cms_GA
Data source: Big Local News · About: big-local-datasette
52 rows where "inspection_date" is on date 2011-12-08
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Suggested facets: facility_name, facility_id, address, city, zip, scope_severity, complaint, standard, eventid, filedate, inspection_date (date), filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8053 | 8053 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 156 | B | 0 | 1 | VJEI11 | Based on observation and staff interview the facility failed to post contact numbers for reporting abuse to the State Agency for residents on one hall, (1) West Wing Hall, of three (3) halls in the facility. Findings include: Observation on 12/08/11 at 11:55 a.m. revealed that there was not an Abuse Hotline poster on the West Unit that explains how to report suspected abuse to the state agency. A tour of the West Wing Unit with Licensed Practical Nurse (LPN) CC at this same time revealed that there was no Abuse Hotline poster prominently displayed for residents, staff or family to utilize. The poster was prominently displayed on the East Wing Unit. | 2016-07-01 |
| 8054 | 8054 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 157 | D | 0 | 1 | VJEI11 | Based on observation, record review and staff and resident interview the facility failed to provide timely notification to the physician and/or family for two (2) residents on a sample of thirty-nine (39). The family of one resident (# 127), was not provided timely notification of significant weight loss and the physician was not notified timely of pain and concerns with a indwelling Foley catheter for one (1) resident (#117). 1. Review of the Clinical Record of resident #127 revealed the resident had a significant weight loss of seven (7) pounds or of 5.83 percent (5.83%) from October 2011 to November 2011. Review of a dietary note dated 11/11/11 revealed the facility identified the weight loss and interventions were put in place to address the weight loss. Further review of the record revealed no evidence the resident's family was notified of the significant weight loss. During an interview on 12/06/11 at 11:00 a.m Licensed Practical Nurse (LPN) NN confirmed she could find no evidence the family was notified of the significant weight loss. 2. Resident A was observed on 12/06/11 at 2:00 p.m. in his wheelchair at the nurses' station requesting that Licensed Practical Nurse (LPN) AA call an ambulance and send him to the emergency room . He pointed to his lower abdomen and complained of pain and burning in the bladder region related to an indwelling urinary catheter. He further stated he felt something was wrong with the catheter and had complained of this since 12/05/11. LPN AA stated she had called the physician's office on 12/05/11 regarding the resident's discomfort and had not received a return call. She further stated she had not attempted to call the physician again. The nurse also explained to the resident that it was normal for him to have discomfort after surgery. The resident continued to complain of discomfort and requesting to go to the emergency room . LPN AA stated she would call the Physician's office again and arrange an office visit if possible. Review of the Nurses' Notes dated 12/05/11 at 5:00 p… | 2016-07-01 |
| 8055 | 8055 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 161 | E | 0 | 1 | VJEI11 | Based on record review and staff interview the facility failed to provide a surety bond with a penal sum sufficient to assure the security of personal funds of residents that were deposited with the facility. This affected all residents with personal funds held by the facility in a trust fund account (number = 103). Findings include: Record review revealed that the facility's surety bond penal sum was currently limited to $45,000 dollars. Further record review revealed that the trust fund's ending bank balance on 9/30/11 was $48,521 and on 10/31/11 it was $46,250. A review of trial fund balance on 12/08/11 revealed that the current total balance was $61,234. This information was verified by the facility's Administrator in an interview on 12/8/11 at 10:00 a.m. | 2016-07-01 |
| 8056 | 8056 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 252 | E | 0 | 1 | VJEI11 | Based on record review and interview the facility failed to provide a homelike atmosphere in dining rooms. This affected all residents who visit the rooms for meals or for recreational activities (census = 131). Findings include: During an observation of the facility's main dining room on 12/05/11 at 12:30 p.m. eleven of eighteen (11 of 18) windows on the west side of the Main Dining Room were noted to have sills and/or sashes that are in various stages of substantial deterioration. This information was confirmed by the facility's Administrator in an interview on 12/05/11 at 2:30 p.m. During the dining experience on 12/05/11 at 11:30 a.m. in the Special Care Unit the following was observed: There were eleven dining (11) chairs in the dining room. All of the chairs were scuffed, with the finish peeling off the arms and legs, there were food particles noted in the crevices of the chairs with dried substances on the chairs. The right arm of one chair was loose. One set of twelve (1 of 12) blinds in the dining room was noted to have bent and broken blades. This was confirmed by the Administrator during an interview on 12/07/11 at 3:00 p.m. | 2016-07-01 |
| 8057 | 8057 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 253 | E | 0 | 1 | VJEI11 | Based on observation and staff interview the facility failed to maintain a clean, organized environment on both the East and West Wings related to worn, or broken furniture, loose baseboards and accumulation of dirt and cobwebs in doorways, furniture and windowsills. Findings include: The following were observed on the West Wing during initial tour on 12/05/11 which began at 8:30 a.m. and again during environmental tour on 12/07/11 at 4:00 p.m: 1. A common room used for dining and activities at the end of Twelve Oaks Hall had a long table with chipped or missing veneer. Molding along the baseboard to the left of back door was loose. A maroon colored sofa along the window area on the left side of the room had a tear in the upholstery one and a half to two inches (1-1/2 to 2 ) long with stuffing exposed. cobwebs under two (2) chairs to the left of the sofa. 2. The lower foot board on the side nearest the window in room 220-2 had a large piece that had broken away. 3. The windows of each resident room on the 300 Hall were dusty and streaked with a white film. Each room had double panes and the white film on one of the panes covered the window, blocking the view to the outside. 4. The common area at end of Twelve Oaks Hall had two (2) large windows, one along the back wall in the right corner, and in the far corner to the left along the side that had loose, ill fitting screens and a heavy accumulation of cobwebs. During environmental tour of the East Wing on 12/08/11 at 10:20 a.m. the following concerns were noted: 1. In the hallway outside of rooms 101 and 102 the baseboard was pulled away from the wall. The wallpaper that was below the chair rail in this same area also was pulled away from the wall above the baseboard. 2. In room 111 there was patched unpainted drywall next to the bathroom door. The drywall at the head of the bed and on the right side of the bed had been gouged and scuffed removing the paint from these areas. 3. In rooms 102, 103, 106, 110, 114, 115, 116, 117, 118, 119, 121 and 123 the wallpaper bo… | 2016-07-01 |
| 8058 | 8058 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 274 | D | 0 | 1 | VJEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to perform a comprehensive assessment for one resident (#26) on a sample of thirty-nine (39) residents who experienced a decline in physical condition after a fall. Findings include: Review of the Quarterly Minimum Data Set Assessment (MDS) for resident #26 dated 6/25/11 revealed the resident required supervision with transfers and ambulation, limited assistance with dressing and supervision with her personal hygiene and was only occasionally incontinent. The resident experienced a fall on 7/11/11 and was hospitalized . The resident returned from the hospital on [DATE] and had an order to receive Physical Therapy (PT). Review of the PT evaluation dated 7/18/11 indicated the resident required maximum assistance with ambulation and transfers. Interview on 12/07/11 at 12:20 p.m, the Registered Physical Therapist (RPT) revealed the resident's current condition was unchanged from the time she returned the facility following the fall. The resident received Physical Therapy (PT) after the fall and made very little progress. She further stated the resident was fully ambulatory and wandered on the unit prior to the fall, and when receiving therapy the resident required maximum assistance with transfers and ambulation. During observations on 12/07/11 at 9:00 a.m. the resident was sitting in a wheelchair in the day room, was constantly chattering and speech was unintelligible. During and interview on 12/07/11 11:30 a.m. the MDS coordinator stated the resident was ambulatory and was taking herself to the bathroom and was only occasionally incontinent before her fall. She further stated since she came back to the facility after the fall her condition had severely declined. Review of the quarterly MDS dated [DATE] revealed the resident required extensive assistance with transfers and dressing, was totally dependent with personal hygiene and was always incontinent. The resident did … | 2016-07-01 |
| 8059 | 8059 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 279 | D | 0 | 1 | VJEI11 | Based on observation, record review and staff interview with facility failed to develop a comprehensive care plan to address dental concerns for one (1) resident (#119) on a sample of thirty-nine (39) residents. Observation of the teeth of resident #119 on 12/07/11 at 10:00 a.m. revealed the resident had missing teeth in the front along with a broken tooth. Review of the annual Minimum Data Set (MDS) assessment completed on 10/25/11 revealed the resident was assessed as having missing and broken natural teeth. The Care Area Assessment (CAA) worksheet dated 10/25/11 indicated the resident had missing and broken natural teeth. The worksheet further indicated the resident had cognitive impairments and decreased mobility limiting his ability to perform personal hygiene. Care planning considerations on the worksheet indicated the resident's dental concerns would be addressed in the care plan Review of the comprehensive care plan revealed no evidence of a care plan to address the resident's dental needs. During an Interview on 12/07/11 at 3:00 p.m. the MDS coordinator confirmed a care plan to address the resident's dental needs had not been developed. | 2016-07-01 |
