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.

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33 rows where "inspection_date" is on date 2011-11-10

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Link rowid ▼ facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
8172 TWIN VIEW HEALTH AND REHAB 115540 211 MATHIS AVENUE TWIN CITY GA 30471 2011-11-10 157 D 0 1 EU8311 Based on record review, staff interview, and facility document review, the facility failed to immediately consult with the physician of one (1) resident (#46), of thirty-three (33) sampled residents. Findings include: Record review for Resident #46 revealed a Nurse's Notes entry of 9/18/11 at 6:30 a.m. which documented that while in the hallway, the resident had removed the lap buddy from the wheelchair, attempted to ambulate and then fell , striking her head on the wall. This Note documented that the resident had a small knot on the back of her head, and that neurological checks were implemented per protocol. During an interview with the Director of Nursing (DON) conducted on 11/09/11 at 2:28 p.m., the DON presented a copy of the Incident Report referencing this resident's 9/18/11 fall which documented that the physician's office was provided notification of the incident, by facsimile, later in the day on 9/18/11. However, review of the Nursing Home Communications sheet which was sent back to the facility from the physician, via facsimile, in response to this incident revealed that it was it was not signed by the physician until 9/19/11, and was not received by the facility until 12:48 p.m. on 9/19/11. Further review of the medical record revealed no evidence to indicate that facility staff had made any additional attempts to contact the physician for consultation about the resident's fall between the 9/18/11 facsimile to the physician's office and the 9/19/11, 12:48 p.m. facsimile back to the facility from the physician. This resulted in an approximate thirty-one (31) hour delay in physician consultation related to this incident involving the resident falling, striking her head, and sustaining an injury to the head. During an 11/10/11, 9:30 a.m. interview with the DON, the DON stated that facility procedure was to facsimile the physician a notification of a resident accident, but only if there was no injury, and then to await the response back from the physician. She stated there was no telephone call, or addit… 2016-06-01
8173 TWIN VIEW HEALTH AND REHAB 115540 211 MATHIS AVENUE TWIN CITY GA 30471 2011-11-10 253 E 0 1 EU8311 Based on observation and staff interviews, the facility failed to maintain the residents environment in good repair for holes in walls, flaking ceiling paint and scuffed paint in 13 of 40 rooms, one (1)common bathing area and one (1) of three (3) water fountains. Findings include: During observation of environmental rounds on 11/9/11 at 3:00 p.m. the following was observed: The general shower room on Unit 1 revealed that the sink was loosely mounted to the wall. The soap dispenser was out of soap. No light cover was observed in the shower room for ceiling light. Four spots of small brown matter was observed on the shower floor. Room 7 revealed a hole in the wall to the right of the window at the 10 inch height. Room 9 revealed paint peeling under the wall mirror with additional peeling observed under electrical outlet across from residents beds. Room 10 revealed a scuffed wall on the lower portion beside bed A. Paint was peeling around center ceiling vent. Room 11 revealed rotten wood around the base boards next to the bathroom. Room 12 revealed no soap dispenser in the bathroom. Room 19 revealed paint peeling on the wall paper border at the lower entrance of the bathroom. Room 20 revealed an empty soap dispenser sitting on top of the non functioning paper towel dispenser. Room 30 revealed a hole in the wall where the bathroom door hits the wall. The bathroom door dragged on the floor. Room 34 revealed a hole in the wall to the left side of the window where the closet door knob hits the wall. Room 35 revealed a two inch hole in the wall at the three foot height, between the closet doors. Room 36 revealed no window blinds for the left window and the resident was lying sideways in the bed to avoid the sun coming in the blindless window. Room 38 revealed the entrance door dragged on the floor. Fire Zone 2 revealed no fire extinguisher which is marked to be located on the wall. Interview with the Maintenance Director and Nursing Home Administrator on 9/9/11 at 5:00 p.m. revealed the above items needed correction. 2016-06-01
8174 TWIN VIEW HEALTH AND REHAB 115540 211 MATHIS AVENUE TWIN CITY GA 30471 2011-11-10 279 D 0 1 EU8311 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that care plans were developed for two (2) residents (# 71, A) on a sample of thirty three (33) residents. The facility's failure to developed a care plan for resident # 71 related to [MEDICAL CONDITION] medications and was related to physical transfer for resident A. 1. Review of the physician orders [REDACTED]. The use of the antipsychotic medications was assessed on the current annual Minimal Data Set (MDS) assessment dated [DATE] as having been used during the assessment period. Review of the Nursing Home Resident Assessment and Care Screening documentation dated 9/01/11 documented the resident was at risk for adverse effects related to the use of [MEDICAL CONDITION] medication and that a care plan would be developed for that care area, however there was no care plan to address the use of psychoactive medications. Interview with the MDS/Care Plan Coordinator on 11/10/11 at 9:05 a.m. revealed she had failed to developed a care plan that addressed the use of the resident's psychoactive medications. 2. An interview on 11/8/11 at 8:34 a.m. with resident A revealed the resident had a bruise above the left eye and that the resident had a fall earlier in the day while transferring from the bed to the chair with standby assist from two (2) Certified Nursing Assistants (CNA). Record Review reveals the resident was assessed on the Minimum Data Set (MDS) on 4/28/11, 7/9/11, 9/30/11,10/5/11 and 10/25/11 of requiring two (2) person physical assist for transfers. Record review of the resident's care plan revealed the resident was care planned to assist with transfers as needed. The Nurse Aide information sheet reveals the resident requires extensive to total care with transfers. An interview with the MDS Coordinator on 11/8/11 at 4:30 p.m. reveals that based upon the MDS assessments she agrees the care plan was not developed for the resident's transfer needs. 2016-06-01
