cognitively intact. Section G: Functional status: needs extensive assistance in the following areas: bed mobility, transfer, dressing, personal hygiene,… | 2020-09-01 |
| 2109 | 2109 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 641 | B | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to document the [DIAGNOSES REDACTED].#15 in the 11/14/18 Annual and the previous four Quarterly Minimum Data Set (MDS) assessments dated 10/11/18, 7/17/18, 6/23/18, and 4/28/18. In addition, the facility failed to accurately document the discharge status as 01 for R#60 for Community (private home/apt, board/care, assisted living, group home in the 1/2/19, MDS Discharge Assessment-Section A2100. The discharge status was documented as acute hospital. The sample size was 34 residents. Findings include: 1. Record review for R#15 revealed was admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of the thinned clinical record revealed the additional [DIAGNOSES REDACTED]. Review of the most recent MDS Annual assessment, dated 11/14/18, did not include the dementia diagnosis. Further review of the previous Quarterly MDS assessments, dated 10/11/18, 7/17/18, and 6/23/18 also omitted the dementia diagnosis. 2. Review of the closed clinical record for R#60 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged , from the facility, on 1/2/19. Review of the most recent MDS Discharge Assessment, dated 1/2/19, documented the discharge status in Section A Identification Information, A2100 as 03. Acute Hospital. Review of the Physician order [REDACTED]. In an interview with the MDS Director on 01/26/19 at 7:24 p.m. regarding the MDS discrepancies, she confirmed the omission of the dementia [DIAGNOSES REDACTED].#60. She accepted responsibility for these inaccuracies. In an interview with the Director of Nursing (DON) on 1/26/19 at 8:00 p.m. revealed that her expectation was that the MDS Director and other MDS contributors would make every effort to be accurate and thorough in their assessments. | 2020-09-01 |
| 2110 | 2110 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 656 | D | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to implement the care plan related to attempting to determine the causes of falls for one resident (R) (R#41), and failed to implement the care plan to give medications as ordered for one resident (R 'B). The sample size was 34 residents. Findings include: 1. Review of R #41's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had short and long term memory problems, was totally dependent for all activities of daily living including transfers and bed mobility, and walking did not occur. Review of R #41's high risk for falls related to confusion, balance problems, incontinence, psychoactive drug use, and unaware of safety needs care plan revealed that it was last revised on 1/1/19. Review of the interventions to this falls care plan revealed that they included to follow the facility fall protocol (initiated 6/8/17), and to review information on past falls, attempt to determine cause of falls, and record possible root causes (initiated 2/12/18). Review of the facility incident reports and nursing progress notes revealed that the resident had falls on 7/3/18, 7/26/18, 8/27/18, 11/22/18, and 1/1/19. During interview with the Director of Nursing (DON) and Assistant DON (ADON) on 1/26/19 at 3:23 p.m., revealed that they discussed falls in the morning clinical meeting and in the stand-up meeting afterwards with all managers. She stated during continued interview that there were no notes or documentation in the clinical meetings of what was discussed until 12/14/18. The DON verified there was no evidence of what was in place at the time of any of R #41's falls, no discussion of the root cause of each fall, what interventions were put into place at the time of or after each fall, nor evaluation for the effectiveness of the current interventions either in clinical meeting notes, incident reports, or computerized nursing progress notes. Cross-refer to F 6… | 2020-09-01 |
| 2111 | 2111 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 689 | E | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure that hot water temperatures in ten resident bathrooms (nine bathrooms shared by more than one resident, and one private bathroom) used by 31 residents and one common shower room on two of two halls were maintained below 120 degrees Fahrenheit (F), and failed to monitor water temperatures more closely when the temperatures were identified to be elevated on 1/17/19. In addition, the facility failed to identify the root cause for multiple falls for one resident (R) (R#41), document what interventions were in place at the time of a fall, put a new intervention in place after each fall, and provide evidence that current interventions were evaluated for their effectiveness in preventing future falls. The sample size was 34. Findings include: 1. Observation of hot water temperatures in bathrooms shared by two resident rooms taken with a surveyor's thermometer on 1/22/19 