| 8060 | 8060 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 282 | D | 0 | 1 | VJEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident and staff interview the facility failed to follow the Comprehensive Care Plan for two (2) residents, # 129 and C of thirty-nine (39) sampled residents by not correctly applying a restraint device for resident # 129 and not providing oral care to resident C. Findings include: Resident # 129 was observed sitting in his wheelchair at an activity on 12/05/11 at 10:30 a.m. A soft waist belt was observed around his waist but it was not secured correctly in the back of the wheelchair. The ties were not crisscrossed and were very loosely looped over the back legs. The resident was observed on 12/06/11 at 9:00 a.m. in his room sitting in his wheelchair with the soft waist belt again not crisscrossed and the tie on the right side not looped around the back leg of the chair. Review of Fall Risk Assessments for each quarter dating back to the resident's admission on 9/3/2011 revealed he was assessed a high risk for falls. Review of the current Comprehensive Care Plan revealed an intervention to apply the soft belt correctly. It was added on 3/18/11 when the resident sustained [REDACTED]. The Director of Nursing (DON) was interviewed on 12/08/11 at 11:10 a.m. and stated the ties for the soft waist belt should be crisscrossed in the back of the wheelchair and looped securely over the bottom back legs of the wheelchair. She further stated an inservice would have to be done to make sure all staff knew the correct way to apply the belt. 2. During resident interview on 12/06/11 at 8:41 a.m. resident C revealed staff did not brush the resident's teeth as needed. Observation of the resident's teeth at that time revealed there was dried food particles present and they needed brushing. Record review revealed the resident had her own teeth. Review of the care plan for resident C dated 10/19/10 and reviewed quarterly revealed an intervention to provide total assistance for oral care daily. Review of the clinical recor… | 2016-07-01 |
| 8061 | 8061 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 309 | D | 0 | 1 | VJEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to follow physician orders [REDACTED].#115 and #175) of the sampled of thirty-nine (39) residents. Findings include: 1. Review of the November 2011 physician orders [REDACTED]. On two (2) days, 11/1/11 and 11/3/11, the residents B/P was above 175 mmHg. On 11/1/11 the B/P measured 176/71 mmHg and on 11/3/11 the B/P was 188/78 mmHg. Review of the November 2011 Medication Administration Record [REDACTED]. On 11/10/11, review of the MAR indicated [REDACTED]. Interview on 12/7/11 at 10:50 a.m. with Licensed Practical Nurse (LPN) OO revealed she needed to clarify the physician order. She confirmed the resident should have received the [MEDICATION NAME] on 11/01/11 and 11/03/11 and she should not have given the medication on 11/10/11. 2. Record review of resident #175 revealed a physician order [REDACTED]. Review of weight records dated 9/11/11 through 11/15/11 revealed a ten (10) pound weight loss. Review of a physician's dated 11/17/11 revealed an order to serve the resident whole milk three (3) times a day. Observation on 12/07/11 at 7:30 a.m. revealed the resident was served and consumed two percent (2%) milk. Observation on 12/07/11 at 12:40 p.m revealed the resident received and consumed 2% milk. Interview on 12/07/11 at 12:40 p.m. the Dietary Supervisor confirmed the resident was to receive whole milk not the 2% milk that was served. | 2016-07-01 |
| 8062 | 8062 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 312 | D | 0 | 1 | VJEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide the necessary services to maintain good oral hygiene for one (1) dependent resident, resident C on a sample of thirty-nine (39) residents. Findings include: Interview on 12/06/2011 at 8:41 a.m. with resident C revealed no one regularly brushed her teeth. The resident stated she did not know if she even had a toothbrush. The surveyor looked in resident's bedside table and observed a toothbrush and toothpaste in the drawer. Observation of the resident's teeth at this time revealed that they were dirty with food dried to the base of her teeth. The resident has her own teeth. Record review of the annual MDS assessment dated [DATE] revealed that resident C was assessed as being alert and oriented. Her BIMS score was 14 out of 15. Interview with Licensed Practical Nurse (LPN) NN on 12/06/2011 at 9:00 a.m. revealed that resident C was considered oriented and credible. Resident C was assessed as being dependent for ADL care and needing the assistance of one staff member. She was assessed as no problems with her teeth. Observation of the resident on 12/07/2011 at 2:30 p.m. revealed that her teeth were still dirty with food and plaque visible. She stated her teeth had not been brushed today. Interview with the unit clerk for the East Wing at this same time revealed that the Certified Nursing Assistants (CNAs) chart in the Activities of Daily Living ( ADL) book resident's care. Review of the ADL sheet for resident C revealed assessment that she needed total care for hygiene but there was no documentation to support that dental care had been provided for this resident. Review of the care plan for resident C dated 10/19/10 and reviewed quarterly revealed that staff were to provide total assistance for oral care daily. There was no documentation in the of the resident refusing oral care. | 2016-07-01 |
| 8063 | 8063 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 323 | E | 0 | 1 | VJEI11 | Based on observation, record review and staff interview the facility failed to provide an environment free from accident hazards for one resident, # 129 of thirty-nine (39) sampled residents and for one resident bathroom on the Secured Unit on the West Wing, and for one common area on one of four (4) halls on the West Wing. This was related to improperly tying a restraint for resident # 129, a loose toilet seat on the secured unit, cleaning chemicals in an unlocked closet on the West wing and a table with a loose leg used for activities in a common area on the West Wing. Findings include: 1. During initial tour of the facility, which began on 12/05/11 at 8:00 a.m., a janitor's closet on Atlanta Avenue on the West Wing was unlocked and contained a chemical dispensing system affixed to the back wall. Housekeeper II was interviewed at 8:18 a.m. stated the closet contained a chemical dispensing center that was used by housekeeping staff to refill their cleaning bottles and that it should definitely be locked. She locked it at 8:20 a.m. 2. A game table in the common area at the end of Twelve Oaks Hall had one (1) very loose and wobbly leg. This was reported 12/05/11 at 8:37 a.m. to the Marketing and Admission Coordinator who immediately removed it. 3. Resident # 129 was observed sitting in his wheelchair at an activity on 12/05/11 at 10:30 a.m. A soft waist belt was observed around his waist but it was not secured correctly in the back of the wheelchair. The ties were not crisscrossed and were very loosely looped over the back legs. The resident was observed on 12/06/11 at 9:00 a.m. in his room sitting in his wheelchair with the soft waist belt again not crisscrossed and the tie on the right side not looped around the back leg of the chair. Review of Fall Risk Assessments for each quarter beginning with the resident's admission on 9/3/2011 revealed he was a high risk for falls. The Director of Nursing (DON) was interviewed on 12/08/11 at 11:10 a.m. and stated the ties for the soft waist belt should be crisscrossed in … | 2016-07-01 |
| 8064 | 8064 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 325 | D | 0 | 1 | VJEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure appropriate interventions to address a significant weight loss were put in place for one (1) resident (# 42) on a sample of thirty-nine (39) residents. Findings include: Review of the clinical record for resident #42 revealed the resident had a weight of 137 pounds on 10/06/11 and a weight of 130 pounds on 11/11/11 resulting in a 6 pound weight loss or a loss of 5.11 percent (%) in one month. Review of the Nutrition Progress note dated 11/11/11 identified the weight loss and noted a nutritional supplement was already in place and the resident had no pressure sores. The note further states the facility would continue to monitor the weights. There were no new interventions noted to address the weight loss. Review of the Medication Administration Record [REDACTED]. The resident was also receiving a multivitamin which was ordered on [DATE]. Further review of the MAR for September and October 2011 revealed the resident would consume 50% to 100% of the supplement and in November 2011 the resident refused the supplement thirty (30) times. Further review of the clinical record indicated the resident developed a stage two (2) pressure sore on his right buttock on 11/28/11, measuring 1.5 centimeters (cm) by 1.5 cm. Review of the Weight Record revealed the resident lost an additional 1.2 pounds on 11/29/11. The Weight Loss Weekly notes from the weekly weight and would meetings were reviewed, and a note was made on 11/29/11 indicating only to continue to monitor. There was no documentation to address the continued weight loss or the development of the pressure sore. During an Interview 12/8/11 at 10:30 a.m. the Director of Nursing (DON) stated the resident had been reviewed at the weekly weight and wound meeting. She confirmed the resident developed a Stage II pressure sore on the right buttocks on 11/28/11. She also confirmed there were no new interventions put into place after the… | 2016-07-01 |
| 8065 | 8065 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 456 | F | 0 | 1 | VJEI11 | Based on observation and staff interview the facility failed to ensure that the mechanical dishwasher was maintained according to the manufacturer's recommendations. This affected all residents on oral alimentation (census = 131). Findings include: An observation made in the facility's kitchen during the initial tour on 12/5/11 at 8:30 a.m. revealed that the dishwasher's final rinse temperature gauge was not working. A check of the internal temperature via the use of a capillary thermometer verified that the final rinse temperature was at or above the recommended operating level. This observation was confirmed by the facility's Maintenance Director. | 2016-07-01 |
