In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

42 rows where "inspection_date" is on date 2010-09-23

View and edit SQL

Link rowid ▼ facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
9385 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 309 G 0 1 FOKJ11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, it was determined that the facility failed to ensure that restorative nursing staff notified supervisory nursing staff about one resident's (#13) complaints of pain during active range of motion exercises from a total sample of 19 residents. This failure resulted in harm for resident #13. Findings include: 1. Resident #13 had been on a "Functional Program" since 7/6/10 for restorative nursing staff to provide active range of motion exercises for both of the resident's legs six times a week as tolerated while he/she was seated in a wheelchair. This "Functional Program" developed by the physical therapist included encouraging the resident to walk with a rolling walker and to refer the resident to the therapist if any concerns arose. The resident's "Restorative Intervention Plan" included active range of motion exercises. The resident's care plan since 6/7/10 included his/her risk for general aches and pains. The goal was that the resident would be given pain medications as needed to relieve pain with an intervention for pain assessment. Restorative aide "KK" was observed on 9/23/10 at 11:05 a.m. providing passive range of motion exercises to the resident's legs and arms while the resident was lying in the bed which was not according to the planned "Functional Program" . The resident yelled "Oh!" when "KK" flexed the resident's right knee and again when "KK" flexed it a second time. When "KK" stopped the range of motion exercises to the resident's right leg, he/she had no further complaints of pain. "KK" stated at that time that the resident had complained about right leg pain during range of motion exercises since he/she began the functional program on 7/5/10. "KK" stated that she/he had notified the nurses about the resident's complaints of pain. However, on 9/23/10 at 11:50 a.m., licensed nurse "LL" stated that she/he had not been notified that resident #13 had complained about havin… 2015-07-01
9386 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 441 D 0 1 FOKJ11 Based on observations, it was determined that the facility failed to ensure that certified nursing assistants changed contaminated gloves during the provision of incontinence care for two (#1 and #4) incontinent residents and that one licensed nurse wore gloves during the administration of eye medication for two residents in a total sample of 19 residents and of six licensed nurses observed during the medication pass. Findings include: According to the American Medical Director's Association Clinical Practice Guidelines for Infection Control, Standard precautions should be applied to all residents. Those precautions emphasized handwashing and glove use when touching body fluids. However, a licensed nurse failed to use gloves to prevent the potential touching of body fluids during the installation of eye drops for residents "A" and "B". 1. During observation of medication administration on 9/21/10 at 4:55 p.m., licensed nurse "MM" washed his/her hands before and after administering one drop of Artificial Tears in both eyes for resident "A". However, "MM" failed to wear gloves. 2. During observation of medication administration on 9/21/10 at 5:00 p.m., licensed nurse "MM" washed his/her hands before and after administering one drop of Artificial Tears in both eyes for resident "B". However, "MM" failed to wear gloves. 3. According to the facility's procedures for "Perineal Care", nursing staff were to change gloves after exposing the resident's perineal area, when visibly soiled, and following the application of skin barrier ointment. The procedures noted that gloves were to be removed after the application of skin barrier ointment because they were considered "soiled" at that time. The procedures instructed staff to remove the gloves after applying a clean brief on the resident. However, nursing staff failed to appropriately change soiled gloves during care for residents #1 and #4 to prevent the spread of infection. During observation of care on 9/21/10 at 3:45 p.m. following an episode of urinary incontinence for… 2015-07-01
9387 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 315 D 0 1 FOKJ11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined the facility failed to provide appropriate catheter care for one resident (#6) in a sample of three residents with indwelling urinary catheters, and failed to provide complete incontinence care for one resident (#4) in a sample of nine incontinent residents in a total sample of 19 residents. Findings include: According to the American Medical Director's Association's Clinical Practice Guidelines, indwelling catheters should be positioned, secured and managed to minimize urethral damage. The facility's policy and procedures for catheter care noted that staff were to avoid tension on the catheter and in and out movement of the catheter. However, nursing staff failed to position and secure resident #6's catheter during care. The facility's procedures for "Perineal Care" documented that nursing staff were to cleanse the resident's labia area by first wiping one side and then the other taking care to fold the cloth so as to use clean sections with each stroke or use a clean cloth each time. The facility's nurse aide competency checklist for "Perineal Care for Female Patients" instructed nursing staff to separate the labia and wash downward on each side. The goal of perineal care was to prevent or reduce the spread of infection. However, nursing staff failed to perform incontinence care correctly for resident #4. 1. Resident #6 was admitted with [DIAGNOSES REDACTED]. During an observation of catheter care being provided on 9/22/10 at 9:50 a.m., certified nursing assistant (CNA) "JJ" failed to position, secure and manage the catheter tubing at the insertion site while cleaning the tubing. 2. During an observation of incontinence care being provide for resident #4 on 9/22/10 at 10:00 a.m., CNA "HH" failed to clean the resident's labia area before repositioning onto his/her side to perform care on his/her buttock area. 2015-07-01
9388 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 371 F 0 1 FOKJ11 Based on observations, it was determined that the facility failed to maintain sanitary conditions in the storage and food preparation areas of the kitchen. Findings include: General observations were made on 9/21/10 at 11:15 a.m. and/or on 9/22/10 at 12:15 p.m. and/or on 9/23/19 at 9:00 a.m. and 9:15 a.m. 1. The tops of the sugar, rice, corn meal and flour bins stored in the dry storage area were soiled and sticky. The tops of those food bins were still soiled and sticky on 9/22/10 at approximately 12:15 p.m. and 9/23/10 at approximately 9:00 a.m. 2. One of the two ovens had debris and large pieces of food under the floor of the oven. The debris and pieces of food were still present on 9/23/10 at 9:00 a.m. 3. The walk in cooler had two, plastic storage containers that were not labelled for contents. One was dated 9/9/10 and the other was dated 9/16/10. In an interview on 9/21/10 at 11:15 a.m., the dietary supervisor said that one container contained a peanut butter and jelly mixture and, the other contained a pimento cheese sandwich mixture. On 9/23/10 at 9:15 a.m., another plastic container which contained an unidentified brown substance was stored in that cooler. 4. There was a dirty and stained, dark green utility cart in the dry storage area. There was a large crack in the top shelf. 5. On 9/22/10 at 8:20 a.m., the small trash can under the handwashing sink was heavily soiled with dirt and dried spills. 6. The toaster on the counter was heavily soiled with a build up of blackened crumbs. 7. The meat slicer was soiled with dried juices and debris. The slicer had been covered prior to that observation. 2015-07-01