beginning at 11:37 a.m. revealed: Rooms 21/23: 124 degrees F room [ROOM NUMBER] (private bathroom): 123 degrees F Rooms 24/26: 121 degrees F Rooms 28/30: 120 degrees F Rooms 33/35: 121.3 degrees F On 1/22/19 at 12:39 p.m., the Administrator was notified of the elevated water temperatures, and stated that no residents had been burned by hot water. During observation with the Maintenance Director on 1/22/19 at 12:42 p.m., the following water temperatures were obtained using the facility's thermometer: Rooms 24/26: 122.0 degrees F Rooms 25/27: 120.0 degrees F Rooms 29/31: 120.0 degrees F Rooms 33/35: 121.3 degrees F During interview with the Maintenance Director at this time, he stated that he tried to keep water temperature in resident bathrooms around 107 degrees, and that he checked water temperatures weekly in two bathrooms on each hall and the common shower (only one of two common showers was currently available for resident bathing on the South Hall). He further stated that one day last week, t… | 2020-09-01 |
| 2112 | 2112 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 690 | D | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to keep the Foley catheter anchored to one resident's (R) leg (R# 59) to prevent tension on the urinary meatus. The sample size was 34 residents. Findings include: Review of R# 59's PPS scheduled Minimum Data Set (MDS) section H- Bladder and Bowel, revealed he had an Indwelling catheter related to [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder and had a Brief Interview for Mental Status (BIMS) score of 5 (a BIMS score of 0 to 7 indicates severe cognition impairment). Review of a care plan for [MEDICAL CONDITION] with a 16 French Foley catheter in place revealed an intervention including but not limited to monitor and document pain related to Foley catheter. Observation on 1/23/19 at 5:45 p.m., 1/24/19 at 8:15 a.m. and 1/24/19 at 9:35 a.m. revealed that the Foley catheter tubing was not anchored to R#59's leg to prevent excessive tension on the catheter during positioning and care. An interview on 1/24/2019 at 2:00 p.m. with Certified Nursing Assistant (CNA) CC revealed that he was aware that R #59 needed the catheter anchored to his thigh and he attempted to taped it down but apparently, the tape did not secure the tubing. He continued to state that he was informed of the correct tape to anchor the tube to resident 's thigh. An interview on 1/24/2019 at 2:45 p.m. with the Director of Nursing (DON) revealed R #59 had the Foley catheter insertion due to retention of urine and after insertion of the Foley catheter, he had over 1000 milliliters (ml) of urine. The physician recommended to continue with R #59's Foley catheter due to retention of urine. The DON revealed her expectation is for the tubing from the Foley Catheter to be anchored to the resident's thigh to prevent excessive tension on the urinary meatus and to prevent pain and discomfort. | 2020-09-01 |
| 2113 | 2113 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 725 | E | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to ensure that there was sufficient staff to pass morning medications in the required timeframes for one resident (R) (R B) on one of two halls (South Hall). Findings include: During interview with R B on 1/22/19 at 2:48 p.m., who stated that any time Licensed Practical Nurse (LPN) MM worked, he/she got their morning medications as late as 12:00 p.m. or 1:00 p.m., and that this happened every time this nurse worked. Review of R B Quarterly Minimum (MDS) data set [DATE] revealed that he/she had a BIMS (Brief Interview for Mental Status) score of 10 (a BIMS score of 8 to 12 indicates moderate cognitive impairment). Review of the resident's (MONTH) 2019 physician's orders [REDACTED]. An interview with LPN II on 1/25/19 at 8:51 a.m. revealed that the nurses had one hour before, or one hour after the scheduled time to give the medication. Observation on 1/26/19 at 9:10 a.m. revealed that the South Hall medication cart was parked at the nurse's station, with no nurse in attendance. Interview with R B at this time revealed that they had not yet received their morning medications. Observation at 1/26/19 at 9:24 a.m. revealed that LPN MM was observed to take her medication cart to the South Hall, and begin to pass medications to R#29 who resided in the first room at the top of this hall. Interview with R B at this time revealed that he/she had not yet received their morning medications. Observation on 1/26/19 at 10:37 a.m. revealed that LPN MM took the resident to her room to give the resident's morning medications. During interview with R B on 1/26/19 at 10:48 a.m., who verified that the nurse had just received her morning medications. During interview with LPN MM on 1/26/19 at 11:05 a.m., she stated that most of the residents' morning medications were scheduled for 9:00 a.m. She further stated that the staff had been told to focus on customer service, so during he… | 2020-09-01 |