| 8066 | 8066 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 465 | B | 0 | 1 | VJEI11 | Based on observation and staff interview the facility failed to provide a sanitary environment related to equipment in the nourishment center for residents on one (1) wing (East), of three (3) wings. Findings include: During environmental tour of the East Wing on 12/08/2011 at 10:35 a.m. the refrigerator, used for residents, in the nourishment center was observed to have loose and torn insulation gasket on the bottom of the refrigerator door. The floor of the freezer section of this refrigerator had frozen food spills on it. The microwave oven in the nourishment center was observed to have food spills and splatters on the walls and a dirty paper towel covered the glass turntable. Interview with the Unit Manager on 12/08/11 at 10:45 a.m. revealed she was not aware of the loose and torn gasket on the refrigerator door. | 2016-07-01 |
| 8067 | 8067 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 514 | E | 0 | 1 | VJEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facilty failed to maintain accurate documentation in the clinical record for three (3) residents (#165, #3, and #130) of a sample of thirty-nine (39) residents. 1. During the medication pass on 12/07/2011 at 9:30 a.m. review of the current physician orders [REDACTED]. The resident was not observed to receive this medication. Interview with the staff nurse, Licensed Practical Nurse (LPN) AA on 12/07/11 at 9:40 a.m. revealed that the medication had been discontinued on 11/21/11 on the Medication Administration Record [REDACTED]. There was not a telephone order on the medical record related to this medication being discontinued. Interview on 12/07/11 at 10:30 a.m. with the Nurse Consultant revealed that they could not locate the telephone order to discontinue the Spriva for resident #165. 2. Resident #3 had new Physician order [REDACTED]. Licensed Practical Nurse (LPN) EE was observed on 12/07/11 at 10:00 a.m. doing the treatments. She followed the orders written on 11/28/11. Review of the Treatment Administration Record (TAR) revealed the orders written on 11/28/11 were current. Review of the current Physician order [REDACTED]. LPN EE was interviewed on 12/08/11 at 10:00 a.m. She stated the treatment orders written on 11/28/11 were correct and they were not updated on the new order sheets for 12/01/11. She agreed this would be confusing. 3. Record Review for resident #130 revealed an admission date of [DATE]. Review of the activity log dated 11/01/11 and 11/02/11, revealed documentation that the resident had participated in activities prior to admission to the facility Interview on 12/07/11 a.m. at 9:54 a.m. with the Activity Director (AD) revealed that resident was not in the facility on 11/01/11 and 11/02/11. Further review of records revealed a physician's orders [REDACTED]. Review of Nurses note dated 11/16/11 at 3:50 p.m. revealed the resident returned from the appointment with n… | 2016-07-01 |
| 8167 | 8167 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2011-12-08 | 225 | D | 0 | 1 | GPWF11 | Based on resident, staff interviews, and review of facility policy, the facility failed to ensure that an allegation of verbal abuse from one (1) resident (RR) from a sample of forty-four (44) residents was reported to the State survey and certification agency timely. Findings include: Interview on 12/6/11 at 2:58 pm with resident RR revealed that on 12/5/11 the room was real hot and that he turned the air conditioner up to reduce the heat. He further revealed that his roommate SS became upset and came over to his bed and pulled back his curtains and stoop over him with his fist balled up threatening to hit him if he moved. Resident RR revealed that his roommate SS told him to get up and come to the door so he could knock him down. RR further revealed that roommate SS stepped away and called him white trash and said to go F___ your mother. Resident RR revealed that he reported the incident to the nurse and they did not say anything. He further revealed that he reported the incident to C2-Unit Manager, the Director of Nursing (DON) and the Social Worker. Interview on 12/7/11 at 2:30 pm with the Unit Manager on C2-Hall revealed that resident RR and his roommates can not get along. Interview on 12/8/11 at 8:00 am with the Director of Nursing ( DON) revealed that this allegation with resident RR is under investigation and the residents have been separated. Interview on 12/8/11 at 9:27 am with the Social Worker Service revealed that resident RR gave her a complaint about SS on Monday and wants resident SS moved. The social service worker provided documentation of a grievance/complaint reported dated 12/5/2011 related to this allegation. Interview on 12/8/11 at 11:30 am with the Administrator, who is the facility's Abuse Coordinator, revealed that there was no report filed with the state related to this allegation of verbal and possible physical abuse and that it should have been reported. He further revealed that it is the facility's policy to interview everyone involved and determine if the incident occurred. He also… | 2016-06-01 |
| 8168 | 8168 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2011-12-08 | 287 | E | 0 | 1 | GPWF11 | Based on review of the facility and state agency records and interview with facility staff and state agency staff, the facility failed to ensure eleven (11) Minimum Data Set (MDS) assessment information was transmitted in a timely manner. Finding includes: Review of the State survey agency records revealed that the facility had eleven (11) late or missing MDS assessments as of 12/5/2011. Interview with the MDS staff on 12/7/2011 at 11:00a.m. revealed that they were not aware that they were behind in any transmission of assessments. Staff further revealed that problems have occurred with transmitting since the 3.0 change over. Interview with State agency MDS Transmittal staff on 12/06/2011 at 10:30a.m. reveal the facility had eleven (11) current late or missing assessments. State Agency staff further revealed that the facility had not contacted the state agency regarding the eleven (11) assessments or any problems related to 3.0. | 2016-06-01 |
| 8169 | 8169 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2011-12-08 | 371 | E | 0 | 1 | GPWF11 | Based on observations, staff interview and review of facility policy, the facility failed to store food properly and under sanitary conditions in one (1) of two (2) freezers, in one (1) of two (2) refrigerators and the vent from the dishmachine. Findings include: Observation conducted during tour of the kitchen on 12/05/2011 at 8:15 a.m. with the Kitchen Manager, revealed there were cooked turkey breasts and legs stored in the freezer covered with plastic wrap. The legs had broken through the plastic wrap allowing the meat to be exposed to the cold air, and there was visible freezer burn with ice crystals and dryness on the meat. There was also a pan of sausage stored in the same freezer that was partially covered by plastic wrap that had visible freezer burn with ice crystals and dryness on the sausage. The dietary manager acknowledged that they were stored improperly. The freezer also contained a clear bag of food on a rack that was out of it's original box that had been opened. The bag was not sealed, labeled or dated. Further observations of the refrigerator revealed a carton of grape tomatoes that had visible mold growing on the tomatoes. There was a container of Hummus and cottage cheese that had been partially used with no open date. The freezer contained a clear bag of food on the rack, out of it's original box that had been opened. The bag was not sealed, and it had no label and no date on it. Staff identified it as diced turkey, and discarded it. Review of facility policy reveals that unused portions and open packages must be covered, labeled and dated. Continues observations of the kitchen on 12/05/2011 at 8:15 a.m. with the Kitchen Manager, revealed that the dishwasher had an attached steam vent coming off the machine, where the clean dishes come out of the machine, that extended up into the ceiling. The vent had peeling duct tape around it with brown grease and grime on it. This situation extended from the dishwasher to the ceiling. The vent was also covered with dust balls all the way up to the ceil… | 2016-06-01 |
| 8170 | 8170 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2011-12-08 | 431 | E | 0 | 1 | GPWF11 | Based on observation, staff interviews and review of the facility policy and procedure for Medication Emergency Boxes (E-Box), the facility failed to ensure that one (1) of five (5) refrigerated Emergency Boxes was locked and failed to ensure that medications were not expired in one (1) box located in medication refrigerator on one (1) unit (A-2) of five (5)units. Findings include: 1. Observation of the refrigerated E-Box on A-2 Unit on 12-05-11 at 2:00pm revealed the box was not locked. Review of the medication sign out slips located in the E-Box indicated one (1) of two (2) injectable vials of Ativan had been signed out on 09-19-11 at 8:30am and another one was signed out on 11-22-11 at 12:10pm. Interview with the interim Unit Manager BB on 12-05-11 at 2:00pm revealed each time the E-box was opened, it was supposed to be resealed and the pharmacy was notified to replace the box. Interview with the Director of Nursing (DON) on 12-07-11 at 8:35am revealed the refrigerated E-Box could be opened more than one time before re-ordering but should be re-sealed each time. The pharmacy checks the medication refrigerator monthly for the security of the E-Box, as well as for expired medications and she was not sure why the E-Box was not locked and medications reordered as per procedure. Interview with the Consultant Pharmacist on 12-08-11 at 12:30pm revealed the medication refrigerators were checked monthly and that the E-Boxes should only be opened once, re-sealed, and re-ordered. Review of the facility policy and procedure for Emergency Pharmacy Services and Emergency boxes indicated that after removal of a medication, the E-box was re-sealed, and re-ordered from the pharmacy. 2. Observation of the medication refrigerator on A-2 Unit on 12-05-11 at 2:00pm revealed three (3) multi-dose vials of Purified Protein Derivative (PPD) had been opened and one (1) vail of Influenza vaccine. PPD Vial # 1 was opened 07-02-11, vial # 2 was opened 07-22-11, and vial # 3 was opened 08-01-11. Vial # 2 also had a manufacturer expiration … | 2016-06-01 |