9389 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 176 D 0 1 FOKJ11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the interdisciplinary team failed to determine who would be responsible for the location of medication administration, storage and documentation of the administration of medication for one resident (#2) who self-administered medication in a total sample of 19 residents. Findings include: During the initial tour of the facility on 9/21/10 at 11:00 a.m. a box containing 0.1% [MEDICATION NAME] ointment was observed on resident #2's overbed table. A review of the clinical record for resident #2 revealed a 4/19/10 physician's orders [REDACTED]. The physician ordered that it be applied to the left knee daily as needed for redness or irritation. The order included that the resident could keep the medication at the bedside. However, there was no evidence that the interdisciplinary team had determined who would be responsible for the location of the ointment administration, the storage of the ointment, and the documentation of the resident's administration of the ointment. During an interview on 9/23/10 at 11:30 a.m., the treatment nurse stated that the resident applied [MEDICATION NAME] ointment to his/her left knee as he/she needed it. The treatment nurse stated that the resident used the ointment frequently and reported its application to the treatment nurse. However, the treatment nurse stated that she did not document on the treatment record when the resident had applied the ointment. See F279 for additional information regarding resident #2. 2015-07-01
9390 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 279 D 0 1 FOKJ11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to develop a plan of care to address one resident's (#2) self-administration of a medication, from a total sample of 19 residents. Findings include: Resident #2 had a 4/19/10 physician's orders [REDACTED]. According to that order, the medication would be kept at his/her bedside. During the initial tour of the facility on 9/21/10 at 11:00 a.m. a box containing 0.1% [MEDICATION NAME] was observed on the resident's overbed table. During an interview on 9/23/10 at 11:30 a.m., the treatment nurse stated that the resident applied the [MEDICATION NAME] ointment to his/her left knee as he/she needed it. The treatment nurse stated that the resident used the ointment frequently and reported when he/she had applied it. However, although the resident's care plan was most recently reviewed by the interdisciplinary team on 7/21/10, they failed to develop a care plan addressing the location of administration of the medication, the storage of it, and who was responsible for the documentation of the administration of it. 2015-07-01
9391 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 311 D 0 1 FOKJ11 Based on staff interview and record review, it was determined that the facility failed to incorporate ambulation into the restorative nursing program to maintain the ability to ambulate for one resident (#1), from a total sample of 19 residents. Findings include: Resident #1 was discharged from physical therapy on 9/17/10. At that time, the physical therapist documented that the resident was ambulating 50 feet with an assistive device and required only contact guard assistance. However, the "Functional Program" established by a second physical therapist on 9/16/10 did not include ambulation activities. On 9/22/10 at 11:45 a.m., restorative aide "CC" stated that the resident's "Functional Program" only included range of motion exercises and sit to stand activities. Restorative Aide "CC" stated that the resident did not receive ambulation as part of the "Functional Program". On 9/22/10 at 1:00 p.m., physical therapist "AA" stated that the resident was not receiving ambulation as part of the"Functional Program" because, he/she was not safe ambulating with the assistance of only one person, and required the assistance of two people for ambulation. On 9/23/10 at 12:15 p.m., physical therapist "BB", who had written the physical therapy discharge summary, stated that upon discharge (9/17/10) the resident was able to ambulate 50 feet with one to two rest periods and required only contact guard assistance. Physical therapist "BB" stated that the resident should have been able to participate with ambulation with the restorative aide. 2015-07-01
9392 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 160 B 0 1 FOKJ11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, it was determined that the facility failed to, upon the death of two residents, convey the personal funds deposited with the facility within 30 days to the individual or probate jurisdiction administering the residents' estates in a total of six closed records of residents who had expired at the facility. Findings include: 1. One resident expired at the facility on [DATE]. However, his/her remaining personal funds of $79.72 were not conveyed until [DATE] (65 days). Those funds were conveyed to a funeral home and not to the individual or probate jurisdiction administering the resident's estate. During an interview on [DATE] at 2:30 p.m., the facility's bookkeeper who handled the patient trust accounts, stated that the facility had been unable to reach the resident's brother to see where to send the check for the resident's remaining personal funds. There was no evidence in the resident's record that the facility had attempted to make contact with the brother. 2. The second resident expired at the facility on [DATE]. However, his/her remaining personal funds of $191.30 were not conveyed until [DATE] (69 days). During an interview on [DATE] at 2:30 p.m., the facility's bookkeeper stated that the facility had been waiting on notification from Medicaid as to what the resident's liability would cost before releasing his/her personal funds. 2015-07-01
9393 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 253 D 0 1 FOKJ11 Based on observations, it was determined that the facility failed to maintain a clean and intact shower stall in one of the two common bath areas (South) and failed to properly seal one air conditioner unit to the wall in one resident room (room 228). Findings include: 1. During the environmental tour on 9/23/10 at 11:20 a.m., there were several areas with a black/brown substance on the tile wall at the back of the first shower stall in the South Hall common bath. There was a broken wall tile at the base of the wall between shower stalls. There were red stained wall tiles below the faucet in one shower stall. 2. The air conditioning unit in room 228 was not secured to the wall which left approximately an one inch gap along the top of the unit. 2015-07-01
9394 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 156 B 0 1 FOKJ11 Based on record review and staff interview, it was determined that the facility failed to provide three residents (#17, #18 and #19) with a Skilled Nursing Facility Advance Beneficiary Notice prior to the discontinuation of skilled services paid for by Medicare Part A. Findings include: According to the Centers for Medicare and Medicaid Services (CMS), a 'Skilled Nursing Facility Advance Beneficiary Notice' (CMS-1055 form) should be given to a Medicare beneficiary or to his/her authorized representative before extended care services or items are reduced or terminated when the nursing facility believes that Medicare will not pay for, or will not continue to pay for services that the nursing facility furnishes and that a physician ordered. However, the facility failed to provide the written notice prior to the discontinuation of skilled services for residents #17, #18 and #19. 1. The facility believed that continued skilled services for resident #17 would not be paid for by Medicare effective 8/17/09. However, the 'Skilled Nursing Facility Advance Beneficiary Notice' was not signed by the responsible party until 8/25/09. During an interview on 9/23/10 at 3:30 p.m., the facility's bookkeeper stated that the family member, who was the authorized representative for the resident, visited the nursing home every day. However, the bookkeeper had no explanation as to why the notice was not signed until 8/25/09 (eight days after discontinuation of services). 2. The facility believed that continued skilled services for resident #18 would not be paid for by Medicare effective 7/19/10. However, the 'Skilled Nursing Facility Advance Beneficiary Notice' was not signed by the resident's authorized representative until 7/23/10 (4 days after discontinuation of services). During an interview on 9/23/10 at 3:30 p.m., the facility's bookkeeper stated that the notice had been mailed but, had not been returned to the facility until 7/23/10. She had no evidence as to when the notice had been mailed to the resident's authorized representa… 2015-07-01