8175 TWIN VIEW HEALTH AND REHAB 115540 211 MATHIS AVENUE TWIN CITY GA 30471 2011-11-10 280 D 0 1 EU8311 Based on observation, record review, and staff interview, the facility failed to ensure that the Care Plan of one (1) resident (B), on the total survey sample of thirty-three (33) residents, was revised to reflect the use of a left hand splint. Findings include: Cross refer to F318 for more information regarding Resident B. Record review for Resident B revealed a Minimum Data Set assessment of 3/08/11 in which Section G, Functional Status, Functional Limitation in Range of Motion, indicated the resident had impairment on one side in both the upper and lower extremity, shoulder, elbow, wrist or hand. During an 11/08/11, 4:40 p.m. observation, Resident B was observed to have significant contracture of the fingers on his left hand. No splint was observed to be applied to the resident's left hand at the time of this observation. Record review revealed an Occupational Therapy (OT) note of 6/02/11 which documented that a hand splint had arrived for application to the resident's left upper extremity, and a subsequent OT Evaluation of 10/31/11 documented that after discharge from Skilled OT on 6/15/11, the resident had then been referred to the Restorative Nursing Program with hand-splinting. Additionally, a Physical Therapy (PT) Referral To Restorative Nursing form of 7/08/11 referred the resident to the Restorative Nursing Program, indicating a plan to apply a left hand/wrist splint for 6 hours daily, 3 hours in morning and 3 hours in the afternoon. Review of the resident's current Care Plan revealed an entry of 5/14/11 which identified a problem of the potential for further loss of range of motion related to contractures to resident's left side, including the wrist and fingers, with approaches having been developed to address this problem. However, there was no evidence to indicate that the Care Plan of Resident B had been updated to reflect the OT and PT plans specifying the application of the splint to the resident's left hand, per the Restorative Nursing Program. During an interview conducted on 11/10/11 at 10:11 a… 2016-06-01
8176 TWIN VIEW HEALTH AND REHAB 115540 211 MATHIS AVENUE TWIN CITY GA 30471 2011-11-10 312 D 0 1 EU8311 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interview the facility failed to ensure that one (1) resident # 93, of thirty three (33) sampled residents, who had a history of [REDACTED]. Findings include: Observation on 11/08/11 at 9:30 a.m. of resident # 93 walking in hallway being assisted by Certified Nursing Assistant (CNA) HH to the Resident Common Area. The resident was wearing socks on their feet but no shoes. On 11/08/11 at 12:30 p.m. the resident was observed walking in the hallway to the Dinning Area. Again, staff was assisting the resident and the resident had only socks on their feet. Observation the following day, 11/09/11 at 9:00 a.m. revealed resident # 93 was being assisted by CNA HH to ambulate in the hallway. The resident wore only socks on their feet. Record review revealed resident # 93 had a history of [REDACTED]. Interview with Certified Nursing Assistant (CNA) HH on 11/09/11 at 9:35 a.m. revealed the resident had no shoes and that was why the resident was not wearing shoes. A check of the resident's closet, at that time, revealed there were shoes in the resident's closet but further examination reveals they belong to another resident. Additional interview with CNA HH revealed he had not notified the Charge Nurse or the Social Worker (SW) that the resident did not have shoes. An interview with the SW on 11/09/11 at 10:05 a.m. revealed she was not aware the resident had no shoes and that the facility did have shoes available for resident's use. 2016-06-01
8177 TWIN VIEW HEALTH AND REHAB 115540 211 MATHIS AVENUE TWIN CITY GA 30471 2011-11-10 318 D 0 1 EU8311 Based on observation, record review, staff interview, and resident interview, the facility failed to ensure that one (1) resident (B) who had a limited range of motion, on the total survey sample of thirty-three (33) residents, received treatment, related to the application of a left hand splint per the Occupational Therapy and Physical Therapy plans, to prevent a further decrease in the resident's range of motion. Findings include: Record review for Resident B revealed a Minimum Data Set assessment of 3/08/11 in which Section G, Functional Status, Functional Limitation in Range of Motion, indicated the resident had impairment on one side in both the upper and lower extremity, shoulder, elbow, wrist or hand. Contracture Assessments of 02/03/11 and 8/22/11 both documented that the resident had very limited range of motion (ROM) to left shoulder, left elbow, left wrist, and fingers of the left hand. During an 11/08/11, 4:40 p.m. observation, Resident B was observed to have significant contracture of the fingers on his left hand. No splint was observed to be applied to the resident's left hand at the time of this observation. Record review revealed an Occupational Therapy (OT) assessment of 4/09/11 which indicated a Skilled OT plan to provide treatment including orthotics fitting and training, and an OT note of 6/02/11 documented that a hand splint had arrived for application to the resident's left upper extremity. A subsequent OT Evaluation of 10/31/11 documented that the resident had received therapy from 4/09/2011 to 6/15/11, and had then been referred to the Restorative Nursing Program with hand-splinting. Additionally, a Physical Therapy (PT) Evaluation of 6/16/11 indicated that PT would provide treatment 3 times weekly for 30 days, including orthotics/prosthetics training. A PT Discharge Summary of 7/14/11 documented that PT had discharged the resident, and a PT Referral To Restorative Nursing form of 7/08/11 referred the resident to the Restorative Nursing Program, indicating a plan to apply a left hand/wrist… 2016-06-01