| 2114 | 2114 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 732 | C | 0 | 1 | SDK511 | Based on observation and staff interviews the facility failed to post the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care and the actual resident census on 1/22/19 and 1/23/19. The facility census was 60. Finding Included: Observation on 1/22/19 at 11:30 a.m. of the staffing posted revealed the following: the name of the facility, date 1/22/19, census 63, per patient day (PPD) 3.08, unit clerk, unit manager, restorative nurse, resident care coordinator, nurse, and CNA (certified nursing assistant) with the employee names. The staffing posting did not differentiate Registered Nurse or Licensed Practical Nurse. Directly behind the posting was daily staffing sheets for 1/23/19 with the same information. An interview was conducted on 01/23/19 at 4:10 p.m. with the Staffing Coordinator regarding the nursing staffing posting requirements. The staffing coordinator revealed she was orientated by the previous staffing coordinator that all nursing staff are to be posted on the sheet along with the employees first and last name and the PPD hours. The staffing coordinator confirmed that they are names on the staffing sheet who do not provided direct patient care. The staffing coordinator also confirmed that she was not aware that she needed to go back and put the actual hours worked by the licensed and unlicensed staff that provided direct patient care. The staffing coordinator also confirmed that she had completed staffing sheets for a week in advance and was not aware that the daily nursing staffing sheets should be completed at the beginning of each shift. An interview was conducted on 1/23/19 at 5:00 p.m. with the Administrator regarding the census and nurse staff information. The Administrator confirmed the census on 1/22/19 at 11:30 a.m. was 60 (58 in house and two in the hospital). The Administrator revealed that the staffing coordinator is responsible for the daily staffing posting and, in her absence, the unit clerk is responsible for the postin… | 2020-09-01 |
| 2115 | 2115 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 880 | F | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide evidence that infection control surveillance data was accurately recorded and/or analyzed to determine clusters of infections, and record what was done in response to increased rates of infections. The facility census was 60 residents. Findings include: Review of the Monthly Antibiotic Stewardship Program Tracking Report for (MONTH) (YEAR) revealed that there were 24 residents with Norovirus symptoms without antibiotic treatment. The total number of infections listed for the month was 43, for an incidence rate of 26%. Review of the Monthly Antibiotic Use Tracking Log for (MONTH) revealed that eight residents were listed as having an SSTI (skin and soft tissue infections), four with an SUTI (symptomatic urinary tract infection), five with an RTI (respiratory tract infections), and one Other infection. There was no notation as to what the Other infection was, nor clarification of the type of SSTIs. Review of a GI (gastrointestinal) Infection List updated 2/26/18 revealed that 24 residents exhibited GI symptoms such as vomiting and diarrhea. Review of an Anti-infective Utilization report for (MONTH) revealed that 17% of the total anti-infectives were topical antibiotics, and 10% were topical antifungals. No evidence was seen that the data was analyzed, nor what the facility did in response to the infection rates. Review of the Monthly Antibiotic Stewardship Program Tracking Report dated (MONTH) (YEAR) revealed that there was a total of 17 infections for an incidence rate of 9.92%. Review of the Monthly Antibiotic Use Tracking Logs for (MONTH) revealed that there were five RTIs, two [MEDICAL CONDITIONS], four SSTI, five Other infections, and one SUTI. There was no indication of what the Other infections were, nor clarification of the type of SSTI. Review of a Nosocomial Infection Report for Skin Infection revealed infections classified as a SSTI included [MEDICAL CONDITION… | 2020-09-01 |
| 2116 | 2116 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 883 | D | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide evidence that education was provided for one resident (R) (R#52) prior to the resident refusing both the influenza and pneumococcal vaccines. Five residents were reviewed for the provision of immunizations, and the sample size was 60 residents. Findings include: Review of R#52's Quarterly Minimum (MDS) data set [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 10 (a BIMS score of 8 to 12 indicates moderate cognitive impairment). Review of an Update Immunization report dated 7/10/18 revealed that the family refused the [MEDICATION NAME] vaccine for R#52. Review of the Update Immunization report dated 10/10/18 revealed that R#52 refused the Influenza vaccine. The section Education Provided To Resident/Family was left blank on both of the immunization reports. During interview with the Licensed Practical Nurse Infection Control Nurse on 1/26/19 at 2:51 p.m., she verified that there was no documentation that education was provided to either the responsible party or resident to ensure they were aware of the risks and benefits of the vaccines so that an informed decision could be made. Review of the facility's Vaccination of Residents policy revised (MONTH) (YEAR) revealed: Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccination. Provision of such education shall be documented in the resident's medical record. | 2020-09-01 |