9395 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 318 D 0 1 FOKJ11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, it was determined that the facility failed to assess one resident (#4) for the use of a device that would help to prevent the increase of contractures of his/her hand from a sample of five residents with limited range of motion from a total sample of 19 residents. Finding include: Resident #4 had [DIAGNOSES REDACTED]. On 11/10/09, the resident was assessed by the Occupational Therapist (OT) as having the 4th and 5th digits of his/her right hand in flexion (being contracted)and digging into his/her palm. The resident received Skilled Occupational therapy from 11/10/09 until 12/21/09 and then was discharged to the Restorative Nursing Program. The "Functional Program" on the OT discharge note included that the resident use a right palm guard with finger separators. The "Restorative Intervention Plan" which began on 12/22/09 included that the resident receive passive range of motion exercises and a splint or brace application six times a week to limit contractures of his/her right hand. However, staff's documentation on that form noted that the resident refused those services for 12 of the 24 times. On the back of the form there were two documented times that the resident fought the staff and refused care. Staff further noted on 1/4/10 that the resident was discharged from the Restorative Nursing program because of not cooperating or allowing range of motion exercises or splinting. However, there was no further assessment for the use of a less restrictive device for preventing further digging into the resident's palm because of the contractures of his/her 4th and 5th digits of his/her right hand. There was no evidence that restorative staff had notified the occupational therapist about the resident's refusal of planned care. The resident was observed on on 9/22/10 at 10:00 a.m. His/Her right hand was in a curled position. CNA "HH," who was providing care for the resident at that time, ask… 2015-07-01
9396 OXLEY PARK HEALTH AND REHABILITATION 115387 181 OXLEY DRIVE LYONS GA 30436 2010-09-23 281 G 0 1 FOKJ11 Based on observation, staff interview and record review, it was determined that licensed nursing staff and restorative nursing staff failed to share information about one resident ' s (#13) complaints of pain during range of motion exercises and failed to adequately supervise the provision of restorative services to ensure compliance with the " Functional Program " for one resident (#13) in a total sample of 19 residents. This failure resulted in harm for resident #13. Findings include: Resident #13 had been on a " Functional Program " since 7/6/10 for restorative nursing staff to provide active range of motion exercises for both of the resident ' s legs six times a week as tolerated while he/she was seated in a wheelchair. The resident ' s care plan since 6/7/10 included his/her risk for general aches and pains. The goal was that the resident would be given pain medications as needed to relieve pain with an intervention for pain assessment. On 9/23/10 at 11:05 a.m., restorative aide " KK " provided passive range of motion exercises to the resident ' s legs and arms while the resident was lying in the bed which was not according to the planned " Functional Program. " During that observation, the resident yelled out at two separate times when " KK " flexed the resident ' s right knee. " KK " stated at that time that the resident had complained about right leg pain during range of motion exercises since he/she began the functional program on 7/5/10. " KK " stated, at that time, that she had notified the nurses about the resident ' s complaints of pain. However, during interviews with a licensed nurse on 9/23/10 at 11:50 a.m., and with a registered nurse on 9/23/10 at 12:50 p.m., they denied having been made aware of the resident having complained of pain during exercises. During an interview with the supervisory nurse for the restorative program, she stated that she had not been notified about the resident ' s complaints of pain during range of motion exercises. The pain assessments done by licensed nursing staff t… 2015-07-01
9544 JEFFERSONVILLE HEALTH & REHAB 115413 113 SPRING VALLEY DRIVE JEFFERSONVILLE GA 31044 2010-09-23 329 D 0 1 2O3N11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the systolic blood pressure (SBP) was monitored daily prior to administration of the antihypertensive medication, [MEDICATION NAME], for one (1) resident (#12) from a sample of twenty-four (24) residents. Findings include: Review of the physician's orders [REDACTED]. Review of the Medication Administration Records (MARs) for April, 2010-September, 2010 revealed the following: May, 2010, there were five (5) occasions when the systolic blood pressure was less than 120 and the medication was given; June, 2010, there were nine (9) times when the systolic blood pressure was less than 120 and the medication given; July, 2010 three (3) occasions when the blood pressure was not monitored at all and the medication given; August, 2010, there were three (3) occasions when the blood pressure was not monitored prior to administration of the medication and nine (9) times when, the systolic blood pressure was less than 120, but the medication was given; September 1-September 22, 2010, two (2) times when the blood pressure was not taken; and six (6) times when the systolic blood pressure was below 120 and the medication was given. Interview with the Director of Nursing (DON) on 9/22/10 at 3:08 pm, revealed that there was no evidence that the resident's blood pressure was being monitored appropriately and/or consistently by the staff. 2015-06-01
9545 JEFFERSONVILLE HEALTH & REHAB 115413 113 SPRING VALLEY DRIVE JEFFERSONVILLE GA 31044 2010-09-23 157 D 0 1 2O3N11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the physician of a change in condition or for non administration of a physician ordered medication for two (2) residents (#8 and #12) from a sample of twenty-four (24) residents. Findings include: 1. Review of the clinical record for resident #8 revealed the resident was prescribed [MEDICATION NAME] 75 milligrams (mg.) and Aspirin 81 mg., both medication with blood thinning properties, each day for a [DIAGNOSES REDACTED]. There was no evidence that the physician was notified to determine if a change in treatment was required. Interview with the Director on Nursing on 09/22/10 at 11:05 a.m. revealed that there was no evidence that the physician was notified about the nose bleeds. 2. Review of the physician's orders [REDACTED]. Review of the April, 2010 Medication Administration Record [REDACTED]. There was no evidence that the physician had been notified that the medication had not been given in April. Interview with the DON on 9/22/10 at 3:40 pm revealed that there was no evidence that the physician had been notified that the [MEDICATION NAME] was not administered during the month of April, 2010. 2015-06-01
9546 JEFFERSONVILLE HEALTH & REHAB 115413 113 SPRING VALLEY DRIVE JEFFERSONVILLE GA 31044 2010-09-23 309 D 0 1 2O3N11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to follow physician orders [REDACTED].#95, #8 and #12) from a sample of twenty-four (24)residents. Findings include: 1. Review of the Medication Administration Record (MAR) for resident # 95, revealed a current physician's orders [REDACTED]. There was no evidence that the medication was administered at 12:00 p.m. on 9/21/10.. During an interview with Licensed Practical Nurse "DD" on 09/22/10 at 8:30 a.m., she revealed that she had missed giving the medication for 09/21/10 at 12:00 p.m. 2. Review of the clinical record for resident #8 revealed a current physician's orders [REDACTED]. twice a day and at bedtime. Continued review revealed that on 6/29/10 a critically high [MEDICATION NAME] level of 38.8 mcg/ml (normal range 10 - 20 mcg/ml) was reported by the laboratory and the results were reported to the physician. On 6/30/10, the physician ordered that the medication be held for two (2) days. Review of the MAR for June and July 2010 revealed the day time medication was held but the evening dose for 6/30/10 and 7/01/10 was documented as administered to the resident. Further review of the clinical record revealed that on 9/13/10 a critically high [MEDICATION NAME] level of 36.7 mcg/ml was reported by the laboratory and the facility notified the physician. On 9/14/10 the physician ordered that the medication be held for three (3) days. Review of the MAR for September, 2010 revealed that again the daytime medication doses were held but the bedtime doses were documented as administered to the resident on 9/14, 9/15 and 9/16/10. Interview with the Director of Nursing (DON) on 9/22/10 at 10:30 a.m. revealed that the medication was documented as given contrary to the physician's orders [REDACTED]. 3. Review of the clinical record for resident #12 revealed that the resident was readmitted to the facility in March, 2010 with [DIAGNOSES REDACTED].. Review of the physician ord… 2015-06-01