| 8171 | 8171 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2011-12-08 | 463 | D | 0 | 1 | GPWF11 | Based on observations, and resident interviews, the facility failed to ensure that the call lights in resident rooms were functioning properly for two resident rooms (A119A and B120B ) on two (2) of five (5) halls. Findings include: During environmental rounds conducted with the Facility Maintenance Staff CC on 12/6/2011 from 9:00 a.m. to10:00 a.m. revealed that the call light in resident rooms A-119A and B-120B did not work. Interview with resident XX conducted on 12/6/2011 at 9:45 a.m. revealed that the call light has not worked for over a month, and that staff were aware. | 2016-06-01 |
| 8257 | 8257 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 157 | D | 0 | 1 | XSF511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined that the facility failed to notify one resident's (#19) responsible party in a timely manner about a significant change in physical condition from a total sample of 29 residents. Findings include: There was a 10/21/11 at 3 p.m. nurse's note which documented that the physician had ordered an x-ray of resident #19's right knee for his/her complaints of pain and [MEDICAL CONDITION]. The 10/24/11 x-ray report of the right knee documented that there was a fracture involving the right supracondylar femur with moderate healing. On 10/25/11, the physician ordered that the resident be referred to an orthopedist. However, there was not any evidence in the clinical record that the facility had notified the resident's responsible party about the order for the x-ray, the results of the x-ray, and the order for the orthopedic consultation until 11/2/11. | 2016-05-01 |
| 8258 | 8258 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 242 | D | 0 | 1 | XSF511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with staff and family, and record review, it was determined that the facility failed to ensure the right of one resident's (D) choice to be assisted out of bed more frequently in a sample of 29 residents. Findings include: Resident D had [DIAGNOSES REDACTED]. During observations on 12/5/11 between 11 a.m. and 4:00 p.m., on 12/6/11 between 7:30 a.m. and 5:00 p.m., on 12/7/11 between 7:30 a.m. and 5:00 p.m., and on 12/8/11 between 8:00 a.m. and 3:00 p.m., resident D was in bed. During an interview on 12/5/11 at 2:00 p.m., the family member of resident D said that the resident was not gotten out of bed into a chair daily however, the resident's preference would have been to get up for at least some time every day. Review of the clinical record revealed that there was not any documentation that getting resident D out of bed into a chair was clinically contraindicated for him/her. According the therapist's documentation on the 2010 Physical Therapy Summary, facility staff did not get the resident out of bed into a chair. Certified Nursing Assistant (CNA) DD stated that the resident was gotten up into a reclining shower chair for showers and that he/she seemed to like it. At that time, a CNA, who worked on the 7 a.m. to 3 p.m. shift, said that staff only got the resident up in a chair and to the dining room once or twice a month when his/her room was being deep cleaned. In an interview on 12/8/11 at 12 noon, skilled therapy staff EE said that he/she did not see a reason that the resident could not be gotten out of bed into a chair. Although nursing staff's documentation and interviews revealed that the resident had the ability to be out of bed and up in a chair, there was no evidence that the facility had addressed the resident's preference and provided the assistance needed for him/her to be out of bed on a more frequent basis. | 2016-05-01 |
| 8259 | 8259 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 253 | B | 0 | 1 | XSF511 | Based on observations, it was determined that the facility failed to maintain the environment free of unpainted walls, holes in a wall, dirt on doorframes and a merri-walker and a correctly hung shower curtains in isolated areas on all three halls (A, B and C). Findings include: Observations were made during the environmental tour of the facility on 12/8/11 at 2:00 p.m 1. The paint had peeled off of the wall in four (4) areas at head of the bed in room A3. There was a small hole in the wall next to the window. 2. Two areas outside the bathroom door in room A1 were unpainted. Each area was approximately 3 inches by 4 inches in diameter. 3. There was an accumulation of wax and dirt at the bottom of the door frames at the entrances to rooms on A hall. 4. Patches of paint had peeled off of the locking doors for A hall's special care unit. 5. There was a plastic curtain hanging across the doorway to C hsll's, men's common shower room The top of the plastic curtain was torn which prevented the hooks from holding it straight. 6. There were dried food smears on the front bar and the bottom side bar of a PVC meriwalker parked on B hall. | 2016-05-01 |
| 8260 | 8260 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 279 | D | 0 | 1 | XSF511 | **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 develop, review and revise the comprehensive care plan for one resident (#24) to include the services to address his/her contractures in a sample of 29 residents. Findings include: Resident #24 had [DIAGNOSES REDACTED]. Licensed staff had coded him/her on the 11/3/11 Minimum Data Set (MDS) assessment as having functional impairments of both lower extremities. However they did not code Specialized rehabilitation and restorative services to indicated that they had been or were being provide. There was a care plan since 10/21/09 to address the resident's potential for pain related to contractures of his/her lower extremities. There was a care plan since 1/08/10 to address his/her decreased mobility. However, the facility had not developed a care plan for the resident's problem of lower extremity contractures. There were not any interventions on the resident's 10/21/09 and 1/08/10 care plans to address the services to be provided to maintain or improve the resident's range of motion ability in his/her lower extremities. See F318 for additional information regarding resident #24. | 2016-05-01 |
| 8261 | 8261 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 280 | D | 0 | 1 | XSF511 | Based on record review, it was determined that the facility failed to revise the care plan to reflect one resident's (#19) use of a knee brace, weight bearing status, and transfer status from a total sample of 29 residents. Findings include: On 11/4/11, resident #19's orthopedic physician ordered that he/she be non-weight bearing, to toe-touch weight bearing and wear a hinged knee brace on his/her right knee. On 11/28/11, the physical therapist documented that the resident was fitted for the knee brace and staff had been educated about putting on and taking off the brace and the use of two persons or Hoyer lift for transfer to and from his/her bed. However, review of the resident's care plan revealed that facility staff had not revised it to include his/her the use of the right knee brace, weight bearing status and the use of two (2) people or a Hoyer lift for transfers. | 2016-05-01 |
| 8262 | 8262 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 281 | D | 0 | 1 | XSF511 | Based on record review and staff interview, it was determined that licensed nursing staff failed to follow up with the physician to ensure timely notification of abnormal laboratory results for one resident (#30) from a total sample of 29 residents. Findings include: Resident #30 had an abnormal urinalysis on 11/16/11. Licensed nursing staff documented on the laboratory report that the results were faxed to the physician on 11/16/11. However, after receiving no response, there was no evidence licensed nursing staff followed up with the physician until 11/19/11. At that time, the physician ordered Cipro,an antibiotic. On 11/23/11, the facility received the resident's urinary culture report. The report documented that the bacteria in the resident's urine was resistant to the Cipro. Licensed nursing staff documented on the laboratory report that the results were faxed to the physician on 11/23/11. However, after receiving no response, there was no evidence licensed nursing staff followed up with the physician until 11/26/11. At that time, the physician ordered a new antibiotic Licensed nurses BB and HH confirmed on 12/7/11 at 3:40 p.m. that nursing staff did not follow up with the physician about the 11/16/11 abnormal urinalysis results until 11/19/11 and the 11/23/11 abnormal urine culture report until 11/26/11. | 2016-05-01 |
| 8263 | 8263 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 282 | D | 0 | 1 | XSF511 | Based on observations, staff interview and record review, it was determined that the facility failed to implement planned interventions to promote the safety of one resident (W) with a risk of falls, and to provide assistance with personal hygiene for two residents (#75 and #25) in a total sample of 29 residents. Findings include: 1. Resident W had a care plan since 2/7/11 for being at risk for falls. There was an intervention for nursing staff to keep his/her call light within reach and for the resident to ask for assistance. However, it was observed that the resident's call light did not work on 12/5/11 at 3:27 p.m., 12/7/11 at 10 a.m., and on 12/8/11 at 8:45 a.m. and 9 a.m. See F323 for additional information regarding resident W. 2. Resident #75 was coded on the 11/18/11 Minimum Data Set (MDS) assessment as needing total assistance for personal hygiene. There was a care plan since 5/27/10 to address his/her self care deficit with an intervention for nursing staff to shave him as needed. However, the resident was observed not to have been shaved on 12/5/11 between 12:45 p.m. and 1 p.m., and 3 p.m., 12/6/11 at 8:30 a.m., 12/7/11 at 8:15 a.m. and 2:40 p.m., and on 12/8/11 at 8:30 a.m. See F312 for additional information regarding resident #75. 3. Resident #25 was coded on the 10/11/11 Minimum Data Set (MDS) assessment as needing total assistance with activities of daily living, including personal hygiene. There was a care plan since 3/17/10 to address his/her need for assistance with personal hygiene related to his/her visual deficit, poor attention span, cognitive impairment and poor coordination and balance. There was an intervention for nursing staff to comb the resident's hair daily. However, during observations on 12/6/11 at 7:30 a.m. and on 12/8/11 between 9:30 a.m. and 11:45 a.m., nursing staff had not combed the resident's hair. See F312 for additional information regarding resident #25. | 2016-05-01 |
