cms_GA
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30 rows where "inspection_date" is on date 2013-02-14
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6780 | 6780 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 241 | E | 0 | 1 | NIB111 | Based on random observations, it was determined that the facility failed to promote the dignity of 19 to 20 residents that ate meals in the main dining room and the six to eight residents that were assisted to eat meals in the assisted area of the main dining room. Findings include: 1. On 2/11/13 at 12:30 p.m., there were 24 residents eating in the main dining room and eight residents eating in the assisted area of that dining room. Nursing staff was observed to put clothing protector towels on 20 of the 24 residents in the main dining area without asking if they wanted a clothing protector. The eight residents in the assisted dining area all faced the back wall with the curtains closed on the two windows in that area. The television set in the main area was on a soap opera that none of the residents were watching. 2. On 2/12/13 at 7:33 a.m., nursing staff put clothing protectors on 19 of the 20 residents in the main dining area without asking if they wanted one. The six residents in the assisted area faced the back wall with the curtains closed. 3. On 2/12/13 at 12:45 p.m., the eight residents in the assisted area of the dining room faced the back wall with the curtains closed. In an interview on 2/13/2013 at 12:45 p.m., the Director of Nursing (DON) said that the curtains were closed in the dining room for residents that were fed by staff to reduce the potential for distracting those residents and to prevent glare on the television in the main dining room. However, after surveyor inquiry, when staff had opened the curtains during meals, observations revealed that the residents being assisted to eat, continued to eat without being distracted. There was not a glare on the television screen in the main dining room. | 2017-10-01 |
| 6781 | 6781 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 246 | D | 0 | 1 | NIB111 | Based on observation and staff interview, it was determined that the facility failed to provide reasonable accommodations for positioning three residents (#47, #59, #162) at the table during meals in the dining room from a total sample of 38 residents. Findings include: 1. Resident #47 was observed on 02/12/13 at 12:30 p.m. in the main dining room seated in a wheelchair at a table for four residents. The tabletop was above his/her chest level. Resident #47 had to reach up to eat his/her meal. 2. Resident #162 observed on 02/12/13 at 12:30 p.m. seated in a wheelchair at a table for four residents. The table top was above his/her chest level. Resident #162 had to reach up to eat his/her meal. 3. Resident #59 observed on 02/12/13 at 12:30 p.m. seated in a Broda Chair at a table for four residents. The table top was above his/her chest level. Resident #59 had to reach up to eat his/her meal. In an interview on 2/13/13 at 12:45 p.m., the Director of Nursing (DON) said that the facility could exchange the tables that were too high for residents to lower tables to accommodate the residents or move the residents to other tables. | 2017-10-01 |
| 6782 | 6782 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 279 | D | 0 | 1 | NIB111 | **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 ensure that a comprehensive care plan that included measurable objectives and timetables and described the services that were supposed to be furnished to meet the medical, mental and psychosocial needs for a resident was completed and available to those direct care staff who were responsible for those services for one resident (#169) from a sample of 38 residents. Findings include: Resident #169 was admitted on [DATE] under Hospice services with [DIAGNOSES REDACTED]. According to the 12/31/12 admission Minimum Data Set (MDS) assessment, the resident had short term and long term memory problems, severely impaired decision making skills, impaired vision, was short tempered/easily annoyed, had trouble falling asleep, was frequently incontinent and had received an anti-anxiety and anti-depressant medication in the last seven days. According to the 12/31/12 Care Area Assessment (CAA) Summary, the resident triggered for cognitive loss/dementia, visual function, communication, urinary incontinence and indwelling catheter, behavioral symptoms, falls, nutritional status, pressure ulcers, [MEDICAL CONDITION] drug use and pain. Licensed nursing staff had documented on the CAA form that those areas would be addressed in the resident's comprehensive care plan. The comprehensive care plan was supposed to be completed and available to direct care staff by 1/04/13. However, review of the resident's clinical record revealed that there was not a comprehensive care plan available for direct care staff to reference that addressed all of the resident's care needs. Review of the resident's clinical record revealed that an Interim Plan of Care that had been placed in the resident's chart on admission continued to be used as of 2/14/13. However, the Interim Care Plan did not address the resident's cognitive loss/dementia, visual function, urinary incontinence, behavioral/mood s… | 2017-10-01 |