9547 JEFFERSONVILLE HEALTH & REHAB 115413 113 SPRING VALLEY DRIVE JEFFERSONVILLE GA 31044 2010-09-23 372 C 0 1 2O3N11 Based on observation and staff interview , the facility failed to ensure that waste was properly contained in two (2) of two (2) dumpsters.. Findings include: Observation on 9/22/10 at 12:00 pm revealed two (2) green dumpsters side by side enclosed by a fence. Neither of them had a plug and a strong, foul, lingering odor was present. The dumpster on the left side had the right flap open; and on the ground, to the left near the fence was a pair of latex gloves. The dumpster on the right side had the top right flap open and was topped high and running over with bags of trash and boxes. On the front corner of this dumpster was a pair of latex gloves. Observation on 9/23/10 at 10:03 am revealed that the two (2) dumpster had white plugs in them, but a strong lingering odor remained. The dumpster on the left had a large black trash bag sticking out above the rim of the dumpster preventing closure. The dumpster on the right, with the split top, contained overflowing boxes preventing closure. There was one (1) white bag of trash in the back corner of the right dumpster. Interview with the Administrator on 9/22/10 at 2:58 pm revealed that a new company had taken over about two-three (2-3) weeks ago from the city and that pick up was Monday and Friday. She indicated that during the holiday week she did have to call for an extra pick up. Continued interview revealed that she was unaware of the debris on the ground and the missing plugs. The Administrator revealed that several unsuccessful attempts had been made to contact the trash company to increase the pick up at the facility. 2015-06-01
9548 JEFFERSONVILLE HEALTH & REHAB 115413 113 SPRING VALLEY DRIVE JEFFERSONVILLE GA 31044 2010-09-23 371 F 0 1 2O3N11 Based on observation, record review and staff interview the facility failed to store and prepare food under sanitary conditions for all residents consuming food (total = 74). Findings include: Observation of the kitchen on 09/20/10 at 10:45 a.m. revealed milk was stored in the walk in cooler above exposed cabbage and onions. The Dietary Manager (DM) reorganized these foods so they were stored properly. Observation of the kitchen on 09/21/10 at 11:30 a.m. revealed the dishmachine contained a rack with a large pot. When the machine was operated by staff the wash and rinse temperatures reached 120 degrees Fahrenheit (F) as required but the chlorine sanitizer did not register on the test strips when checked by staff. The dishmachine was operated through complete wash and rinse cycles three (3) times and no sanitizer registered on the test strip. The DM was present at this time and called repair person. Review of a service receipt dated 9/21/10 provided by the Administrator revealed the repair company changed the tubing on the sanitizer bucket. Continued observations revealed a Styrofoam cup with ice and fluid on a preparation counter without a lid. In the dry storage area, a closed closet approximately four (4) feet wide and two (2) feet deep contained many stored food items including cereal, soup, cake mix, gravy mix and dry milk, on the floor of this closet was a multitude of rodent droppings. The floor had an accumulation of debris such as papers, plastic, dirt and a puddle of a sticky substance. Further observations revealed a shelf unit that contained chemicals in a small hallway between the kitchen and the staff bathroom. The floor was very dirty and approximately two (2) inches of debris, including paper and dirt, appeared to be pushed up against the back wall. An accumulation of dirt and debris was under the reach in cooler. Review of the cleaning schedule revealed staff had signed the form that the floors had been clean as of 9/19/10. Interview with the DM on 9/22/10 at 3:50 p.m. revealed she thought hot foo… 2015-06-01
9549 JEFFERSONVILLE HEALTH & REHAB 115413 113 SPRING VALLEY DRIVE JEFFERSONVILLE GA 31044 2010-09-23 502 D 0 1 2O3N11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that laboratory tests were completed as ordered by the physician for one (1) resident (# 8) from a sample of twenty-four (24) residents. Findings include: Review of the physician's orders [REDACTED]. On 6/29/10 a critically high [MEDICATION NAME] level of 38.8 mcg/ml (normal range 10 - 20 mcg/ml) was reported by the laboratory and the results were reported to the physician. On 6/30/10, the physician, after making adjustments to the medication, ordered a [MEDICATION NAME] level be done on 7/02/10. There was no evidence that the laboratory test was done until 7/07/10. Continued review of the clinical record revealed that on 9/13/10 a critically high [MEDICATION NAME] level of 36.7 mcg/ml was reported by the laboratory and the facility notified the physician. On 9/14/10 the physician ordered that the medication be held for three (3) days and repeat the [MEDICATION NAME] level. There is no evidence that the test was completed until 9/22/10. Interview with the Director of Nursing on 9/22/10 at 10:30 a.m. revealed that the laboratory tests were not completed as ordered. 2015-06-01
9550 JEFFERSONVILLE HEALTH & REHAB 115413 113 SPRING VALLEY DRIVE JEFFERSONVILLE GA 31044 2010-09-23 428 D 0 1 2O3N11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that appropriate recommendations for dose reductions were made for for one (1) resident (# 17) from a sample of twenty-four (24) residents. Findings include: Review of the clinical record for resident #17 revealed a physician's orders [REDACTED]. Review of the Drug Regimen Review, performed by the consultant pharmacist, revealed that a gradual dose reduction was recommended on 6/29/09. The physician responded timely and ordered the medication to remain at the dose of 10 mg. each evening. There was no evidence that the consultant pharmacist had recommended a gradual dose reduction for this medication since 6/2009 as required. Interview with the Director of Nursing on 9/23/10 at 12:05 p.m. revealed the pharmacist had intended to review this resident's medications in August 2010 but did not. 2015-06-01
9551 JEFFERSONVILLE HEALTH & REHAB 115413 113 SPRING VALLEY DRIVE JEFFERSONVILLE GA 31044 2010-09-23 279 B 0 1 2O3N11 Based on record review and staff interview the facility failed to develop a care plan for activited that included approaches related to unsupervised community activities for two (2) residents (# 15 and #17) from a sample of twenty-four (24) residents. Findings include: 1. Review of the clinical record for resident #17 revealed Social Service Progress Notes dated 01/27/10 and 4/20/10 indicating that the resident signs out and ambulates around the community unsupervised. Review of the care plan for resident #17 revealed a care plan that addressed activities including that the resident had a strong preference to be out in the community. There were no approaches that specifically addressed this activity. Interview with a Certified Nurses Assistant on 9/21/10 at 4:05 p.m. revealed this resident leaves the facility and walks around in the community. 2. Review of the care plan for resident #15 revealed a care plan that addressed activities including that the resident goes out into the community. There were no approaches that specifically addressed this activity. Interview with the Administrator on 9/22/10 at 3:00 p.m. revealed that she was aware that these residents leave the facility to walk around the community. Continued interview revealed that they are required to sign in and out and both residents are compliant. Review of the sign in/out sheet revealed that both resident sign in and out when leaving the facility. 2015-06-01
9552 JEFFERSONVILLE HEALTH & REHAB 115413 113 SPRING VALLEY DRIVE JEFFERSONVILLE GA 31044 2010-09-23 322 D 0 1 2O3N11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to administer the appropriate amount of flush, as prescribed by physician, for one (1) resident (#18) with a gastric tube from a sample of twenty-four (24) residents. Findings include: Observation during medication pass of Licensed Practical Nurse (LPN) "CC" on 9/22/10 at 5:48 p.m. for resident #18 revealed that the LPN "CC" administered 50 cubic centimeters (cc) of water flush through the gastric tube, turned away from the resident and then turned back and administered another 50cc of water flush, for a total of 100 cc.. Review of the medical record for resident #18 revealed a physician's orders [REDACTED]. During an interview with LPN"CC" on 09/22/10 at 5:53 , he revealed that he did not know what amount of fluid was to be administered. Continued interview revealed that he had given only 100 c of water instead of the ordered 200cc 2015-06-01