8178 TWIN VIEW HEALTH AND REHAB 115540 211 MATHIS AVENUE TWIN CITY GA 30471 2011-11-10 323 E 0 1 EU8311 Based on observation, staff and resident interviews, the facility failed to provide a safe environment, specifically, mattresses of sufficient length to accommodate bed frames, toilets securely anchored to the floor, a loose toilet seat and gerichairs with missing side panels for a census of 106 residents and to assist one (1) resident (A) with transfer resulting in a fall without injury which the staff involved failed to report to the charge nurse, DON or Administrator. Findings include: 1. During environmental rounds on 11-9-11 at 3:00 p.m. the following was revealed: Room 3 bathroom toilet seat to be loose and sliding side to side. Room 7 bed b revealed the mattress to be four to six inches shorter than bed frame. Room 9 bed b revealed the mattress was five inches shorter than the frame and footboard had up-raised brackets. Room 13 bed A revealed a mattress six inches short at the headboard. Room 21 revealed a toilet that slides side to side, two inches to each side. Room 26 bed A revealed a mattress that was five inches too short at the headboard. Room 33 bed A revealed a mattress that was short four to five inches at the headboard. Room 35 revealed a loose toilet. Room 39 revealed a loose toilet that rocks side to side and front to back. Random observation revealed two geri chairs with one chair missing the right side panel and one chair missing left and right side panels. The residents who use both chairs have some ability to move about in the chairs. Interview on 11/9/11 at 5:00 p.m. with the Maintenance Director and Nursing Home Administrator revealed the above needed correction. 2. An interview and observation with resident A on 11/08/11 at 8:34 a.m. revealed the resident had a large bruise above the left eye. The resident stated that she had fallen earlier that morning when transferring from the bed to the wheelchair. The resident revealed that Certified Nurse Assistant (CNA) AA was in the room and told the resident to get up but did not assist the resident. The resident revealed that CNA AA was told re… 2016-06-01
8179 TWIN VIEW HEALTH AND REHAB 115540 211 MATHIS AVENUE TWIN CITY GA 30471 2011-11-10 463 E 0 1 EU8311 Based on observation and staff interview the facility failed to maintain a functioning call light system for one general bathing area. Findings include: During environmental rounds on 9/09/11 at 3:00 p.m. revealed that the call light system was not functioning in the toilet area or shower room in the general bath room on Unit One. The call system did not light up outside of the room nor at the nurse's station. Interview with Maintenance Director and Nursing Home Administrator on 9/09/11 at 3:00 p.m. revealed that he concurred with the above findings. 2016-06-01
8299 A.G. RHODES HOME, INC, THE 115275 350 BOULVARD, S.E. ATLANTA GA 30312 2011-11-10 309 D 0 1 MNRU11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Physician's orders, the Medication Administration Records (MAR) and staff interviews, the facility failed to ensure that physician's orders were followed for one (1) resident (#154) from a sample of twenty seven (27) residents. Findings include: Review of a physician's order dated 6/16/11 for resident #154 indicated [MEDICATION NAME] HCL 25mg (3) every six (6) hours at 0500, 1100, 1700, and 2300. Hold medication for systolic blood pressure (SBP) less than 120 (SBP Review of the MARs for September, October, and November 2011 indicated that the [MEDICATION NAME] 75mg was administered fifteen (15) times when the SBP was below 120, and there were three (3) times when there was no evidence that blood pressure (B/P) or medication were done/given. September 2011 MAR: On 9/2/11 at 11:00am, B/P was 110/68 and [MEDICATION NAME] was given On 9/5/11 at 5:00am, B/P was 115/69, and medication was given On 9/5/11 at 5:00pm, B/P was 118/68, and medication was given On 9/6/11 at 11:00am, B/P was 110/60, and medication was given On 9/19/11 at 5:00pm, B/P was 102/62, and medication was given On 9/19/11 at 11:00pm, B/P was 102/62, and medication was given On 9/27/11 at 11:00am, there was no evidence on the MAR indicated [REDACTED]. October 2011 MAR: On 10/4/11 at 11:00am there was no evidence that the B/P was taken or that medication was administered. On 10/14/11 at 5:00am, B/P was 107/67, and medication was given On 10/22/11 at 5:00am, B/P was 112/67, and medication was given On 10/24/11 at 5:00am, B/P was 117/66, and medication was given On 10/24/11 at 5:00pm, B/P was 116/73, and medication was given On 10/27/11 at 5:00pm, B/P was 118/60, and medication was given On 10/28/11 at 11:00am B/P was 119/60, and medication was given November 2011 MAR: On 11/1/11 at 5:00am, B/P was 105/59, and medication was given On 11/3/11 at 11:00am there was no evidence that the B/P was taken or that medication was administered. On 11/4/11 at 11:00am, B/P was 10… 2016-03-01
8452 THOMASVILLE HEALTH & REHAB, LLC 115427 120 SKYLINE DRIVE THOMASVILLE GA 31757 2011-11-10 282 D 0 1 D93G11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and a closed record review, it was determined that the facility failed to follow the plan of care to do weekly skin assessments for one (#52) of two residents with a history of/or having pressure sores, from a sample of 23 residents. Findings include: Resident #52 was admitted to the nursing facility on 5/26/11 and discharged on [DATE]. Staff developed his/her 6/1/2011 plan of care to address his/her risk for developing pressure sores. One intervention was for nursing staff to do weekly skin assessments. However, there was no evidence that nursing staff had done those assessments in July 2011, August 2011 and through October 12, 2011. See F314 for additional information regarding resident #52. 2016-01-01