| 2117 | 2117 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2018-02-01 | 582 | D | 0 | 1 | VU1G11 | Based on Notice of Medicare Non-Coverage form, staff interview and policy review, the facility failed to document the Quality Improvement Organization (QIO) name and the toll-free number of the QIO for three of three residents (R#17, #35, #200) reviewed. Findings include: 1. Review of R#17's Notice of Medicare Non-Coverage form with skilled services ending on 9/8/17 lacked the QIO and toll-free number of the QIO. 2. Review of R#35's Notice of Medicare Non-Coverage form with skilled services ending on 7/22/17 lacked the QIO and toll-free number of the QIO. 3. Review of R#200's Notice of Medicare Non-Coverage form with skilled services ending on 7/15/17 lacked the QIO and toll-free number of the QIO. Interview with Social Services Designee (SSD) in her office, on 2/1/18 at 9:32 a.m. confirmed she had not remove the guidance for the insertion and replace it with the QIO name and toll free number. Review of the policy titled, Notice of Medicare Non-Coverage (CMS- ) and Detailed Explanation of Non-Coverage (CMS- ) dated 1/2017 indicated the facility must insert the name and telephone numbers (including TTY) of the applicable QIO in no less than 12-point type. The facility failed to provide the resident and or responsible party the name of the QIO and phone number. | 2020-09-01 |
| 2118 | 2118 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2018-02-01 | 656 | D | 0 | 1 | VU1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of the policy, it was determined the facility failed to develop a comprehensive care plan for six residents (Residents (R ) #12, R#13, R#16, R#17, R#98, R#99) from a sampled 21 residents. The following residents were identified with the following concerns: - Record review revealed R#12 developed three facility acquired pressure ulcers and was placed on air fluid pressure mattress, - Record review revealed R#13 started [MEDICAL TREATMENT] an no care plan initiated, - Record review revealed R#16 required encouragement for nutrition, - Record review revealed R#17 had a limitation in range of motion and was to receive restorative services, - Record review revealed R#98 had [MEDICAL CONDITION] and no care plan regarding nutritional needs and required assistance to the bed pan or commode for bowel removal, - Record review revealed R#99 was admitted with three pressure ulcers, was placed on an air mattress, required off-loading of the heels, turning and repositioning, and assistance to the bathroom. Findings include: Review of the policy titled, Comprehensive Care Plan dated 12/2017 revealed it was the policy of this center to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Review of #12's annual Minimum Data Set ((MDS) dated [DATE] revealed R#12 the resident required total dependence of two people with bed mobility, transfers, toilet use, and personal hygiene, the resident did not walk, was total dependence of one person with locomotion, required extensive assistance of two people with dressing, and required extensive assistance of one person with eating. The resident was at risk for the development of pressure ulcers and had the prese… | 2020-09-01 |
| 2119 | 2119 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2018-02-01 | 686 | D | 0 | 1 | VU1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Social Circle 686 PS Based on record review, observation, staff interviews, and policies, the facility failed to assess and document multiple unstageable pressure ulcers for two residents (R#12 and R#99). The sample size was 21 residents. Findings included: Review of facility policy titled, Wound Prevention/Wound and Skin Treatment revised (MONTH) 2005 revealed: all wounds will have a Differentiation Evaluation completed within 24 hours of discovery all wounds will be evaluated upon discovery and weekly and documented on the Wound Treatment and Evaluation Record a weekly wound report will be completed by the wound nurse or designee the following preventive standards for mobility/activity/sensory deficits should be initiated when indicated: reposition as often as needed based on skin integrity after pressure has been reduced or redistributed, for dependent residents sitting in a chair, or those who remain in bed or a reclining chair with the head greater than 30 degrees, off-loading hourly may be appropriate, depending on evaluation of resident tissue tolerance, use pillows/positioning orthotics for pressure relief on all bony prominences use heel protectors