9553 JEFFERSONVILLE HEALTH & REHAB 115413 113 SPRING VALLEY DRIVE JEFFERSONVILLE GA 31044 2010-09-23 325 G 0 1 2O3N11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to provide nutritional interventions for two residents (#89 and #95) from a sample of twenty-four (24) residents. This failure resulted in actual harm for one (1) resident (#89) Findings include: 1. Review of the medical record for resident # 89 revealed [DIAGNOSES REDACTED]. Continued review revealed that the resident demonstrated behaviors of frequent pacing, agitation, confusion, and resistance to care at times. Review of the Registered Dietician's admission assessment revealed that the resident was sixty seven inches tall and her target weight was 121 to 149 pounds (lbs). Upon admission on 01/08/10 her weight was at 119 lbs. Review of the resident's weights over six (6) months revealed the following: 04/01/10=124 lbs, 05/07/10= 121.40lbs., 06/03/10=119 lbs., 07/02/10=114.60lbs., 08/02/10=111.40 lbs. and 09/07/10=112.40 lbs. Calculation of weight loss over a three (3) month period from 05/07/10 to 08/02/10 revealed an eight (8) percent weight loss. Any percentage over 6% over three (3) months is considered as a significant weight loss. Review of the Dietary Manager's calculations and notes for August, 2010 weight loss revealed knowledge of the 8% weight loss. There was no evidence that an intervention related to this significant weight loss had been recommended or that the Registered Dietician (RD) had been alerted of this significant weight loss. Review of the RD notes revealed that the last note was dated 7/09/10. Review of the Nursing Risk Management notes revealed a meeting on 08/03/10 with documentation revealing a weight loss of 8% in three (3) months with no interventions other than to monitor and encourage to eat and drink. Continued review revealed notes dated 08/11/10 and 08/19/10 to continue weekly weights. On 08/26/10 a note indicated that weekly weights were to be discontinued and resident monitored monthly and on 09/10/10 the team meeting noted a we… 2015-06-01
9621 CANTON NURSING CENTER 115606 321 HOSPITAL ROAD CANTON GA 30114 2010-09-23 241 E 0 1 4S5R11 Based on observations and staff interview the facility failed to promote dignity during dining for five (5) residents, randomly observed during a meal and three (3) residents (#130, #47, and #135) from a sample of twenty-seven(27) residents. Findings Include: a. Dining observations conducted 9/20/2010 at 12:40pm revealed facility staff was observed asking residents if they wanted cloth protector placed on them. Five (5) residents stated they did not want them. Continue observations of this same meal at 12:50 p.m., Certified Nursing Assistant (CNA) "CC" came into the dining room and began placing cloth protectors on residents without asking the residents if they wanted protectors. The five (5) residents that had earlier indicated that they did not want a cloth protector had a protector placed on them by "CC" without asking for permission. One (1) of the five (5) residents was in the midst of eating when "CC" interrupted her to place the cloth protector on her. Interview conducted 9/20/2010 at 1:07pm with CNA "CC" revealed that she was train to tell the residents that she is about to place a cloth protector on them because they are going to mess up their clothes. Interview with staff development "AA" conducted 9/21/2010 at 8:14 a.m. revealed that facility staff are trained to always ask residents if they would prefer a cloth protectors if they are alert and if the resident is not alert to apply the cloth protectors. b. Observation conducted 9/21/2010 at 8:30am revealed resident #130 were seated at a dining table with one other resident. Resident #130 table mate received her tray at 8:05am and Resident # 130 did not receive his meal until 8:24am.. Resident #130 attempted to leave the dining room before receiving his meal. Staff continued to inform the resident that his meal tray would be out soon. Interview with "AA" and CNA "DD" on 9/21/2010 at 8:30am revealed that resident #130 eat his breakfast in dining room every morning and is an early arrival, however, his tray is placed on the third cart which is served arou… 2015-06-01
9898 GRACEMORE NURSING AND REHAB 115554 2708 LEE STREET BRUNSWICK GA 31520 2010-09-23 322 D 0 1 ZUT111 **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 one (#6) of four sampled residents with feeding tubes received the correct amount of feeding as ordered by the physician from a total sample of 14 residents. Findings include: Resident #6 had a current physician's orders [REDACTED]. feeding was still infusing. During an interview on 9/22/10 at 8:30 a.m., licensed nurse "TT" stated that he/she did not know why the resident's tube feeding was still infusing. Review of the clinical record, Medication Administration Record [REDACTED] 2015-04-01
9899 GRACEMORE NURSING AND REHAB 115554 2708 LEE STREET BRUNSWICK GA 31520 2010-09-23 371 F 0 1 ZUT111 Based on observation and staff interview, it was determined that the facility failed to ensure that the high temperature dishwasher was properly functioning to effectively destroy potential food borne illness. Findings include: During an observation of dietary staff washing dishes in the high temperature dishwasher on 9/23/10 at 8:20 a.m., the rinse cycle only reached 150 degrees Farenheit (F.). During an interview with the dietary manager at that time, she stated that the rinse cycle should reach 180 degrees F. (to effectively rinse dishware). 2015-04-01
9966 GRACEWOOD NSG FACILITY(UNIT 9) 11A200 100 MYRTLE BLVD., EAST CENTRAL REG HOSP GRACEWOOD GA 30812 2010-09-23 371 F 0 1 C3EB11 Based on observation, record review, review of facility policy, and staff interview the facility failed to store, prepare and serve food under sanitary conditions. This was evidenced by: storing pots and utensils that were dirty and wet; improper storage of food scoops; not ensuring that walk-in refrigerators were clean; not repairing water leaks; maintaining potentially hazardous hot food food on the steam table below 135 degrees Fahrenheit; improper storage of baking pans; improper functioning of the dishwashing machine; and lack of sanitizer in the manual 3 compartment sink. This failure affected all residents who were fed orally. Findings include: Observation on 9/21/10 between 10:00 a.m.-11:30 a.m. with the Dietary Manager revealed the following concerns: 1. Three of six serving ladles were stored wet; 1 of 2 scoops was stored dirty and wet; 6 large baking pans were stored wet. 2. A large storage unit of sugar contained a scoop with the handle touching the product. 3. The walk-in meat refrigerator had a very strong foul odor. Interview at that time with the dietary staff who maintained this area revealed that the area is cleaned daily. However, review of the facility's Central Kitchen Cleaning Checklist for the Meat Room revealed that the last cleaning verification was signed on 7/26/10. 4. Observation of the tray line at the beginning of the lunch meal on 9/21/10 revealed that the Dietary Manager calibrated her thermometer and obtained the following temperatures from food being held on the steam table: Pureed beets 100 degrees Fahrenheit (F) Pureed green beans 100 degrees F Pureed carrots 100 degrees F Ground carrots 98 degrees F Ground noodles 118 degrees F Pureed noodles 112 degrees F Pureed beef 130 degrees F Review of the food temperature log for 9/21/10 for the lunch meal revealed that dietary staff had only checked the temperature of three (3) food items on the steam table. 5. Observation of the dishwashing machine with the Food Service Supervisor on 9/22/10 at 8:00 a.m. revealed the following: The ma… 2015-04-01
9967 GRACEWOOD NSG FACILITY(UNIT 9) 11A200 100 MYRTLE BLVD., EAST CENTRAL REG HOSP GRACEWOOD GA 30812 2010-09-23 372 F 0 1 C3EB11 Based on observation, review of facility policy and staff interview the facility failed to ensure that areas around refuse containers were clean and free of foul odors to prevent harborage of pests. Findings include: Observation on 9/21/10 between 10:00 a.m.-11:30 a.m. with the Dietary Manager revealed the following concerns: One (1) of two (2) trash compactors located in a parking area behind the loading dock had a stream (about 9 feet long) of a dark foul smelling liquid that also contained some unknown debris. The Dietary Manager indicated that the bottom of one of the trash compactors had been leaking and needed to be replaced. This replacement occurred several days ago, but the area around the compactor had not been cleaned. The top of the waste oil container (located in the same parking area) had a pool of oil that contained food debris. Review of the facility's Clean Parking Area policy revealed that it would be hosed down daily. This was not done. 2015-04-01