| 6783 | 6783 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 280 | D | 0 | 1 | NIB111 | **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 revise care plan interventions for one resident (#90) to appropriately reflect his/her assessed physical and cognitive status and abilities in a total sample of 38 residents. Findings include: Resident #90 had [DIAGNOSES REDACTED]. Licensed staff coded the resident as sometimes understanding, as having short and long term memory problems, and as having severely impaired decision making skills on the 12/18/12 and 9/25/12 Minimum Data Set (MDS) assessments. Observation of the resident on 2/12/13 at 12:30 p.m. revealed that he/she was seated in a Broda chair. The resident talked repeatedly but, not appropriate to a subject or surroundings. The resident would call the staff his/her mother, would ask that staff talk to him/her when staff was talking to him/her and called out here I am mommy. There was a care plan since 4/30/12 to address the resident's history of falls and confusion and disorientation at times. There was an intervention for all staff to encourage the resident to use his/her cane. There were Acute Care Plans for Falls that were dated 1/26/13 and 1/28/13. Those plans had interventions for nursing staff to encourage the resident to allow assistance with ambulation as needed, and to encourage the resident to keep the call light within reach and use when needing assistance. A review of the February 1 - 13, 2013 CNA-ADL Tracking Form revealed staff documentation that the ambulation activity by the resident did not occur. A review of the Nurse Aide Information Sheet revealed that the area to indicate a walking status was blank and a handwritten note to use a Broda chair was at the locomotion entry line. During an interview on 2/14/13 at 7:30 a.m., licensed practical nurse (LPN) FF said that she had not observed the staff attempting to ambulate the resident. Therefore, those interventions were based on required responses and abilities … | 2017-10-01 |
| 6784 | 6784 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 281 | D | 0 | 1 | NIB111 | Based on observation, review of the facility's Procedural Guidelines for the administration of feedings and medications via gastrostomy tube, and staff interview, it was determined that the facility failed to ensure that licensed nursing staff verified placement of a gastrostomy tube prior to the administration of medications for one resident (#80) from a sample of 38 residents. Findings include: According to the facility's Procedural Guidelines for the safe administration of tube feedings and administration of medication via gastrostomy tube, nursing staff were supposed to verify placement of the gastrostomy tube prior to medication administration or feeding by instilling air into the gastric tube and auscultating for the sound of rushing air by placing a stethoscope over the stomach. However, licensed nurse CC failed to verify placement of the gastrostomy tube with air prior to medication administration for resident #80. On 2/14/13 at 8:10 a.m., during observation of medication administration for resident #80, licensed nurse CC inserted the syringe into the resident's gastrostomy tube and pulled back on the plunger to check for residual. There was no residual in the syringe. Nurse CC then removed the plunger and flushed the resident's gastrostomy tube with 50 cubic centimeters (cc) of water followed by the medications. However, CC failed to verify placement of the gastrostomy tube by inserting air into the tube and auscultating for air prior to the administration of the water flush and medications. Nurse CC stated, at that time, that the nurse on the previous shift had checked the resident's gastrostomy tube for placement at 6:00 a.m. and had told her that there were no problems. On 2/14/12 at 9:50 a.m., licensed nurse DD stated that staff were supposed to verify placement of the gastrostomy tube with air prior to the administration of any medications or feedings. Nurse DD' stated that she/he would verify placement herself/himself and not rely on another staff member's verification. | 2017-10-01 |