and/or pillows to keep heels off of bed, avoid positioning on trochanters, a complete wound evaluation and documentation shall be done weekly on the Wound Treatment Evaluation Record which includes: location, staging, size, exudate, pain, wound bed, and description of wound edges and surrounding tissue. Review of facility policy titled, Pressure-Redistribution/Reduction Surfaces dated 2005 indicated, as with all support surfaces, accurate physician's orders [REDACTED]. The manufacturer's directions will determine procedures for support surfaces. Place the manufacturer's directions for the devices used in the facility behind this page. 1. Review of R#12's clinical record listed the Diagnoses: [REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed R#12 had difficulty … | 2020-09-01 |
| 2120 | 2120 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2018-02-01 | 688 | D | 0 | 1 | VU1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, it was determined the facility failed to provide Restorative Therapy (RT) service, as ordered by Physical Therapy for one (#17) resident of 21 sampled residents. Finding include: Record review revealed R#17 had been admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 7/31/17, documented the resident had no impairments in Range of Motion (ROM) with upper or lower extremities. The resident's [DIAGNOSES REDACTED]. The assessment also documented the resident when moving from seated to standing position he was not steady, except with stability from human assistance. The resident did not ambulate during the assessment period and did not turn around and face the opposite direction while walking. The resident did not move on and off the toilet. The resident was not steady while transferring from surface to surface. Review of the facility's document titled Nursing Evaluation, dated 7/18/17, in the section titled, Contractures/Limited Range of Motion (ROM) was blank. On 7/19/17, a Joint Range-Of-Motion and Mobility Screen, was completed. The screening documented the resident had no range of motion limitations. The PT (Physical Therapy)- Therapist Progress & Discharge Summary, documented start of care, 7/19/17 and end of care 7/24/17. Short Term Goal History included bed mobility, gait training, pain management and strength building. It also documented GOAL NOT MET, with an explanation of the resident being discharged to the hospital unexpectedly and that no functional gains noted this week. A quarterly Minimum Data Set ((MDS) dated [DATE], documented the resident had no ROM impairment of upper extremities and had impairments in ROM on both side of the lower extremities. The assessment documented the resident required extensive assistance from two staff to transfer between surfaces, with toilet use and hygiene. On 10/17/17, a Joint Range-Of-Motion and Mobility… | 2020-09-01 |
| 2121 | 2121 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2018-02-01 | 690 | D | 0 | 1 | VU1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interviews, and facility policy review, it was determined the facility failed to have a Physician order and medical justification for the use of a catheter for one resident (R#98) and failed to assess and provide a toileting program for two residents (R#98 and R#99). Sample size was 21 residents. Findings included: Review of the facility policy titled Incontinence Management dated 6/2003, revealed the policy lacked the intervention that the facility needed to have a physician order and medical justification for the use of the catheter. Further review of this policy revealed the objectives of the bowel incontinence management were to develop a regular, predictable bowel evacuation patter and to prevent fecal impaction or incontinence. The Guidelines included the Restorative Nurse or designee was to initiate the Bowel Retraining assessment for identified residents, review the program and treatment plan with the resident and discuss goals and outcomes, and document the interventions in the care plan and update as needed. Review of the Practice Guidelines for Bladder Programs included: the Restorative Nurse or designee is to initiate the Bladder Retraining Assessment for identified residents, complete Part 1 of the Bladder Retraining Assessment to determine considerations and identify causes of incontinence which may need to be resolved prior to initiating Part II of the assessment (such as UTI or fecal impaction, etcetera), if indicated, complete Part II of the Bladder Retraining Assessment and complete the Bladder Toileting Record, complete Part III of the Bladder Retraining Assessment, document decision making for bladder program inclusion/exclusion, and develop and implement an individualized care plan. Review of the policy titled, Urinary Incontinence Management (with no date), revealed: each resident would be assessed upon admission and quarterly by an admission or designated nurse to … | 2020-09-01 |
Advanced export
JSON shape: default, array, newline-delimited
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 );