9968 GRACEWOOD NSG FACILITY(UNIT 9) 11A200 100 MYRTLE BLVD., EAST CENTRAL REG HOSP GRACEWOOD GA 30812 2010-09-23 469 F 0 1 C3EB11 Based on observation, record review and staff interview the facility failed to maintain an environment that is free from pests. This failure affected all residents who were served food prepared in the kitchen and who were fed in the dining area on Unit 1. Findings include: Observation with the Dietary Manager and Food Service Supervisor in the kitchen on 9/20/10, between 11:15 a.m.- 11:40 a.m., 9/21/10, between 10:00 a.m.-11:30 a.m. and 9/22/10 between 8:00 a.m.- 9:00 a.m. revealed live roaches on the steam table, other food preparation surfaces, walls and floor. Review of the facility's pest extermination contract revealed the contract was valid until until 6/30/13. According to this contract, the kitchen was scheduled for two (2) service treatments per month to address an infestation of German Roaches. Interview with the Dietary Manager (DM) on 9/21/10 at 10:00 a.m. revealed roaches in the kitchen area had been an on-going problem. She added that the most recent extermination service for the kitchen was provided on 9/08/10. However, the tray line area continues to be heavily populated with roaches. During dining observation on 9/20/10 at 12:45 p.m. in Unit 1 dinning area, three (3) large roaches were observed on the floor of the dinning area while four (4) resident's were being fed lunch by staff. An interview with Registered Nurse "RR" at this time revealed that the exterminator had sprayed about three (3) days ago. The meal trays were delivered on a rolling cart from the main kitchen. A large gap was noted at the bottom and top of the outside door located in the dinning room. Observation on 9/22/10 at 4:45 p.m. of the Unit 1 shower room revealed several small bugs crawling on the shower table. Observation on 9/22/10 at 4:15 p.m. of resident room 267 revealed a small bug crawling on the hand washing sink. 2015-04-01
9969 GRACEWOOD NSG FACILITY(UNIT 9) 11A200 100 MYRTLE BLVD., EAST CENTRAL REG HOSP GRACEWOOD GA 30812 2010-09-23 281 G 0 1 C3EB11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide services that met professional standards of quality. This was evidenced by the failure to clarify with the physician the urgency of providing x-ray services to rule out a possible fractured extremity resulting in harm for one (1) resident #23 of twenty one (21) sampled residents. Findings include: Record review revealed that resident #23 had a Health Note dated 3/02/10 at 7:00 a.m., indicating that nursing staff noted swelling of the right upper thigh and knee, with a light brown discoloration below the knee. It also indicated that the right lower extremity was warm to touch. Based on facility assessments (MDS, dated [DATE]) the resident was unable to communicate or make her needs known and was totally dependent on staff for all activities of daily living. Review of a physician's orders [REDACTED]. Review of a Health Note dated 3/02/10 at 10:00 a.m. revealed the nurse indicated that the x-ray would be done on 3/03/10, 24 hours after the injury was identified. In an interview on 9/22/10 at 11:00 a.m. with Licensed Practical Nurse (LPN) "AA" she acknowledged the physician's orders [REDACTED]. She added that since the physician did not request "stat" (immediate) x-rays she accepted that date without question. The nurse did not clarify with the physician the urgency of obtaining the x-rays sooner than 3/03/10. The Registered Nurse (RN) Manager was also present at the time of the interview with this LPN and later indicated that because of the resident's condition she would have expected the LPN to report the 24 hour delay of x-ray services to the RN Manager for further guidance. This was not done. The RN Manager acknowledged that other arrangements could have been made to have the x-ray services provided in a timelier manner. Standards of Practice for Licensed Practical Nurses-- In accordance with 2.3.2 Standards Related to Licensed Practical Nurses: The licensed practical n… 2015-04-01
9970 GRACEWOOD NSG FACILITY(UNIT 9) 11A200 100 MYRTLE BLVD., EAST CENTRAL REG HOSP GRACEWOOD GA 30812 2010-09-23 309 G 0 1 C3EB11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that, residents were closely monitored for acute pain, following a new injury. This was evidenced by the failure to assess for potential pain for one (1) resident #23 following a leg injury and resulted in harm to the resident. The sample size was twenty one (21) residents. Findings include: Record review revealed that resident #23 was [AGE] years old, non-verbal and has [DIAGNOSES REDACTED]. Further record review revealed a Health Note dated 3/02/10 at 7:00 a.m., indicating that nursing staff noted swelling of the right upper thigh and knee and lower leg area, with a light brown discoloration below the knee. It also indicated that the right lower extremity was warm to touch. Review of a Health Note dated 3/03/10 at 2:00 a.m. indicated the resident's right lower extremity was painful to touch when assessed. In another note dated 3/03/10 at 3:00 a.m. nursing staff indicate the resident's right leg is tender to touch. In the Health Note dated 3/03/10 at 5:30 a.m. nursing staff indicate the resident was transported to the hospital emergency room via ambulance and determined to have sustained a fractured tibia and fibula. Record review revealed the resident had a physician orders [REDACTED]. Review of the resident's March 2010 Medication Administration Record [REDACTED]. The first dose of [MEDICATION NAME] was administered nine (9) hours after the injury was identified. There was no documentation that the resident was being monitored and assessed more closely for potential pain during that nine (9) hour period. This was confirmed in an interview with the Registered Nurse Manager on 9/22/10 at 3:30 p.m. 2015-04-01
9971 GRACEWOOD NSG FACILITY(UNIT 9) 11A200 100 MYRTLE BLVD., EAST CENTRAL REG HOSP GRACEWOOD GA 30812 2010-09-23 225 G 0 1 C3EB11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to have evidence that injuries of unknown source were thoroughly investigated. This was supported by the failure to interview all staff who may have been in contact with/or witnessed an incident related to the fractured tibia and fibula of one (1) resident #23 of twenty one (21) sampled residents. The failure to conduct a thorough and complete investigation of an injury of unknown origin resulted in harm to resident #23. Findings include: Record review revealed that resident #23 was [AGE] years old, non-verbal and has [DIAGNOSES REDACTED]. The annual MDS, conducted 11/10/09, assessed the resident as having severely impaired cognitive skills, unable to make needs known and totally dependent on staff for all care and activities of daily living. The resident was also assessed as requiring 2 persons or more for positioning, transfers and lifting. Further record review revealed a Health Note dated 3/02/10 at 7:00 a.m., indicating that nursing staff noted swelling of the right upper thigh and knee and lower leg area, with a light brown discoloration below the knee. It also indicated that the right lower extremity was warm to touch. Review of the facility's Investigative Report dated 3/05/10 revealed that on 3/03/10 the resident was sent to the emergency room (ER) for evaluation of the swelling and discoloration of the right lower extremity. The ER confirmed that the resident sustained [REDACTED]. This Investigative Report also had a Summary of Interviews. In addition, the Registered Nurse Manager provided an attachment of five (5) statements from Certified Nursing Assistants and one (1) from an Occupational Therapy Technician who worked either first or second shift. However, there was no evidence of interviews or inquiries from staff who worked third shift (11:00 p.m.-7:00 a.m.) the morning the injury was discovered. An interview on 9/22/10 at 3:15 p.m. with the Registered Nurse Manager… 2015-04-01