8453 THOMASVILLE HEALTH & REHAB, LLC 115427 120 SKYLINE DRIVE THOMASVILLE GA 31757 2011-11-10 311 D 0 1 D93G11 Based on observation, record review and staff interview, it was determined that the facility failed to develop a plan for the use of splints for one (#7) of 23 residents. Findings include: Resident #7 had a 9/24/11 Occupational Therapy Services (OT) discharge note that he/she no longer required skilled OT services and was provided with bilateral hand/wrist splints for support and protection of joints. According to the discharge note, restorative nursing staff would follow the resident after his/her discharge from skilled OT services. However, review of the resident's clinical record revealed there was not any evidence that restorative nursing staff had provided services to the resident. During an interview on 11/10/11 at 9:20 a.m., a restorative nursing certified nursing assistant (CNA) AA stated that the resident had not been on the restorative nursing program. The resident was observed on 11/09/2011 at 12:30 p.m. and 2:45 p.m. and on 11/10/11 at 8:30 a.m. without any braces on his/her hands and/or wrists During an interview on 11/10/11 at 9:35 a.m., the Occupational Therapist stated that a restorative nursing program was supposed to have been developed according to the OT discharge summary. However, that therapist was not able to provide documentation that it had been done. She stated that the resident had refused to wear the braces most days so, that was probably why a restorative program was not developed. During an observation at that time, the occupational therapist located the resident's braces in the closet of the therapy office. 2016-01-01
8454 THOMASVILLE HEALTH & REHAB, LLC 115427 120 SKYLINE DRIVE THOMASVILLE GA 31757 2011-11-10 314 D 0 1 D93G11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a closed record review and staff interview, it was determined that the facility had failed to ensure that one (#52) of two residents, who were at risk for developing pressure sores, received weekly skin assessments from a sample of 23 residents. Findings include: Resident #52 was admitted to the nursing facility on 5/26/11 and discharged on [DATE]. Nursing staff developed a 6/1/2011 plan of care to address the problem of his/her risk of developing new pressure sores. There was an intervention for nursing staff to do weekly skin assessments. According to licensed nursing staff's documentation on 6/23/11 at 4:00 a.m., the resident had an approximately 1 (centimeter) cm. by 1 cm. open area on his/her sacrum. The area was described as healed and treatment was discontinued on 7/4/11. Nursing notes on 7/18/11 at 4:00 a.m. documented that there was a small open area with a depth less than 0.1 cm. on the resident's sacrum area, near his/her left buttock. However, the CNA, who documented the resident's skin condition on the (CNA) STNA Skin Report form on 7/19/2011, did not include the area identified the previous day. The resident was hosptalized on [DATE] and was re-admitted on [DATE] without staff noting any skin breakdown. Nursing staff did not not note any skin breakdown until 9/9/11. At that time, nursing staff described a 1.6 cm, stage 2 pressure sore on the resident's left sacrum. However, there was not any evidence that weekly skin assessments had been done July, August or through October 12, 2011. During an interview on 11/08/11 at 5:15 p.m., the treatment nurse acknowledged that she could not locate the resident's weekly skin assessments for July 2011, August 2011 and October 2011. 2016-01-01
8455 THOMASVILLE HEALTH & REHAB, LLC 115427 120 SKYLINE DRIVE THOMASVILLE GA 31757 2011-11-10 322 D 0 1 D93G11 **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 assist one resident (A) who was fed by a gastrostomy tube, to resume normal eating skills from a total sample of 23 residents. Findings include: Resident A had a physician's orders [REDACTED]. There was also a 10/6/11 order to change to [MEDICATION NAME] continuously at a rate of 42 cubic centimeters (cc) per hour through his/her gastrostomy tube. The resident was observed eating lunch on 11/9/11 at 12:15 p.m. He/She was served lunch while his/her tube feeding formula was still infusing. The resident stated that he/she was not hungry and only ate bites of his/her lunch. During an interview on 11/7/11 at 11:00 a.m., the resident's family member stated that the resident was served a tray at every meal but, he/she was usually too full from the tube feeding to eat the meal. The family member said he/she had not seen staff turn off the tube feeding to allow the resident to eat. In the October 19, 2011 registered dietician's notes, it was noted that resident A often refused oral intake of meals or snacks and without additional oral intake his/her weight loss would continue so, she recommended that the flow rate for the tube feeding formula be increased to 50 cc/hr to meet at least meet two-thirds of the resident's nutritional needs. However, there was no evidence that facility staff developed a plan to promote the resident's oral intake of the ordered diet. During an interview on 11/11/11 at 11:00 a.m., the Director of Nursing stated that the resident had been receiving continuous tube feedings since June 2011. However, the DON could not provide any evidence that the facility had attempted to assist the resident to resume his/her normal eating skills. 2016-01-01