| 6785 | 6785 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 282 | G | 0 | 1 | NIB111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, it was determined that the facility failed to address signs of pain and provide pain management as described in the Plan of Care during the provision of pressure sore and wound treatment for one resident (#112) of three residents with pressure ulcers, and to implement interventions for the potential for nutritional impairment for one resident (#37) in a total sample of 38 residents. This failure resulted in actual harm that was not immediate jeopardy for resident #112. Findings include: 1. Resident #112 was admitted into the facility in September of 2011 with [DIAGNOSES REDACTED]. Review of the documentation on the Licensed Nurse Skin Assessments dated September of 2012 revealed that resident #112 had no wounds/pressure ulcers. Licensed nursing staff documented on the October, 2012 skin assessment that the resident had red areas in his/her groin and small open areas. On the November 26, 2012 skin assessment, the licensed nurse documented that there was a black area on the right heel and treatment in progress to the scrotum folds. On January 23, 2013 the nurse documented that resident #112 had deep tissue injury on the right heel. There was a care plan, updated on 11/21/2012, to address his/her alteration in skin integrity/pressure ulcer. Pressure ulcer to right medial heel (Deep Tissue Injury). There was an intervention to observe for pain and treat as ordered. The goal included to reduce pain and discomfort. However, during an observation of pressure ulcer wound care and care to the ulcers in the resident's groin area on 02/12/13 at 2:28 p.m., the resident cried out in pain but, the nurse failed to intervene and treat the pain. See F314 for additional information regarding resident #112. 2. Resident #37 had a care plan since 11/06/12 to address his/her potential for nutritional impairment. There were interventions for staff to determine the resident's food preferences and provide as… | 2017-10-01 |
| 6786 | 6786 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 287 | B | 0 | 1 | NIB111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and review of a list of missing Minimum Data Set (MDS) 3.0 Assessments, it was determined that the facility failed to transmit four MDS assessments and failed to complete and transmit four discharge MDS assessments in a sample of eight residents with (GA) MDS Missing OBRA Assessments. Findings include: During an interview on 2/13/13 at 7:30 a.m., the licensed practical nurse (LPN) MDS staff AA reviewed the list of eight missing OBRA assessments. LPN AA stated that four of those MDS' had been coded incorrectly and so were not transmitted. LPN AA said that four of those MDS' had not been completed for residents who had been discharged on [DATE], 2/28/11, 10/01/12 and 11/06/12. After surveyor inquiry, LPN AA reported that all eight MDS' on the list had been corrected and/or completed and transmitted. | 2017-10-01 |
| 6787 | 6787 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 314 | G | 0 | 1 | NIB111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, it was determined that the facility failed to address signs of pain and provide pain management during the provision of pressure sore treatment for one resident (#112), to notify the physician about the registered dietician's recommendations to promote healing of a pressure sore for one resident (#140), and failed to follow up with the physician timely about the status of an infected pressure sore for one resident (#133) of two of four active residents with pressure sores and one closed record with a pressure sore from a total sample of 38 residents. This failure resulted in actual harm that was not immediate jeopardy for resident #112. Findings include: 1. Resident #112 was admitted into the facility in September of 2011 with [DIAGNOSES REDACTED]. Review of the documentation on the Licensed Nurse Skin Assessments dated September of 2012 revealed that resident #112 had no wounds/pressure ulcers. Licensed nursing staff documented on the October, 2012 skin assessment that the resident had red areas in his/her groin and small open areas. On the November 26, 2012 skin assessment, the licensed nurse documented that there was a black area on the right heel and treatment in progress to the scrotum folds. On January 23, 2013 the nurse documented that resident #112 had deep tissue injury on the right heel. There was a care plan, updated on 11/21/12, to address his/her alteration in skin integrity/pressure ulcer. Pressure ulcer to right medial heel (Deep Tissue Injury). There was an intervention to observe for pain and treat as ordered. The goal included to reduce pain and discomfort. However, during an observation of pressure ulcer wound care and care to the ulcers in the resident's groin area on 02/12/13 at 2:28 p.m., the resident cried out in pain but, the nurse failed to intervene and treat the pain. During an observation of pressure ulcer wound care and care to ulcers in the resident's gr… | 2017-10-01 |