| 8264 | 8264 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 309 | D | 0 | 1 | XSF511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to follow physician's orders for monitoring an AV graft site and chest catheter site for one resident (#98) who received [MEDICAL TREATMENT] from a total sample of 29 residents. Findings include: According to the Quick Reference Guide for the Management and Care of [MEDICAL TREATMENT] Residents provided by the facility, the licensed nurse was supposed to auscultate the AV graft for bruit and palpate for thrill each shift and document findings. However, licensed nursing staff failed to document those assessments for resident #98. Resident #98 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a catheter in his/her left upper chest that was the designated [MEDICAL TREATMENT] access device and an AV graft in his/her left upper extremity. The resident received [MEDICAL TREATMENT] every Monday, Wednesday and Friday. The resident had an 11/30/11 physician's order for licensed nursing staff to auscultate the AV graft site for bruit and to palpate thrill every shift, to monitor the AV graft site for infection, [MEDICAL CONDITION] and bleeding and, to apply pressure for 15 minutes if the site was bleeding and notify the physician if bleeding did not stop as needed. There was a care plan intervention since 12/2/11 for licensed nursing staff to observe the resident's left chest catheter site after [MEDICAL TREATMENT] for excess bleeding and to notify the physician if present. On 12/8/11 at 12:35 p.m., licensed nurse GG stated that she/he monitored the resident's AV graft site every shift for bruit/thrill, bleeding, [MEDICAL CONDITION] and infection. GG stated that she/he monitored the resident's left chest catheter site for bleeding after the resident returned from [MEDICAL TREATMENT]. However, GG stated that she/he did not document having done those assessments. Review of the nurses' notes from 11/30/11 to 12/3/11 and of the resident's Treatment Admin… | 2016-05-01 |
| 8265 | 8265 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 312 | D | 0 | 1 | XSF511 | Based on observations, staff interview and record review, it was determined that the facility failed to provide assistance with personal hygiene for two residents (#75 and #25) in a sample of 29 residents. Findings include: 1. Resident #75 was coded on the 11/18/11 Minimum Data Set (MDS) assessment as needing total assistance for personal hygiene. There was a care plan since 5/27/10 to address his/her self care deficit with an intervention for nursing staff to shave him/her as needed. However, the resident was observed to have been unshaved on 12/5/11 between 12:45 p.m. and 1 p.m., and 3 p.m., 12/6/11 at 8:30 a.m., 12/7/11 at 8:15 a.m. and 2:40 p.m., and on 12/8/11 at 8:30 a.m. Certified nursing assistant (CNA) QQ stated on 12/8/11 at 8:30 a.m., the resident was supposed to shaved on the days he/she received a bath. A review of the Activities of Daily Living (ADL) book documentation revealed that the staff had bathed resident on 12/7/11. 2. Resident #25 was coded on the 10/11/11 Minimum Data Set (MDS) assessment as needing total assistance with activities of daily living, including personal hygiene. There was a care plan since 3/17/10 to address his/her need for assistance with personal hygiene related to his/her visual deficit, poor attention span, cognitive impairment and poor coordination and balance. There was an intervention for nursing staff to comb the resident's hair daily. However, during observations of the resident in bed on 12/6 at 7:30 a.m. and on 12/8/11 between 9:30 a.m. and 11:45 a.m., nursing staff had not combed the resident's hair. During an interview on 12/8/11 at 9:30 a.m., certified nursing assistant (CNA) AA, assigned to provide care for the resident, stated that all she did was provide incontinence care as needed for resident #25. She said that the night shift CNAs provided all of the other care for him/her. | 2016-05-01 |
| 8266 | 8266 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 318 | D | 0 | 1 | XSF511 | **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 ensure that two residents (#15 and #24) with limited range of motion received appropriate services and the application of positioning devices as planned in a total sample of 29 residents. Findings include: 1. Resident #15 had [DIAGNOSES REDACTED]. He/She was coded on the 9/17/11 Minimum Data Set (MDS) assessment as having functional impairments on both sides of his/her upper and lower extremities. There was a care plan since 8/18/10 with an intervention for nursing staff to perform active and passive range of motion exercises to all of the resident's extremities and through all planes of motion, daily seven days a week. There was a care plan since 7/5/11 to address the resident's requirement for a splint/brace to both of his/her hands and elbows related to contracture management. That plan had interventions for nursing staff to provide range of motion exercises prior to splint placement. There were physician's orders [REDACTED]. There was a 7/24/09 Rehabilitation Screening form that noted the resident might benefit from physical therapy services to establish a restorative program. The 7/27 - 8/07/09 Physical Therapy Initial Plan of Treatment Evaluation form documented that a restorative program was established to maintain range of motion and prevent contractures. The November 2011 Restorative Nursing Program Flow Sheet documentation recorded that the resident was discontinued from restorative services on 11/06/11 and that certified nursing assistants (CNAs) were to do passive range of motion exercises to both of the resident's upper extremities while providing care prior to splint placement. During an interview on 12/8/11 at 1 p.m., licensed nurse BB stated that the designated nursing staff to provide restorative services had been discontinued in August or September of 2010. She said that the floor CNAs now provided those services for resi… | 2016-05-01 |
| 8267 | 8267 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 323 | D | 0 | 1 | XSF511 | Based on observation, interviews with a resident and staff, and record review, it was determined that the facility failed to ensure that one resident (W) had a working call light to call for staff assistance from a total sample of 29 residents. Findings include: Resident W had a care plan since 2/7/11 for being at risk for falls. There were interventions for nursing staff to keep the call light within reach and for the resident to ask for assistance. However, the resident's call light was observed to not have been working on 12/5/11 at 3:27 p.m., 12/7/11 at 10 a.m., and on 12/8/11 at 8:45 a.m. and 9 a.m. On 12/8/11 at 8:45 a.m., resident W stated that his/her call light had not worked for a week. The resident stated that he/she had told facility staff who had entered his/her room. The resident stated that, on 12/7/11 during the afternoon shift, he/she had needed a staff member to come turn off the air conditioner in his/her room. He/she used the call light and nothing happened so, he/she had yelled out and a certified nursing assistant (CNA) had come in. The resident stated that he/she had told that CNA that the call light did not work. The CNA told the resident that she would write up a work order. However, there was no evidence a work order had been completed. The Administrator stated on 12/8/11 at 9:25 a.m. that maintenance staff had replaced the resident's call light the previous week but, no one had reported that it was not working again. | 2016-05-01 |
| 8268 | 8268 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 364 | E | 0 | 1 | XSF511 | Based on observations and interviews with residents, it was determined that the facility failed to consistently provide food that was palatable to residents and at the proper temperature in a census of 73 residents who consumed oral diets. Findings include: During the initial tour on 12/5/11 at 11 a.m., residents E and B stated that the facility ran out of coffee and food items. Resident B stated that the sausage patties were not cooked well enough. Resident C stated that Northern beans were cooked too soft. On 12/8/11 at 2:50 p.m., resident F reported that the food did not taste good. He/She said that the food was overcooked, especially the vegetables. Observation in the main dining room on 12/5/11 at 1:30 p.m. revealed that 10 of the 24 residents did not eat the greens and 11 of the 24 residents did not eat the fruit cocktail. A review of the grievance log documentation revealed that there had been 11 complaints in 11 months about the food served. A review of the Resident Council meeting minutes revealed that there had been food complaints three times in five months from May through October 2011. Those complaints included the food was not good, food delivered cold, food cooked too hard, vegetables not done, not enough food, cold coffee and undercooked food. The facility's action plans to respond included inservice and re-education of staff, updated care cards and one-to-one interviews. On 12/6/11 at 7:20 a.m., the temperature of the hot food on the breakfast trays for B hall were 120 degrees Fahrenheit (F.). The coffee was 140 degrees F. On 12/7/11 at 12:45 p.m., a test tray for palatability revealed that the rice was overcooked. It was pasty and mushy. The broccoli was soft with minimal form to it. | 2016-05-01 |
| 8269 | 8269 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 366 | E | 0 | 1 | XSF511 | Based on observation, resident interview and record review, it was determined that the facility failed to offer and provide substitutes to residents who refused and/or did not eat the food served in a census of 73 residents who were served oral diets. Findings include: During the initial tour on 12/5/11 at 11:00 a.m., resident B stated that substitutes were not offered for vegetables. Resident G stated that if a resident asked for an alternate food item, they were given a sandwich. Observation of lunch on 12/5/11 at 1:00 p.m. revealed that 11 of the 24 residents did not eat the fruit cocktail and 10 of 24 residents did not eat the greens. However, staff did not offer a substitute food item of similar nutritive value. A review of the facility's grievance file documentation revealed a complaint about substitutes not being offered in October 2011. The form noted that the complaint had been resolved with inservice and re-education of staff. On 12/8/11 at 2:50 p.m., another resident, F, complained that he/she was not offered a substitute if a food was not eaten. | 2016-05-01 |