8456 THOMASVILLE HEALTH & REHAB, LLC 115427 120 SKYLINE DRIVE THOMASVILLE GA 31757 2011-11-10 441 D 0 1 D93G11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of personnel files and staff interview, it was determined that the facility failed to ensure that one new employee had a [MEDICATION NAME] skin test prior to beginning to work in a sample of 14 employees reviewed. Findings include: According to the personnel files, the Administrator was hired on 4/26/11. However, there was no evidence that the Administrator had a [MEDICATION NAME] skin test until 7/22/11. The Administrator confirmed, during an interview on 11/10/11 at 10:05 a.m., that the test was not completed and the results known prior to his/her date of hire (4-26-2011). 2016-01-01
8542 EASTMAN HEALTHCARE & REHAB 115622 556 CHESTER HIGHWAY EASTMAN GA 31023 2011-11-10 241 D 0 1 LBOJ11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to provide care in a manner to promote dignity for one (1) resident (P) from a sample of thirty-three (33) residents. Findings include: Observation of resident P on 11/07/11 at 1:00 p.m. sitting in a wheelchair on the 100 hall revealed the resident in a pair of gray jogging pants which were saturated from the groin area down to the knees. The resident was sitting in the hallway with other residents. Continued observation revealed that the resident was seated in this area from 1:00 p.m. until 1:56 p.m. in saturated clothing while eight (8) staff members passed him, some more than once. Three (3) visitors passed down the hallway during this time. Observation on 11/07/11 at 1:56 p.m. revealed another resident began to push resident P down the hall, midway down the hallway a staff member interceded and continued to push him to his room. Observation at 2:30 p.m. revealed the resident in his room in the same wet clothing. A Certified Nursing Assistant (CNA) entered the room at 3:00 p.m. and took the resident to the bathroom for care. After care, the sweat pants were observed to be soaked down both legs from the groin area to the ankle area and the incontinent brief was saturated and wreaked of urine. Review of medical record for resident P revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessmen dates 10/19/11 revealed that the resident was assessed as frequently incontinent, required total assistance with toileting and extensive assistance with dressing. Continued review revealed that the resident was not on a toileting plan. Review of the resident care plan dated 10/19/11 revealed: Resident requires extensive assistance with Activities of Daily Living (ADL), incontinence care every 2 hours as needed, and assist and encourage to use toilet. Interview on 11/08/11 at 12:30 pm with CNA DD revealed that the resident usually asks to go… 2016-01-01
8543 EASTMAN HEALTHCARE & REHAB 115622 556 CHESTER HIGHWAY EASTMAN GA 31023 2011-11-10 280 D 0 1 LBOJ11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and family and staff interview the facility failed to notify the responsible parties of the care plan meeting for one (1) resident (Z) from a sample of thirty three (33) residents. Findings include: During a telephone interview with the responsible party for resident Z on 11/08/11 at 10:54 a.m., she indicated that she is aware of what care plan meetings are but does not know when they are and therefore does not attend them. Continued interview revealed that she is not informed as to when the meeting will be held. Review of the medical record revealed a care plan conference sheet for the time period of May 2011 through November 2011. There was no evidence that a family member had attended this meeting and no evidence that the family was notified, but did not attend. The area is left blank. Review of Social Services notes revealed information about the resident and the initial social service assessment but nothing to indicate that the responsible party was invited to a care plan meeting. The resident was admitted to the facility on [DATE] and is shown as being re-admitted on [DATE]. Interview with the Social Services Director on 11/08/11 at 5:03 p.m. indicated she did not mail the notices out for care plan meetings because responses back to her were poor. She indicated that her most success had come from placing the notices in the resident's room. Continued interview revealed that many of the responsible parties were out of town and she did not get a good response, but since she has been putting them in the room her response is a little better. She does call a few of them but mostly she just places the notices in the room. The Social Services Director acknowledged that residents, family members and/or the responsible party are informed during admission about the care planning meetings. During Interview with the Social Service Director on 11/09/11 at 8:47 a.m. a copy of the notice which is placed on the closet door of the … 2016-01-01
8544 EASTMAN HEALTHCARE & REHAB 115622 556 CHESTER HIGHWAY EASTMAN GA 31023 2011-11-10 282 D 0 1 LBOJ11 Based on record review and staff interview the facility failed to follow the care plan related to a Physical Therapy evaluation for one (1) resident (#82) from a sample of thirty three (33) residents. Findings include: Review of the care plan and medical record for resident #82 revealed that the resident had a fall on 09/26/11 in the dining room with laceration to posterior head and another fall on 10/01/11 from his wheelchair to the floor in the hallway. The resident was care planned on 10/01/11 for a referral to Physical Therapy (PT) for an evaluation and treatment as indicated. However, there was no evidence that an evaluation had been in the medical record. Interview with Minimum Data Set (MDS) Coordinator on 11/10/11 at 10:50 a.m. revealed that usually a screening is performed after each fall and that she would check with therapy. After checking with Therapy she indicated no screening was performed. Interview with the Certified Occupational Therapist Assistant (COTA) AA on 11/10/11 at 11:15 a.m. revealed that after speaking with another therapist, he could not find any paperwork for this resident, but the other therapist would continue to look. Interview with the COTA AA on 11/10/11 at 11:59 a.m. revealed that there was no evidence that a screening or evaluation had been completed on this resident after the second fall. 2016-01-01