9972 GRACEWOOD NSG FACILITY(UNIT 9) 11A200 100 MYRTLE BLVD., EAST CENTRAL REG HOSP GRACEWOOD GA 30812 2010-09-23 441 D 0 1 C3EB11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the nurse failed to clean the stethoscope after direct contact on resident #14 abdomen and proceeded to use the same stethoscope making direct contact with resident #23. The sample included twenty-one (21) residents. The findings included: During observation of medication pass on 9/22/10 at 8:21 a.m. LPN "GG" used the diaphragm of the stethoscope placing it on the abdomen of resident #14 when checking for placement of the gastrostomy tube ([DEVICE]). LPN "GG" took the stethoscope and hung it on the side of the medication cart. At 8:50 a.m. LPN "GG" removed the same stethoscope from the medication cart. The nurse did not clean the diaphragm of the stethoscope and proceeded to place it on the abdomen of resident #23 to check the placement of the [DEVICE]. Interview with LPN "GG" on 09/22/10 9:57 a.m. revealed the nurse confirmed she did not clean the stethoscope and used it for both residents. 2015-04-01
9973 GRACEWOOD NSG FACILITY(UNIT 9) 11A200 100 MYRTLE BLVD., EAST CENTRAL REG HOSP GRACEWOOD GA 30812 2010-09-23 322 E 0 1 C3EB11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interview that facility failed to ensure that nursing staff checked gastric ([DEVICE]) tube placement before administering medications for six (6) residents (#12, 14, 17, 21, 22, and 28) and failure to administered medication through the NG tube by gravity flow for two (2) residents (#4 and 37). There were twenty four (24) of thirty two (32) residents on nasogastric feedings. Findings include: During observation of medication administration on 9/22/10 at 7:58 a.m. with Licensed Practical Nurse (LPN) "QQ" for resident #22, and at 8:25 a.m. for resident #28, who receive feeding and medication through a gastric tube, revealed that LPN "QQ" did not check placement of the [DEVICE] prior to administration of medications. Review of the facility policy and procedure for giving medications through a feeding tube revealed that the LPN should check placement before giving medications and that medications giving via a [DEVICE] should be allowed to flow by gravity. An interview with the Nurse Manager and the Assistant Director of Nursing on 9/22/10 at 12:05 p.m. revealed that placement should be checked by injecting a small amount of air into the tube then checking for bowel sounds with a stereoscope. She does not know why this was not done. During observation of medication pass on 9/21/10 at 3:40 pm for resident #37, LPN "HH"did not use a gravity method to administer the medications. The nurse injected all medications with a syringe. Observation on 9/21/10 at 3:52 pm revealed LPN "HH" did not use a gravity method to administer medications via the [DEVICE] to resident #4. Observation during medication pass on 9/21/10 at 4:05 pm revealed RN "II" did not ascultate to check placement of the [DEVICE] (resident #17) according to the facility's policy. At 4:25 pm LPN "II" did not ascultate to check placement of the [DEVICE] for resident #21. During medication pass on 9/22/10 at 8:07 am LPN "JJ" did not check place… 2015-04-01
10391 MIONA GERIATRIC & DEMENTIA CENTER 115338 201 POPLAR STREET IDEAL GA 31041 2010-09-23 365 J 1 0 9E5H11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident medical record review, staff interview, resident interview, and facility investigative summary review, the facility failed to ensure that one (1) resident (#1), on the survey sample of five (5) residents, was served a pureed diet, in accordance with a physician's pureed diet order and facility policy. Resident #1, who had a [DIAGNOSES REDACTED]. This failure to provide food prepared in a pureed consistency resulted in the likelihood of serious harm to this resident. It was therefore determined that an immediate and serious threat to resident health and safety existed on September 15, 2010, and was removed on September 23, 2010, at which time the facility took action to remove the immediate jeopardy. Findings include: Record review for Resident #1 revealed a Minimum Data Set assessment of 07/16/2010 which documented that the resident had a swallowing problem. The resident's Care Plan documented an admission date of [DATE], and documented that the resident had [DIAGNOSES REDACTED]. A Care Plan entry of 01/20/2010 indicated as a Problem/Need that the resident had difficulty swallowing, and also documented the resident's [DIAGNOSES REDACTED]. Approaches for this problem included to provide and serve the resident's diet as ordered. A September 2010 Medication Orders sheet referenced a physician's orders [REDACTED]. A Nurse's Note of 09/15/2010 at 7:50 p.m. documented that a licensed nurse administered the resident's medications with water without difficulty. A 09/15/2010, 8:10 p.m. Nurse's Notes entry documented that the nurse glanced at the resident and noted the resident to be cyanotic around the mouth and in respiratory distress. This Note documented that the nurse called for assistance from two (2) other nurses and a certified nursing assistant (CNA). A 09/15/2010, 8:15 p.m. Nurse's Notes entry again noted that the resident was in respiratory distress, and also documented that the resident was non-verbal and trying to breathe… 2014-07-01
10494 OAKS - BETHANY SKILLED NURSING, THE 115705 1305 EAST NORTH STREET VIDALIA GA 30475 2010-09-23 323 K 1 0 KDKL11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident medical record review, facility Incident Report review, review of the facility's Fall Occurrence Reduction Program Policy, and staff interview, it was determined that the facility failed to provide adequate supervision, related to repeated resident falls, for four (4) residents (#1, #2, #7, and #8), who had been assessed as being at risk for falls, on a total survey sample of twenty (20) residents. These four (4) residents experienced a total of forty-three (43) falls during the period extending from 03/09/2010 through 08/22/2010, sustaining injuries including hematomas to the head, bleeding from the nostril, eye and cheek swelling, an eyeball hemorrhage, elbow lacerations, and bruising to the hip. Additionally, Residents #1, #2, and #7, all of whom received anticoagulant drug therapy, struck the head a total of five (5) times, two (2) times, and three (3) times, respectively, during these falls. The failure of the facility to appropriately and adequately supervise these residents and implement effective interventions to minimize falls resulted in a situation in which the non-compliance was likely to cause serious injury, harm, impairment, or death for these four (4) residents, and for all residents at risk for falls. It was therefore determined that an immediate and serious threat to resident health and safety existed on April 28, 2010, and was removed on September 23, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Review of the facility's Fall Occurence Reduction Program Policy revealed the policy indicated that all residents would be assessed for their risk for falls upon admission, and then quarterly and upon any decline or improvement in status, residents would be reassessed for their fall risk, with the implementation of the appropriate interventions. However, during an interview conducted with Nurse "EE" on 09/02/2010 at 9:30 a.m., this nurse acknowledged that t… 2014-07-01
10495 OAKS - BETHANY SKILLED NURSING, THE 115705 1305 EAST NORTH STREET VIDALIA GA 30475 2010-09-23 280 K 1 0 KDKL11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident medical record review, facility Incident Report review, review of the facility's Fall Occurrence Reduction Program Policy, and staff interview, it was determined that the facility failed to appropriately review and revise care plans to ensure the ongoing development of effective interventions and approaches to provide adequate supervision related to repeated falls for four (4) residents (#1, #2, #7, and #8), who had been assessed as being at risk for falls, on a total survey sample of twenty (20) residents. These four (4) residents experienced a total of forty-three (43) falls during the period extending from 03/09/2010 through 08/22/2010, sustaining injuries including hematomas to the head, bleeding from the nostril, eye and cheek swelling, an eyeball hemorrhage, elbow lacerations, and bruising to the hip. Additionally, Residents #1, #2, and #7, all of whom received anticoagulant drug therapy, struck their heads a total of five (5) times, two (2) times, and three (3) times, respectively, during these falls. The failure of the facility to reassess and reevaluate these residents and their Plans of Care appropriately to develop interventions and approaches to minimize falls had resulted in a situation in which the non-compliance was likely to cause serious injury, harm, impairment or death for these four (4) residents, and for all residents at risk for falls. It was therefore determined that an immediate and serious threat to resident health and safety existed on April 28, 2010, and was removed on September 23, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Review of the facility's Fall Occurrence Reduction Program Policy revealed the policy indicated that all residents would be assessed for their risk for falls upon admission, and then quarterly and upon any decline or improvement in status, residents would be reassessed for their fall risk, with the implementation of t… 2014-07-01