| 6788 | 6788 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 325 | D | 0 | 1 | NIB111 | **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 implement planned interventions to address a continued weight loss and a potential for nutritional impairment for one resident (#37) in a total sample of 38 residents. Findings include: Resident #37 had [DIAGNOSES REDACTED]. There was a 2/02/13 physician's orders [REDACTED]. There was a care plan since 11/26/12 to address his/her potential for nutritional impairment. There were interventions for staff to determine the resident's food preferences and provide as feasible, and to provide supplements as ordered. Review of the Weight Flow Sheet documentation revealed the resident had a significant weight loss of 17.4% in five months from 9/11/12 at 178 pounds (lbs.) to 147 lbs. on 2/08/13. Staff documented that the resident weighed 178 lbs. on 9/11/12, 170 lbs. on 9/17/12, 168 lbs. on 10/8/12, 161 lbs. on 11/17/12, 153 lbs. on 12/10/12, 152 lbs. on 1/07/13, 150 lbs. on 1/14/13 and 1/25/13, 149 lbs. on 1/31/13, and 147 lbs. on 2/08/13. However, during observations of meals served to the resident on 2/12/13 at 12:45 p.m., and on 2/13/13 at 8:50 a.m. and 12:50 p.m., staff did not serve him/her a Health Shake. A review of the list of residents that received Health Shakes, provided by the dietary manager on 2/13/13, revealed that resident #37 was not on the list to receive Health Shakes. During an interview on 2/13/13 at 1:50 p.m., the Director of Nurses (DON) confirmed that the resident should have received Health Shakes with meals. A review of the Diet History/Food Preference form revealed that it was blank. Staff had not determined the resident's food preferences as planned since 11/26/12. During an interview on 2/13/13 at 1:50 p.m., the DON stated that the resident was last seen by the Registered Dietician (RD) on 9/23/12 and she made no recommendations at that time. She said that the resident was above his/her ideal body weight. There was a 10/2… | 2017-10-01 |
| 6789 | 6789 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 328 | D | 0 | 1 | NIB111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observations and review of the facility's policy, it was determined that the facility failed to maintain clean air filters on oxygen concentrators in four resident rooms (109A, 212A and B, and 104P) for four residents with oxygen therapy in a sample of 16 residents that had respiratory therapy in a total sample of 38 residents. Findings include: The facility's procedure for infection control for oxygen concentrators noted that the equipment was to be visibly clean. The external filter was to be clean. However, staff failed to maintain clean oxygen concentrator filters in four resident rooms for four residents that used oxygen (rooms 109A, 212A and B, and 104P). 1. During the initial tour on 2/11/13 at 12 p.m., the oxygen concentrator filter in room [ROOM NUMBER]A was heavily coated with dust. 2. On 2/12/13 at 1:15 p.m. and 2/13/13 at 10:30 a.m., the oxygen concentrator filter in room [ROOM NUMBER]B was coated with dust. 3. On 2/13/13 at 9:30 a.m. and 2/14/13 at 7:30 a.m., the oxygen concentrator filter in room [ROOM NUMBER]A was coated with dust. 4. On 2/13/13 at 9:30 a.m., 10:37 a.m., 2:18 p.m., and 3:56 p.m., and on 2/14/13 at 7:30 a.m., the oxygen concentrator filter in room [ROOM NUMBER]P was heavily coated with dust. | 2017-10-01 |
| 6790 | 6790 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 329 | D | 0 | 1 | NIB111 | **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 follow the physician's orders for psychoactive medications for one resident (#52) in a total sample of 38 residents. Findings include: Resident #52 was admitted in June of 2011 with [DIAGNOSES REDACTED]. There was a 1/29/13 physician's telephone order for nursing staff to discontinue giving [MEDICATION NAME] to the resident and give 0.5 milligrams (mg) of [MEDICATION NAME] twice a day. That order was on the Physician's Order Form for February, 2013 for agitation and was scheduled to be given at 9 a.m. and 5 p.m However, a review of the January and February Medication Administration Records (MARs) revealed that nursing