8545 ABBEVILLE HEALTHCARE & REHAB 115623 206 MAIN STREET EAST ABBEVILLE GA 31001 2011-11-10 280 D 0 1 1JXD11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined that the facility failed to continue to implement planned interventions to address the positioning needs of one resident (#63) and failed to revise interventions to address continued falls for one resident (#38) in a total sample of 28 residents. Findings include: 1. On the 5/27/11 Minimum Data Set (MDS) assessment, licensed staff coded resident # 63 as having limitaton with range of motion to one side of his/her upper extremity. On the 9/1/11 MDS assessment, the resident was coded with a decline in the limited range of motion to include both of his/her upper extremities. There was a care plan since 8/28/10 to address his/her risk for injury from falls due to limited mobility, havig been bed to gerichair bound and having [MEDICAL CONDITION] and a [MEDICAL CONDITION] disorder. The interventions included having the call light close (to the resident) and for staff to promptly answer it, staff providing all activities of daily living, for staff to transfer the resident with the hoya lift, and staff to monitor the resident for positioning for possible injury. A new intervention was added on 8/22/11 for the resident to be screened by occupational therapy services for an evaluation if indicated. However, although the resident was observed to lean to the left in his/her geri-chair, there was no evidence that the resident was provided any restorative therapy services after his/her hospital return in July 2011 or was evaluated by the occupational therapist for further skilled therapy. See F 311 for additional information regarding resident # 63. 2. Resident #38 had a care plan and physician's orders [REDACTED]. There was an intervention for physical therapy skilled services to be provided for the resident three times a week for two weeks for therapeutic exercises therapeutic activities, gait-training, and neuromuscular re-education. However, there was no evidence that the physic… 2016-01-01
8546 ABBEVILLE HEALTHCARE & REHAB 115623 206 MAIN STREET EAST ABBEVILLE GA 31001 2011-11-10 282 D 0 1 1JXD11 Based on observations, record review and staff interview, it was determined that the facility failed to implement care plan interventions to provide oral care for one resident A and to provide assistance with shaving for one resident (#74) in a total sample of 28 residents. Findings include: 1. On the 9/01/11 and 5/27/11 Minimum Data Sets (MDS) assessments, licensed staff coded resident A as needing total assistance for hygiene. There was a care plan since 8/28/11 to address his/her dependence on staff to meet his/her activities of daily living (ADL) needs because of his/her limited mobility. There was an intervention for staff to explain procedures prior to performing his/her daily oral care. However, the resident was observed on 11/7/11 at 3:20 p.m., 11/9/11 at 8:30 a.m. and 11:30 a.m., and on 11/10/11 at 9:50 a.m. to have teeth that were caked with debris. See F312 for additional information regarding resident A. 2. Resident #74 had a care plan since 11/8/11 to address his/her self care deficit with an intervention for nursing staff to assist him with shaving on bath days and as needed. According to staff documentation on the the resident's ADL Flow sheet that was reviewed on 11/10/11 9:10 am, the resident had been given a shower every day from 11/1 thru 11/9/11. However, resident #74 was observed to have had several days growth of facial hair on 11/8/11 at 8:17 a.m. and 4:32 p.m., on 11/9/11 at 8:50 a.m., 11:05 a.m., 3:00 p.m. and 4:05 p.m. and, on 11/10/11 at 8:00 a.m. and 10:10 a.m. See F312 for additional information regarding resident #74. 2016-01-01
8547 ABBEVILLE HEALTHCARE & REHAB 115623 206 MAIN STREET EAST ABBEVILLE GA 31001 2011-11-10 311 D 0 1 1JXD11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, it was determined that the facility failed to continue to provide services to address the maintenance or improvement of positioning for one resident (#63) in a total sample of 28 residents. Findings include: Resident # 63 had [DIAGNOSES REDACTED]. The resident had been coded on the 5/27/11 Minimum Data Set ( MDS) assessment as having limitation with range of motion on one side of his/her upper extremity. On the 9/01/11 MDS, the resident was coded to have had a decline of limited range of motion in both of his/her upper extremities. staff developed a care plan to address the resident's risk for injury due to limited mobility, being bed to chair bound and having [MEDICAL CONDITION] and a [MEDICAL CONDITION] disorder. There was an intervention for staff to monitor his/her positioning for possible injury. Staff added an intervention on 8/22/11 for the resident to be screened by occupational therapy services and evaluated as indicated. The resident was observed attending a church service on 11/9/11 at 10:30 a.m. He/she was seated in a geri-chair in the reclining position. Although staff had provided a back support and bolster for the left arm of the resident's geri-chair, his/her upper torso was leaning toward the left side. The resident was observed to still be in the activity room at 11:30 a.m. Despite the resident continuing to lean to the left side of the geri-chair, the staff, who was present in the room, failed to attempt to reposition the resident into the correct position. The resident continued to be leaning to the left side while seated in geri-chair in the day room at 3 p.m. Although there were positioning devices to the back and left arm of the geri-chair, the resident continued to inappropriately lean to the left so that there was not any support for his/her head or neck. On 11/10/11 at 8:30 a.m., the resident was observed seated in geri-chair. He/She was leaning to the left si… 2016-01-01