10572 PRUITTHEALTH - AUGUSTA HILLS 115672 2122 CUMMING ROAD AUGUSTA GA 30904 2010-09-23 282 D     5C5911 Based on record review and staff interview the facility failed to ensure that a care plan related to constipation was followed for one (1) resident ("C") on a sample of twenty seven (27) residents. Findings include: Review of the care plan developed for a problem of constipation for resident "C" included interventions of assess the resident's bowel elimination pattern, monitor for signs and symptoms of constipation such as no bowel movement in three days and to administer laxatives as ordered. Review of the Activities of Daily Living Care Plan Sheet for July 2010 revealed that between 7/15/10 and 7/22/10 (6 days) there was no documentation that the resident was having bowels movements. Interview with the resident's family on 9/22/10 at 10:45 am revealed that the resident was having symptoms of nausea, spitting up as well as abdominal and rib pain during this time and the facility did nothing until they brought it to their attention. Interview with Director of Nursing (DON) on 9/23/10 at 8:55 am revealed that the care plan was not followed related to the resident's bowel elimination problem. Cross refer to F309 2014-04-01
10573 PRUITTHEALTH - AUGUSTA HILLS 115672 2122 CUMMING ROAD AUGUSTA GA 30904 2010-09-23 309 D     5C5911 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and family interview the facility failed to ensure that physician orders [REDACTED]. Findings include: Review of a Nurses Note dated 5/30/10 documented that a resident's ("C") family member requested that the resident be given medications for constipation, a problem the resident had had since admission to the facility. Review of the Physician order [REDACTED]. On 5/31/10 there was a Physician order [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Activities of Daily Living Care Plan sheets for July 2010 revealed there was no documentation that the resident had a bowel movement between 7/16/10 and 7/22/10 (6 days). On 7/22/10 a Physician order [REDACTED]. Review of the August 2010 physician's orders [REDACTED]. The August 2010 MAR documented the [MEDICATION NAME] was given as ordered. The September 2010 Physician order [REDACTED]. A physician's orders [REDACTED].[REDACTED] Interview with the resident's family member on 9/22/10 at 10:45 am revealed that when the facility stopped giving the resident the [MEDICATION NAME] and [MEDICATION NAME] in July 2010 and the resident became impacted, was having abdominal pain and nausea. She stated the staff only addressed this problem after she brought it to their attention. Interview with the DON on 9/22/10 at 11:10 am revealed she received the Physician order [REDACTED]. She confirmed that the [MEDICATION NAME] and the [MEDICATION NAME] were documented as being given in June 2010 even though there was an order to discontinue it on 5/31/10. She also revealed that after the [MEDICATION NAME] and [MEDICATION NAME] was reordered on [DATE] neither medication was carried over on the September 2010 Physician order [REDACTED]. 2014-04-01
10574 PRUITTHEALTH - AUGUSTA HILLS 115672 2122 CUMMING ROAD AUGUSTA GA 30904 2010-09-23 279 D     5C5911 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to developed a care plan for one (1) resident (#164) on a sample of twenty seven (27) residents when the resident had a change in condition that required a defibrillator implant. Findings include. Review of the discharge summary dated 6/01/10 for resident #164 revealed the resident was discharged from the hospital to the nursing home with a [DIAGNOSES REDACTED]. Review of Nurses Notes dated 6/23/10 revealed the resident was sent to the hospital for a cardiac defibrillator implant. He returned to the facility on [DATE] with the defibrillator to his left chest with steri-strips intact. There was no evidence in the record that a care plan was developed related to the care and monitoring of the defibrillator implant. Interview with the Licensed Practical Nurse (LPN) Minimal Data Set Assessment Coordinator on 9/22/10 at 8:25 a.m. confirmed there was no care plan for the resident's defibrillator and interventions should have been put into place when the resident returned with the defibrillator implant. 2014-04-01
10575 PRUITTHEALTH - AUGUSTA HILLS 115672 2122 CUMMING ROAD AUGUSTA GA 30904 2010-09-23 372 E     5C5911 Based on observation and staff interview the facility failed to ensure that trash and garbage was transported from the main kitchen to dumpsters located outside of the building in a manner to prevent potential contact with residents. Findings include: Observations on 9/21/10 at 10:45 a.m., 9/22/10 at 10:50 a.m., and 9/22/10 at 2:25 p.m. revealed that staff from the facility's kitchen were transporting trash and garbage in open receptacles that were not covered with lids. The observations further revealed that food scraps from resident meals and trash from the kitchen were in these open, unlidded garbage receptacles and that the garbage bags inside the receptacles were not tied to secure their contents. The garbage was transported from the kitchen through the main dining room, through the main facility lobby and then down the 200 hall corridor. The emptied garbage receptacles were returned from the trip to the dumpsters back to the kitchen via the same reverse route. This information was confirmed in an interview with the facility's Food Service Director (FSD) on 9/23/10 at 11:30 a.m. 2014-04-01
10576 PRUITTHEALTH - AUGUSTA HILLS 115672 2122 CUMMING ROAD AUGUSTA GA 30904 2010-09-23 248 D     5C5911 Based on observation, record review and staff interview the facility failed to provide an activity program that met the needs of one (1) resident, #58, from a sample of twenty-seven (27) residents. Findings include: Record review of resident #58 revealed that she had experienced a recent mental and physical decline and spent her days in her room because she did not feel like attending group activities. The resident also ate all of her meals in her room. Observations of the resident during the course of a standard survey conducted on September 20-23, 2010 confirmed that the resident remained in her room during this period of time. There were no observed visits by the Activity Department staff to the resident during this time frame. There was also no Activity Calendar posted in the resident's room. A review of the resident's Care Plan dated 7/05/10 and updated on 9/15/10 revealed that the resident was at risk for social isolation and her Care Plan had interventions which included the provision of 1:1 in room visits by the activity staff as well as the provision of activity supplies for the resident. The interventions also provided for an Activity Calendar to be posted in the resident's room. An interview with the facility's Activity Director (AD) on 9/22/10 at 3:00 p.m. revealed that the resident was placed on an activity plan in July 2010 that provided her with 1:1 visits at least twice per week. These personal visits were to include reading, massages, nail care, aroma therapy and social visits. However, the AD confirmed in the interview that the resident had not been provided with an individualized program and that she had not been provided with any in-room activities as planned. 2014-04-01
10577 PRUITTHEALTH - AUGUSTA HILLS 115672 2122 CUMMING ROAD AUGUSTA GA 30904 2010-09-23 463 E     5C5911 Based on observation and staff interview the facility failed to ensure that all call lights located in resident rooms were functioning properly. Eight (8) of forty-five (45) call lights tested were found to be defective. Findings include: During the course of the standard survey investigative process, 45 call lights were tested to see if they were functional. The following resident rooms contained call lights that were not working: 107A; 201 bathroom; 313A; 313B; 313C; 315A; 315B; and 315C. This information was confirmed by Licensed Practical Nurse "JJ" at the time of observation on 9/21/10 at 1:50 p.m. 2014-04-01

Advanced export

JSON shape: default, array, newline-delimited

CSV options:

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
);