staff failed to discontinue the [MEDICATION NAME] as ordered on [DATE]. Licensed nursing staff had given the resident both the [MEDICATION NAME] and the Risperdone, until after surveyor inquiry on 2/13/13. During a telephone interview on 2/13/13 at 3:15 p.m., Hospice Nurse HH said that she had been monitoring resident #52 for his/her response to the change in psychoactive medication from [MEDICATION NAME] to [MEDICATION NAME]. The Hospice nurse said that he/she had observed that resident #52 was more sedated and quiet since the [MEDICATION NAME] was started but, did not realize that the facility failed to stop the [MEDICATION NAME]. The Hospice nurse said that the failure to discontinue the Haloperidal could contribute to sedation for resident #52. In an interview on 2/14/13 at 8:30 a.m., the Director of Nurses (DON) stated that, after surveyor inquiry, the Medical director had made rounds last evening (2/13/13) and evaluated resident #52. Review of the 2/13/13 Physician's Progress Note revealed that the physician had documented that there were no adverse effects from the [MEDICATION NAME] and [MEDICATION NAME] both having been given to resident #52 and that the [MEDICATION NAME] was discontinued yesterday (2/13/13). | 2017-10-01 |
| 6791 | 6791 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 371 | F | 0 | 1 | NIB111 | Based on observation, staff interview and record review, it was determined that the facility failed to ensure that two ice makers used for all residents that received iced beverages from the kitchen and one nurse's station ice maker (400 hall) were clean and sanitary. Findings include: 1. During an initial tour of the facility's kitchen with the dietary manager on 02/11/13 at 12:00 p.m., the interior of the ice machine in the kitchen had a large amount of a black mold like substance on the area where the ice would fall from the ice maker into the ice bin. At that time, the dietary manager said that the ice machine was cleaned two weeks ago by the maintenance department. Review of the documentation of the ice machine maintenance indicated that the last cleaning was done on January 17,2013. The maintenance staff designated on the Ice Machine Form that the various tasks were performed by writing OK. On January 17, 2013, the maintenance staff did not indicate that the interior of the ice machine was cleaned. The staff noted on the Ice Machine Form that the ice bin was cleaned and sanitized in August of 2012. The facility form also indicated that the machine was due to be cleaned on January 31, 2013. The facility did not have a record of cleaning the ice machine on January 31, 2013. 2. Observations of the pantry ice machine in the 400 hall nurse's station on 02/12/13 at 10:00 a.m., 11:10 a.m. and 4:35 p.m., and on 2/13/13 at 7:20 a.m., revealed a black mold like substance around the rim of the interior of the ice machine. The substance could drip down onto the ice from the condensation inside of the machine. On 2/13/13 at 2:24 p.m., the environmental staff observed the black mold inside the ice machine. The staff turned the machine off and took the ice that was in the machine and filled the ice chest that the staff used to serve the residents. At 2:36 p.m., a resident came to the nurse's station and requested his/her pitcher to be filled with ice. Nursing staff went to the ice chest and filled the pitcher up with the … | 2017-10-01 |
| 6792 | 6792 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2013-02-14 | 441 | D | 0 | 1 | NIB111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and random observations, it was determined that the facility failed to maintain infection control procedures to ensure the sanitary storage of oxygen nasal cannulas in five resident rooms (110, 201, 207B, 307B and 312A) for five residents who used oxygen in a sample of 16 residents with respiratory therapy in a total sample of 38 residents. Findings include: According to guidelines published by the US Centers for Disease Control and Prevention, the main principles of good respiratory practice, for preventing infections associated with respiratory therapy, included the cleaning and drying of any reusable equipment and storage in a clean, dry place. However, staff failed to store nasal cannulas for five residents in a clean, dry place when not in use. During the initial tour on 2/11/13 at 12 noon, nasal cannulas were stored uncovered outside room [ROOM NUMBER], and in rooms 307B and 312A. 1. A nasal cannula was not covered and the tubing was wound around the headrest of an electric wheelchair outside room [ROOM NUMBER]. 2. An uncovered nasal cannula was on the top of the small oxygen tank next to the resident's bed in room [ROOM NUMBER]B. 3. The uncovered nasal cannula and tubing were hanging off the bookcase in room [ROOM NUMBER]A. 4. Observations on 2/11/13 at 1:32 p.m. revealed that there was an uncovered nasal cannula on the dresser in room [ROOM NUMBER]. 5. Observations on 2/12/13 at 9 a.m. revealed that there was an uncovered nasal cannula on the top knob of the small oxygen tank in room [ROOM NUMBER]B. 6. Observation on 2/13/13 at 9:30 a.m. revealed that there was an uncovered nasal cannula and tubing draped over the top of the oxygen concentrator in room [ROOM NUMBER]P. At 2:18 p.m., the uncovered nasal cannula was on the floor next to the oxygen concentrator. | 2017-10-01 |