8548 ABBEVILLE HEALTHCARE & REHAB 115623 206 MAIN STREET EAST ABBEVILLE GA 31001 2011-11-10 312 D 0 1 1JXD11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to provide oral care for one resident (A) and to assist with shaving for one resident (#74) in a total sample of 28 residents. Findings include: 1. Resident Ahad [DIAGNOSES REDACTED]. On the 9/01/11 Minimum Data Set (MDS) assessment, licensed staff had coded him/her as needing total assistance for hygiene. The resident's care plan since 8/28/11 noted that the resident depended on staff to meet his/her activities of daily living (ADL) needs because of his/her limited mobility. There was an intervention for (nursing) staff to explain procedures prior to performing the resident's daily oral care. However, it was observed that daily oral care was not provided for resident A. The 9/20/11 nurse's note at 12:30 p.m. described the resident having had a tooth come out while he/she was eating. The tooth was described as having been black in color and, chipped and broken in places. Nursing staff wrote that the other teeth surrounding the open area were dark in color. However, there was no evidence that the resident's attending physician or a dentist had been contacted about those problems with the resident's teeth. During an interview on 11/7/11 at 3:10 p.m., resident A stated that staff helped him/her to brush his/her teeth less than once a month. The resident's teeth were observed on 11/7/11 at 3:20 p.m., on 11/9/11 at 8:30 a.m. and 11:30 a.m., and on 11/10/11 at 9:50 a.m. to have been caked with debris. 2. On the 10/27/11 MDS assessment, licensed nursing staff coded resident #74 as needing total assistance with personal hygiene and grooming. Nursing staff developed a care plan dated 11/8/11 to address the resident's self care deficit with an intervention for nursing staff to assist with shaving on his/her bath day and as needed. Review of the resident's ADL flow sheet revealed nursing staff's documentation that the resident had been given a shower on … 2016-01-01
8549 ABBEVILLE HEALTHCARE & REHAB 115623 206 MAIN STREET EAST ABBEVILLE GA 31001 2011-11-10 323 D 0 1 1JXD11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined that the facility failed to provide interventions to prevent falls for one resident (# 38) from a sample of 28 residents and to secure razors in one common shower room (100 hall) of three common shower rooms in the facility. Findings include: 1. Review of the medical record for resident #38 revealed staff documentation about the resident having fallen but not been injured on 08/12/11, 08/29/11, 09/11/11, 09/12/11, 09/12/11, 10/04/11, 10/19/11 10/23/11, and 11/09/11. The facility developed and implemented interventions to prevent falls. Record review revealed that the resident had been provided skilled physical therapy services from 9/01/11 to 9/09/11 to reduce the likelihood of falls then, a referral had been made for restorative nursing services for maintaining skill in ambulation and strength in both legs. Staff's documentation revealed that the resident was provided range of motion exercises as ordered from 09/10/11 through 11/10/11. However, the resident continued to fall with the last fall documented as happening on 11/09/11. The physician wrote an order on 10/24/11 for physical therapy staff to evaluate and treat the resident as indicated. The order was for the resident to be seen by a skilled physical therapist three times a week for two weeks for skilled physical therapy services. However, there was no evidence that those services had been provided. During an interview on 11/10/11 at 10:45 a.m., occupational therapist CC could not locate evidence that a physical therapy evaluation had been done despite the order for it or that those skilled services had been provided. During an interview on 11/10/11 at 11:00 a.m., the Restorative Nursing Services registered nurse (RN) AA and certified nursing assistant, (CNA) BB said that nursing staff was not aware of any physical therapy services but, were providing restorative nursing services. During an interview on 11/10/… 2016-01-01
8550 ABBEVILLE HEALTHCARE & REHAB 115623 206 MAIN STREET EAST ABBEVILLE GA 31001 2011-11-10 371 F 0 1 1JXD11 Based on observation, staff interview, and record review, it was determined that the facility failed to hold and serve potentially hazardous food at safe temperatures to prevent potential food borne illnesses for seven of eight residents on pureed diets and 28 of 76 residents who were served mechanical soft or regular diets. Findings include: During an observation on 11/7/11 at 12:35 p.m., foods were observed being held and served in the danger zone (above 41 degrees Fahrenheit (F.) and below 135 degrees F.) which allowed for the growth of organisms which could cause food borne illness. Pureed chicken was being held and served at 120 degrees F. The potato salad was being held and served at 54 degrees F The foods were checked with a facility calibrated thermometer. Seven residents had been served the pureed chicken. There were 28 residents who had been served the potato salad. In an interview on 11/08/11 on 12:37 p.m., the Dietary Manager said that the potatoes were warm when the salad was mixed. However, the temperature log documentation indicated that the potatoes had been at 40 degrees F at 11:55 a.m On 11/08/11 at 1:20 p.m., the Dietary Manager stated that residents on a mechanical soft diet and those eating at the first seating in the dining room had been served potato salad. 2016-01-01
9554 CHESTNUT RIDGE NSG & REHAB CTR 115423 125 SAMARITAN DRIVE CUMMING GA 30040 2011-11-10 156 E 0 1 06HO11 Based on record review and staff interview the facility failed to maintain copies of approved, standardized Advance Beneficiary Notices with all required information completed. The facility also failed to provide evidence that the notices were provided far enough in advance to allow sufficient time for the beneficiary to consider all available options and failed to provide evidence that residents and/or their responsible parties were given the opportunity to make choices related to their future coverage. This affected all residents (census = 136) whose Medicare coverage ended while they were residing in the facility. Findings include: Record review for residents receiving Part A and Part B Medicare benefits revealed that the facility did not maintain the proper documents related to options available to residents when their benefits ended. The records maintained by the facility also did not include page 1 of form CMS- which indicated the date that the resident's skilled services ended. The facility also was unable to produce copies of forms CMS- and CMS-R-131 which allowed these residents or their responsible parties to request a demand bill to pay for continued skilled services after their Part A or Part B medicare coverage ended. 2015-06-01