| 8270 | 8270 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 371 | E | 0 | 1 | XSF511 | Based on observations, it was determined that the facility failed to maintain sanitary and cleanable surfaces in isolated areas of the kitchen area. Findings include: Observations were made during the kitchen observation tour with the dietary manager on 12/7/11 at 3:30 p.m 1. There was a removable white film on the plastic crates that contained clean plates, cups, and bowls. 2. There was an approximately three foot by four foot section of floor tiles missing in front of cooler #1. 3. The laminated cardboard shelving beneath the preparation tables that were next to and behind the steam table had worn edges with exposed cardboard. 4. The ice machine located outside of the kitchen had a scattered dark material on the plastic chute inside the bin. | 2016-05-01 |
| 8271 | 8271 | FOLKSTON PARK | 115630 | 36261 NORTH OKEFENOKEE DRIVE | FOLKSTON | GA | 31537 | 2011-12-08 | 406 | D | 0 | 1 | XSF511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide or obtain the mental health services necessary to meet the psychosocial needs of one resident (#56) who required a preadmission screening (PASRR II) in a total sample of 29 residents. Findings include: Resident #56 was admitted with [DIAGNOSES REDACTED]. On June 23, 2011, the physician signed a preadmission screening that documented that the resident had been referred to skilled nursing facility placement as part of his/her discharge/rehab plan. The screening assessment noted the resident's long history of depression and [DIAGNOSES REDACTED]. The assessment documented that the resident would benefit from group/individual counseling and case management services. However, there was no evidence that the facility had provided or obtained counseling and case management services for the resident. On 12/7/11 at 10:30 a.m., licensed nurse BB said that the facility was waiting for a call from the physician for a referral to psychiatric services. After surveyor inquiry, a case manager evaluated the resident that same day. | 2016-05-01 |
| 8286 | 8286 | AZALEALAND NURSING HOME | 115534 | 2040 COLONIAL DRIVE | SAVANNAH | GA | 31406 | 2011-12-08 | 323 | E | 0 | 1 | Inf | Based on observation, record review and staff interview, the facility failed to keep water temperatures below 120 degrees Fahrenheit (F) for four (4) resident rooms on two (2) of three (3) halls, and in one (1) of three (3) common shower rooms. The facility also failed to ensure that chemicals were kept in a locked area in two (2) of three (3) common shower rooms, and one (1) Storage Room on one (1) of three (3) halls. There were seven (7) residents in the facility identified as being independently mobile and cognitively impaired. The facility census was eighty-seven (87) residents. Findings include: 1. On 12/05/11 starting at 1:35 p.m., the following water temps were taken using the surveyors' thermometers: Room 18 on the Skidaway Hall: 120.4 degrees F Common Bathroom 1 on Colonial Hall: 121.6 F Room 13 on the Colonial Hall: 123 degrees F At 2:10 p.m., the Maintenance Director checked water temps with the facility's thermometer and obtained the following readings: Colonial Bathroom 1: 120.1 degrees Room 18 on Skidaway Hall: 126 degrees; the faucet was hot to touch Room 24/25 on Skidaway Hall: 124.7 degrees The Maintenance Director stated he tried to keep the water temps between 110 and 116 degrees. 2. On 12/06/11 at 7:40 a.m., observations in the unlocked Bathroom 1 on the Colonial Hall revealed a cabinet on the wall that had a lock on it with the key inserted in the lock. However, the key did not have to be turned to open the cabinet. Contents of the cabinet included one full bottle with a screw-on cap, and one 1/3-full spray bottle of Comet Cleaner with Bleach. Labeling included that it was an eye and skin irritant, and that a physician should be called immediately if swallowed. This was verified by the Director of Nurses (DON), who said the cabinet should be kept locked. At 7: 56 a.m., observations in the unlocked Bathroom 2 on the Skidaway Hall revealed an unlocked wall cabinet that contained a full can of Betco Glybet Disinfectant spray. Label precautions included that it caused eye and skin irritation. Thi… | 2016-04-01 |
| 8287 | 8287 | AZALEALAND NURSING HOME | 115534 | 2040 COLONIAL DRIVE | SAVANNAH | GA | 31406 | 2011-12-08 | 332 | E | 0 | 1 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that their medication error rate was less than 5%. Four (4) errors out of fifty-three (53) opportunities for two (2) of ten (10) residents were noted by two (2) nurses on one (1) of three (3) halls for a med error rate of 7.54%. Findings include: On 12/06/11 at 9:55 a.m., Licensed Practical Nurse (LPN) 'AA' was noted to give resident # 115 his/her morning medications, including [MEDICATION NAME], and [MEDICATION NAME]. Later review of the physician's orders [REDACTED].#115 at 8:00 a.m. This was verified by LPN 'AA' at 2:20 p.m. On 12/06/11 at 4:05 p.m., LPN 'BB' was noted to give resident # 31 the medications Carvedilol and [MEDICATION NAME]. Later review of the physician's orders [REDACTED]. This was verified by LPN 'BB,' who stated she usually gave the Carvedilol at the same time as the [MEDICATION NAME]. On 12/07/11 at 3:15 p.m., the Director of Nurses (DON) stated the staff had one hour before, and one hour after the scheduled time to give a med. | 2016-04-01 |
| 8288 | 8288 | AZALEALAND NURSING HOME | 115534 | 2040 COLONIAL DRIVE | SAVANNAH | GA | 31406 | 2011-12-08 | 505 | D | 0 | 1 | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure for one (1) resident (#88), that follow up on abnormal laboratory results with the physician was done in a timely manner. Findings include: Resident #88 who had multiple [DIAGNOSES REDACTED]. Record review revealed the resident had a critical high potassium blood result on 11/23/11 of 6.4 (normal is 3.5-5.3). The physician ordered the administration of [MEDICATION NAME] 30 grams and a second dose to be given on 11/24/11. The potassium level was to be checked six (6) hours after the second dose was administered. The order was modified to give the second dose of [MEDICATION NAME] 30 grams on 11/25/11 and then repeat the potassium level. On 11/25/11 the potassium level was elevated at 5.5. The lab results were faxed to the physician's office on 11/26/11. Review of the resident's record did not reveal follow up from the physician or the facility staff. An interview with Register Nurse (RN) CC, Unit Manager on 12/07/11 at 11:57 p.m. revealed that she had not received a response from the physician regarding the elevated lab results and should have followed up with the physician to verify the need for addition medication or labs. An interview with the Director of Nursing (DON) on 12/07/11 at 1:20 p.m. revealed it was the Unit Manager's responsibility for ensuring follow up on all laboratory results. | 2016-04-01 |
| 8753 | 8753 | CLINCH HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2011-12-08 | 166 | D | 0 | 1 | Z9XU11 | Based on observations, review of the facility's grievance policy, and staff interview, it was determined that the facility failed to keep the residents apprised of the facility's progress toward a resolution of reported grievances about missing items for three residents (C, A , and D) in a total sample of 26 residents. Findings include: The facility's Resident Grievance Procedure was that a Grievance/Complaint Report Form was supposed to be completed and given to the Social Services Director or Administrator for a report (verbal or written) concerning theft of property, etc. within three (3) working days of the date that the grievance was filed. The resident or complainant was supposed to receive notification of the results of the facility's investigation. However, the facility failed to notify residents A, C and D regarding the results of the investigations about their reports of missing property. During an interview on 12/08/11 at 8:00 a.m., Social Services staff stated that if any resident reported missing items to her during the Resident Council meetings, a grievance form was written and given to housekeeping staff. If the housekeeping staff did not find it (the missing items) then, they were supposed to report back to her. She would then search the resident's room with the resident. 1. During an interview on 12/06/11 at 10:23 a.m., resident C said that he/she had reported to a laundry staff person that a shirt was missing for a few days but, no one had reported back to him/her about it. During a subsequent interview on 12/08/11 at 7:30 a.m., the resident said that he had reported reported the missing shirt to the laundry person again on 12/06/11 but, the resident did not know the employee's name. During the 12/6/2011 interview , the resident had added that when he/she had previously reported in October that some personal items were missing, the facility's response to him/her was that there was not enough staff. On 12/07/11 at 1:30 p.m., laundry staff person WW stated that she usually told the Director of Nur… | 2015-11-01 |
| 8754 | 8754 | CLINCH HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2011-12-08 | 225 | D | 0 | 1 | Z9XU11 | Based on review of personnel files and staff interview, it was determined that the facility failed to thoroughly investigate the past history of one employee in a sample of 11 employees. Findings include: A review of 11 employees' personnel files revealed that one did not contain evidence of the results of a criminal background check. The employee had been hired by the facility on 2/14/11 but, a criminal background check on him/her had not been done since 10/18/07. | 2015-11-01 |
| 8755 | 8755 | CLINCH HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2011-12-08 | 253 | E | 0 | 1 | Z9XU11 | Based on observations and a family interview, it was determined that the facility failed to maintain an environment that was free from urine odors on two halls (A and B), free of torn furniture on one hall (B), sagging bedframes on three halls (A, B, and C), missing toilet paper holder spindles on one hall (A) and the women's common bath, a dirty shower guerney in the women's common bath and, missing corner tiles in the men's common bath. Findings include: Observations were made during the initial tour on 12/5/11 at 12:40 p.m., at 2:45 p.m. and between 2:30 p.m. and 4:30 p.m., on 12/6/11 at 9:30 a.m., 11:30 a.m., and 1:05 p.m., and on 12/8/11 at 10:20 a.m. A Hall 1. There were urine odors in the rooms and/or bathrooms of A6, A8, A10, A11, A13 and A14. During an interview on 12/6/11 at 10:45 a.m., the family member of resident A stated he/she always smelled urine odors when visiting the resident. 2. There were sagging bedframes in rooms A2, A6, A7, A8, A9, and A13. 3. The toilet paper holder spindle was missing in the bathroom of room A13. B Hall 1. There were sagging bedframes in rooms B2B, B4B, B5A, B6B, B8B, B10B and C beds, B11B B13B, and B14B. 2. There was torn vinyl covering on the brown couch in the B hall day room. 3. On 12/5/11 at 2:45 p.m., there was a strong urine odor in room B12. On 12/6/11 at 1:05 p.m., there was not a resident present in the room but, the strong urine odor was evident. C Hall 1. There were sagging bedframes in room C2A and B beds Women's common bath 1. There was a missing toilet paper holder spindle. 2. There was a black substance under the blue cushion of the shower guerney. Men's common bath 1. There were missing tiles on the corner of the shower stall. | 2015-11-01 |