9555 CHESTNUT RIDGE NSG & REHAB CTR 115423 125 SAMARITAN DRIVE CUMMING GA 30040 2011-11-10 279 D 0 1 06HO11 Based on record review and staff interview the facility failed to develop a plan of care with interventions related to a therapeutic diet for one (1) resident, resident #44, on a sample of thirty-five (35) residents. Findings include: On 11/08/11 at 3:00 p.m. review of the care plan for resident # 44 dated 8/10/11 and reviewed on 11/02/11 revealed that there were no plan of care related to a therapeutic diet for diabetes, interventions initiated related to supplements or potential for weight loss. Interview with the Licensed Practical Nurse (LPN) Unit Manager on 11/8/11 at 2:15 p.m. revealed that the dietary department is responsible for the nutrition care plan. Interview with the Minimum Data Set (MDS) Coordinator on 11/8/11 at 2:40 p.m. revealed that resident # 44 triggered on the Care Area Assessment (CAAs) documentation and the dietary department stated they would care plan for nutrition but it was never developed. Cross refer to F 325 2015-06-01
9556 CHESTNUT RIDGE NSG & REHAB CTR 115423 125 SAMARITAN DRIVE CUMMING GA 30040 2011-11-10 325 D 0 1 06HO11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that a therapeutic diet ordered by the physician was initiated for one (1) resident, resident #44 on a sample of thirty-five (35) residents. Findings include: During dining observation on 11/07/11 at 1:15 p.m. resident #44 received a regular diet with a mighty shake. On 11/08/2011 at 8:00 a.m. and 1:15 p.m. resident #44 received a regular diet for breakfast and lunch. Record review revealed the Minimum Data Set ((MDS) dated [DATE] assessed resident # 44 as being on a therapeutic diet. Review of the Registered Dietician (R.D.) notes dated 8/15/11 revealed that she recommended a No Concentrate Sweets (NCS) diet related to the [DIAGNOSES REDACTED]. Observation of the resident on 11/07/11 at 1:00 p.m. and on 11/08/11 at 8:00 a.m. and at 1:00 p.m. revealed that resident # 44 received a regular diet for all three meals. In addition, she received a mighty shake for lunch both meals that was not sugar-free. The resident also received ice cream for lunch on 11/08/11. Interview with the Licensed Practical Nurse (LPN) Unit Manager on 11/08/11 at 2:15 p.m. revealed that the resident should have received a NCS diet. The LPN Unit Manager stated that the nursing staff are responsible for sending diet changes to the dietary department. Interview with the Dietary Manager (DM) on 11/08/11 at 2:20 p.m. revealed that she had not received a change in diet orders for resident # 44 and the resident has been receiving a regular diet since her admission on 7/21/11. The Mighty Shake was ordered on [DATE] to be given with lunch and was supposed to be sugar-free. 2015-06-01
9557 CHESTNUT RIDGE NSG & REHAB CTR 115423 125 SAMARITAN DRIVE CUMMING GA 30040 2011-11-10 514 D 0 1 06HO11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility maintain accurate documentation related to drug dosage for one (1) resident, resident # 4 on a sample of thirty-five (35) residents. Findings include: Record review of the medications for resident # 44 revealed that she was on [MEDICATION NAME] 40 milligrams by mouth at 6:30 a.m. for reflux. The current monthly Physician order [REDACTED]. Observation of the current medication blister pack was [MEDICATION NAME] 20 milligrams by mouth at 6:30 a.m. with eight pills missing. Review of the current Medication Administration Record [REDACTED]. Interview with the Director of Nurses (DON) on 11/09/11 at 8:00 a.m. revealed that the order is for [MEDICATION NAME] 40 mg and the pharmacy sent the wrong medication. She stated that they used floor stock for the drug and she did not know why the pharmacy sent the blister pack of [MEDICATION NAME] for this resident. Interview with the Administrator on 11/09/11 at 8:10 a.m. revealed that she would call the pharmacist and clarify what strength they have been sending for this resident. On 11/09/11 at 9:15 a.m. the Administrator brought the surveyor documentation from the pharmacy that the order was changed on 11/02/11 with the consent of the physician. The pharmacist stated that the current orders were printed on 10/23/11 and this change did not make the current orders. However, he stated they did send the [MEDICATION NAME] 20 milligrams for November and the staff has been giving the 20 milligrams and documenting that they are giving 40 milligrams. Interview with the Administrator on 11/09/11 at 9:35 a.m. confirmed that the pharmacy had sent the [MEDICATION NAME] 20 milligrams for resident # 44 and the nursing staff had given it but documented that they were giving [MEDICATION NAME] 40 milligrams. 2015-06-01
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 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 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 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 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 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

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CREATE TABLE [cms_GA] (
   [facility_name] TEXT,
   [facility_id] INTEGER,
   [address] TEXT,
   [city] TEXT,
   [state] TEXT,
   [zip] INTEGER,
   [inspection_date] TEXT,
   [deficiency_tag] INTEGER,
   [scope_severity] TEXT,
   [complaint] INTEGER,
   [standard] INTEGER,
   [eventid] TEXT,
   [inspection_text] TEXT,
   [filedate] TEXT
);