| 8756 | 8756 | CLINCH HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2011-12-08 | 279 | D | 0 | 1 | Z9XU11 | Based on observation, record review and family interview, it was determined that the facility failed to develop a plan of care to address one resident's (A) hygiene needs from a sample of 26 residents. Findings include: Resident A was assessed and coded by the facility on the 10/19/11 Minimum Data Set (MDS) significant change comprehensive assessment as requiring extensive assistance with hygiene and dressing. However, there was not a care plan developed to address the resident's needs for staff assistance with his/her dressing, bathing and hygiene needs.The resident was observed on12/6/11 at 9:45 a.m. and 11:30 a.m. drooling from his/her mouth onto his/her shirt. There was a dried white substance on his/her shirt. On 12/7/11 at 8:00 a.m., and 12:30 p.m., there was dried white drool on his/her shirt. On 12/7/11 at 12:30 p.m. during lunch, the resident had drool streaming from his/her mouth. During an interview on 12/6/11 at 10:45 a.m., the family member of resident A stated that the resident's shirt was always wet with drool when they visited him/her three times a week. See F312 for additional information regarding resident A. | 2015-11-01 |
| 8757 | 8757 | CLINCH HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2011-12-08 | 312 | D | 0 | 1 | Z9XU11 | Based on observations, record review and family interview, it was determined that the facility failed to provide assistance needed for one resident's (A) hygiene needs from a sample of 26 residents. Findings include: Resident A was assessed and coded by the facility on the 10/19/11 Minimum Data Set (MDS) assessment as requiring (staff) extensive assistance with hygiene and dressing. However, the facility had not developed a care plan interventions for staff to address his/her bathing and hygiene needs. In an interview on 12/6/11 at 10:45 a.m., the family member of resident A stated that the resident's shirt was always wet with drool when they visited him/her three times a week. The resident was observed on 12/6/11 at 9:45 a.m. and 11:30 a.m. drooling from his/her mouth onto his/her shirt. There was dried white drool on his/her shirt during observations on 12/7/11 at 8:00 a.m. and 12:30 p.m. During lunch on 12/7/11 at 12:30 p.m., the resident had drool streaming from his/her mouth. | 2015-11-01 |
| 8758 | 8758 | CLINCH HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2011-12-08 | 314 | D | 0 | 1 | Z9XU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and resident interview, it was determined that the facility failed to provide pressure relief interventions for two residents with pressure ulcers (#83 and #67) and to maintain a dressing on a coccyx pressure ulcer for one resident (#67) in a sample of three residents with pressure ulcers from a sample of 26 residents. Findings include: 1. Resident #67 had [DIAGNOSES REDACTED]., [MEDICAL CONDITION], hard of hearing, agitation, pacemaker, depression, [MEDICAL CONDITION], pressure ulcers, and an overactive bladder. There was a care plan since at least 10/03/11 with interventions to address skin care. There was an intervention for nursing staff to provide pressure relieving measures, to provide treatment as ordered and monitor for effectiveness. There was an 11/29/11 treatment record that documented the resident as having returned to the facility after debridement of a right heel ulcer. At that time, the nurse had staged the pressure sore on the resident's right heel as a stage 3. She also documented that the resident had a stage 2 pressure ulcer on his/her coccyx. During observation of pressure ulcer treatment on the resident's coccyx 12/07/11 at 2:20 p.m., the treatment nurse placed an adherent dressing on the resident's coccyx. However during an observation of the wound site with the treatment nurse on 12/08/11 at 9:30 a.m., there was not a coccyx dressing in place. In an interview at that time, the treatment nurse stated that she changed the resident's coccyx dressing every three days and as needed. She said that she had not planned to assess or change that dressing that day because, no one had reported to her that the dressing was not in place. She stated that she would not have checked the wound site until later that day. On 12/6/11 at 2:00 p.m., observation of two certified nursing assistants revealed that, although they applied foot rests to the resident's wheelchair while he/she was sitting in the … | 2015-11-01 |
| 8759 | 8759 | CLINCH HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2011-12-08 | 323 | E | 0 | 1 | Z9XU11 | **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 safely maintain bed side rails on 11 residents' beds, assistive devices for one resident (#67), and safe foot wear for one resident (# 85) in a total sample of 26 residents and a census of 92 residents. Findings include: 1. Resident #67 had been assessed by staff on 11/18/11 to be at risk for falls dur to poor safety awareness and a history of trying to get out of bed unassisted. There was a care plan to address the resident's risk of falls with an intervention for the use of supportive devices to promote positioning. There was a physician's orders [REDACTED]. However, on 12/06/11 at 12:00 p.m., two certified nursing assistants (CNAs) were observed placing foot rests on the wheelchair in which the resident was seated instead of seating him/her in a gerichair as ordered. 2. Resident #85 had a history of [REDACTED]. Although the facility developed a 10/20/11 plan of care to address the resident's risk for falls, there were not any interventions in place to address the proper non-slip footwear that the resident should wear. The resident was observed ambulating while wearing non-grip socks on 12/6/11 at 4:45 p.m. and on 12/7/11 at 8:30 a.m. and 12:30 p.m. On 12/8/11 at 7:45 a.m., the resident was not wearing non-slip socks while walking and his/her pants were too long. His/Her pants covered the top and bottom of his/her feet. During an interview on 12/8/11 at 12:25 p.m., licensed staff BB stated that the resident should wear non-slip socks when he/she was not wearing shoes. During an observation on 12/8/11 at 12:35 p.m., certified nursing assistant (CNA) CC found one of the resident's shoes in his/her closet and the other shoe jammed between the siderail of his/her bed and the wall. The shoe was dusty. 3. During environmental observations with the Maintenance supervisor on 12/07/11 beginning at 2:20 p.m., there was a three to five inch gap bet… | 2015-11-01 |
| 8760 | 8760 | CLINCH HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2011-12-08 | 327 | E | 0 | 1 | Z9XU11 | Based on observations, and staff interview, it was determined that the facility failed to provide adequate care to ensure and promote sufficient fluid intake for residents in a census of 73 residents who were not tube fed and not on fluid restrictions. Findings include: 1. Observations on C Hall on 12/5/11 at 4:15 p.m., revealed the following: a. There were pitchers of ice but not any straws and cups in rooms C3B, C4B, and C7A. b. The resident in room C5A had a pitcher of water but, no cup or straw. c. There was an empty water pitcher and, no cup or drinking straw in room C6A. 2. There not cups or straws observations in some rooms on the C hall on 12/7/11 at 9:30 a.m.: a. There were pitchers of ice but no drinking straws or cups in rooms C2A and C3B. b.There was an empty water pitcher and no cup or drinking straw in room C8A. c. There was a small amount of water in the pitcher but, no cup or straw in room C8B. 3. The following rooms were observed to either not have water available in the room or no cup or drinking straw available on the A-Hall on 12/5/11 between 12:30 p.m. and 4:30 p.m., on 12/6/11 between 9:30 a.m. and 11:30 a.m.,on 12/7/11 at 9:35 a.m. and on 12/8/11 at 9:25 am' a. Resident #77 did not have water available on 12/5/11 and 12/8/11. On 12/7/11 at 9:30 a.m., there was only a cup half full of warm water available for him/her. b.There was a pitcher with ice but, no cup or drinking straw in rooms A2B, and A7B. c. Although, tThere was a half full cup of water in room A9B, the water pitcher contained an arrangement of dead flowers. d. The water pitcher was out of the resident's reach (across the room) in room A10B. The resident was asking for something to drink. e. There was not any water available to drink in room A13A and C. 5. Observations on 12/06/11 at 10:23 a.m., and on 12/08/11 at 7:30 a.m., 10:30 a.m., and 11:30 a.m., revealed an empty pitcher on the resident's bedside in room B3B. 6. Observations were made on on the A hall on 12/07/11 beginning at 7:30 a.m. a. There were no drinking straws or c… | 2015-11-01 |
| 8761 | 8761 | CLINCH HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2011-12-08 | 428 | D | 0 | 1 | Z9XU11 | Based on staff interview and record reviews, it was determined that the facility failed to assure that the resident's physician responded to the pharmacist's recommendations in a timely manner for two residents (#2 and #75) in a total sample of 26 residents. Findings include: 1. The consultant pharmacist made a recommendation on 8/18/11 for the physician to re-evaluate the continued use of Bactrim for resident #2 and discontinue it. However, the physician did not respond to that recommendation until 10/6/11. He declined the recommendation but, did not provide a rationale for his decision. On 7/25/11, the consultant pharmacist had recommended the same action but, the physician did not respond until 8/11/11. On 5/24/11, the consultant pharmacist noted that resident #2 had been given 50 milligrams (mg) of Seroquel since July 2009. He inquired of the physician if it was the lowest dose or if the resident was stable enough to consider a dose reduction to 25 mg. However, the physician did not respond until 6/06/11. He declined the recommendation but, did not provide a rationale for his decision. 2. Resident #75 had an 7/25/11 consultant pharmacist's recommendation for a gradual dose reduction in Zyprexia to 5 mg at bedtime. However, the physician did not respond until 8/11/11. On 8/18/11, the consultant pharmacist recommended that the physician decrease the Buspar to 15 mg twice a day and noted that the resident also was given Prozac and Effexor XR. However, the physician did not respond until 10/6/11. There was an 11/28/11 consultant pharmacist's recommendation for the physician to evaluate the use of Ambien and Melatonin as duplicate as needed medications. There was not a response from the physician as of 12/08/11. During an interview on 12/8/11 at 8:57 a.m., the Director of Nursing (DON) stated that she was responsible for getting the consultant pharmacist's reports to the physician . She said that the facility had been having problems getting the physician to respond to them. She stated that she had called him nume… | 2015-11-01 |
| 9870 | 9870 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2011-12-08 | 157 | G | 1 | 0 | 1UJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Resident Occurrence Report Review, facility staff Witness Statement review, and staff interview, the facility failed to immediately consult with the physician, and notify the family, of a fall and ongoing complaints of pain for one (1) resident ("A"), on the total survey sample of nine (9) residents, after Resident "A" expressed pain after having sustained a fall which resulted in a fracture. This delay in physician consultation resulted in a delay in obtaining the necessary care and treatment for [REDACTED]. Findings include: Cross refer to F309 for more information regarding Resident "A". Review of a Resident Occurrence Report Result report which referenced Resident "A" revealed that on 05/06/2011, the resident had attempted to get up from a wheelchair and fallen, with moderate pain noted. A 05/07/2011 written Witness Statement of Restorative Aide "CC" documented that on 05/06/2011, he had seen Resident "A" in the hallway on the floor on her side. During a 12/08/2011, 9:30 a.m. interview, Administrative Nurse "GG" stated that during investigation, Aide "CC" stated he had observed Resident "A" between 5:45 p.m. and 6:08 p.m., when he clocked out. In a 05/16/2011 written Witness Statement, Certified Nursing Assistant (CNA) "EE" documented that on 05/06/2011, between 5:00 p.m. and 6:00 p.m., she had witnessed Resident "A" complaining of pain while being taken to the dining room. During the 12/08/2011, 9:30 a.m. interview, Administrative Nurse "GG" stated that dinner had been served on 05/06/2011 at approximately 6:20 p.m., and that according to information obtained from Nurse "BB", Resident "A" had been transported back to the nurse's station at approximately 6:45 p.m. A family member arrived at approximately 7:15 p.m., and the resident continued to complain of pain, but Nurse "BB" stated that although Nurse "AA" told her of the resident's earlier fall at that time, Nurse "AA" acknowledged that he had not consul… | 2015-04-01 |
| 9871 | 9871 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2011-12-08 | 309 | G | 1 | 0 | 1UJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Resident Occurrence Report Review, facility staff Witness Statement review, staff interview, and family interview, the facility failed to adequately monitor the status, and obtain timely treatment for [REDACTED]. which resulted in a fracture. This resulted in a delay in obtaining timely and necessary treatment for [REDACTED]. Findings include: Review of a Resident Occurrence Report Result form which referenced Resident "A" revealed that on 05/06/2011, the resident had attempted to get up from the wheelchair and had fallen. This report documented that upon assessment, moderate pain had been noted when the resident stood up. In a 05/07/2011 written Witness Statement of Restorative Aide "CC", this aide documented that on 05/06/2011, as he was in the hallway passing the nurse's station, he had seen Resident "A" on the floor on her side, and had assisted Nurse "AA" and Nurse "DD" to help the resident up. During a 12/08/2011, 9:30 a.m. interview with Administrative Nurse "GG", Nurse "GG" stated that during the facility's investigation into the resident's fall, Aide "CC" had stated he had observed Resident "A" on the floor in the hallway between 5:45 p.m. and when he clocked out at 6:08 p.m. In a 05/16/2011 written Witness Statement of Certified Nursing Assistant (CNA) "EE", CNA "EE" documented that on 05/06/2011, between 5:00 p.m. and 6:00 p.m., she had witnessed Resident "A" being taken to the dining room, and that the resident was yelling she was in "so much pain", and was stating "my hip". During the 12/08/2011, 9:30 a.m. interview with Administrative Nurse "GG" referenced above, Nurse "GG" stated the facility's investigation had revealed that dinner had been served in the dining room on 05/06/2011 at approximately 6:20 p.m., and acknowledged that CNA "EE" had witnessed Resident "A" being taken to the dining room on 05/06/2011 after the resident had fallen at the nurse's station. Nurse "GG" stated that, according … | 2015-04-01 |
| 9872 | 9872 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2011-12-08 | 224 | G | 1 | 0 | 1UJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Resident Occurrence Report Review, facility staff Witness Statement review, staff interview, and family interview, the facility failed to prohibit neglect, related to the provision of care after a fall resulting in a fracture, for one (1) resident ("A"), on the total survey sample of nine (9) residents. This resulted in a delay in obtaining timely pain relief and treatment for [REDACTED]. Findings include: Cross refer to F157 and F309 for additional information regarding Resident "A". Review of a Resident Occurrence Report Result form which referenced Resident "A", and completed by Nurse "AA", revealed that on 05/06/2011, the resident had attempted to get up from the wheelchair and had fallen, and that upon assessment, moderate pain had been noted when the resident stood up. However, further record review revealed no evidence to indicate that the resident received any treatment for [REDACTED]. In a 05/16/2011 written Witness Statement of Certified Nursing Assistant (CNA) "EE", CNA "EE" documented that on 05/06/2011, she had witnessed Resident "A" being taken to the dining room yelling that she was in "so much pain" and stating "my hip". However, although this observation was after the resident's fall, and although the resident continued to complain of significant pain, there was no evidence to indicate that the resident had received any treatment for [REDACTED]. A May 2011 Medication Record for Resident "A" revealed an entry, timed at 7:30 p.m. on 05/06/2011, which documented the administration of a 325 milligram dose of Tylenol by Nurse "AA". However, during a 12/08/2011, 1:39 p.m. family interview, this family member stated that Nurse "AA" had brought Resident "A" pain medication at around 7:30 p.m. on 05/06/2011 because the family member had requested something for the resident's pain. A Nurse's Note of 05/06/2011, written by Nurse "BB", documented Resident "A"'s continued complaint of pain on her right side… | 2015-04-01 |
| 9964 | 9964 | FORT GAINES HEALTH AND REHAB | 115696 | 101 HARTFORD ROAD, WEST | FORT GAINES | GA | 39851 | 2011-12-08 | 323 | D | 1 | 0 | IVK811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure adequate supervision to prevent falls, per the plan of care, for one (1) resident (#1), from five (5) residents with a history of falls, from a survey sample of six (6) residents. Findings include: Record review for Resident #1 revealed a 10/23/2011, 9:15 p.m. nursing note entry indicating that the resident was found sitting on the floor in her room by the window and facing the wall. The bed was moved from the wall to the center of the room. The resident stated that she was trying to sit on her bed when the bed rolled out from under her. The resident sustained [REDACTED]. After this fall referenced above, on 10/24/2011, there were new interventions to lock the bed and continue bed and chair alarms. However, observation of the resident on 11/23/2011 at 11:05 a.m. revealed that she was sitting up in her wheelchair in her room. There was no chair alarm observed on the wheelchair. The resident was observed again on 11/23/2011 at 4:00 p.m. while in the bed. There was no bed alarm attached to the bed. This was acknowledged by Licensed Staff "AA" during interview on 11/23/2011 at 4:00 p.m. | 2015-04-01 |
| 9965 | 9965 | FORT GAINES HEALTH AND REHAB | 115696 | 101 HARTFORD ROAD, WEST | FORT GAINES | GA | 39851 | 2011-12-08 | 314 | D | 1 | 0 | IVK811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure that the appropriate care was provided to promote the healing of existing pressure sores for one (1) resident (#4), of two (2) residents with pressure sores, from a survey sample of six (6) residents. Findings include: Record review for Resident #4 revealed that a new physician's orders [REDACTED]. This treatment was to add Santyl to the wound on the coccyx three times a week, on Monday, Wednesday and Friday. There was a prior order of 11/01/2011 to clean with wound cleanser and to apply border gauze three times a week, on Monday, Wednesday and Friday. Observation of the resident after she was put to bed by staff on November 23, 2011 at 1:05 p.m. revealed that there was an area of slough on the coccyx with no dressing over it and a small stage two area on the left inner buttock. During interview with Certified Nursing Assistants (CNAs) "ZZ" and "LL" at that time, these CNAs stated the area on the left buttock was on the resident the day before; however, it had not been reported to any licensed staff. Record review at 1:50 p.m. on 11/23/2011 revealed that there was no documentation on the treatment sheet, the weekly skin assessment sheet, or the nursing notes of any new stage two area on the left buttock. Further record review revealed that there was no documentation to verify that the above order to the pressure sore on the coccyx had been done as ordered on Friday, 11/18/2011, or on Monday, 11/21/2011. During an observation of the pressures sores on the resident's coccyx and left buttock on 11/23/2011 at 2:00 p.m. with Licensed Staff "AA" in attendance revealed that she had not been made aware of the stage two area on the left buttock. She also acknowledged that the physician had not been made aware of the the new stage two area on the left buttock. During the treatment to the coccyx wound conducted at that time, Licensed Staff "AA" used the same gauze wi… | 2015-04-01 |
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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 );