| 6885 | 6885 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2013-02-14 | 157 | D | 0 | 1 | P02P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to notify the physician timely for two (2) residents on a sample of thirty-three (33) residents. One resident, (Q) developed a pressure ulcer and one resident, (# 253) had significant weight loss. Findings include: Resident #253 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident had an admission weigh of 200.8 pounds. Further review of the weight record indicated the resident had a weight of 190.4 pounds on 12/25/13 which indicated a significant weight loss of 5.1% since admission. In addition, the resident had a weight of 179.2 on 1/12/13 which indicated a significant weight loss of 21.6 pounds or 10.7% in one month. The resident had an Admission Minimum Data Set assessment dated [DATE] which indicated the resident had no weight loss or gain prior to admission. Review of the Weight Progress Notes Form revealed an entry dated 12/27/12 which identified a weight loss of 10.4 pounds since admission. A snack at 3:00 p.m. each day of milk and a sandwich was added as an intervention. However, there was no indication the physician was notified of the significant weight loss. During an interview on 2/13/13 at 3:50 p.m. Licensed Practical Nurse AA stated she was aware of the weight loss on 12/25/12 and should have completed the Form for Significant Weight Loss. She further stated this would have reminded her to notify the physician of the significant weight loss. She confirmed she did not notify the physician of the significant weight loss until 2/12/13. Review of resident Q's clinical record revealed they were admitted to the facility with a fractured left hip, and also had [DIAGNOSES REDACTED]. Review of a right foot and ankle x-ray obtained on 02/04/13 revealed that the resident had a [MEDICAL CONDITION] malleolus and distal fibula, with mild lateral subluxation of distal tibia. Review of orthopedic physician's orders [REDACTED]. Review of Nurs… | 2017-09-01 |
| 6886 | 6886 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2013-02-14 | 281 | D | 0 | 1 | P02P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to clarify the parameters for when to administer insulin, and clarify when to use a walking boot for one (1) resident (Q). The facility also failed to clarify a pressure ulcer treatment order and assess a residents skin condition after the removal of a cast for one (1) resident (#270). The sample size was thirty-three (33) residents. Findings include: 1. Review of resident Q's physician's orders [REDACTED]. Further review of the order revealed it did not specify how much insulin to give if the FSBS exceeded 353. Review of resident Q's Medication Administration Records (MAR) revealed that the blood sugar exceeded 353 on 12/19/12; 01/16/13; and 02/09/13. Further review of the MAR indicated [REDACTED]. During interview with Registered Nurse (RN) Unit Manager DD on 02/14/13 at 8:40 a.m., she stated that the nurse that did the FSBS should have contacted the physician when the blood sugar exceeded 353, as there was no order for insulin coverage above that. Cross-refer to F 309. 2. Review of an orthopedic physician's orders [REDACTED]. Walker boot to right lower leg. Diagnosis: [REDACTED]. Further review revealed the order did not specify when the resident was to wear the boot. On 02/13/13 at 8:55 a.m., Licensed Practical Nurse (LPN) Treatment Nurse BB was observed performing a dressing change to an open blister to resident Q's right outer ankle. During interview, LPN BB stated the wound was found on 02/09/13, and was caused by the velcro walking boot. During interview with LPN CC at 9:15 a.m., she stated that they continued to apply the walker boot after the blister was discovered, but that they had covered the wound with a protective dressing. Review of a Grievances/Complaint Form dated 02/09/13 revealed that a complaint was filed by a family member of resident Q which noted that the resident had their boot on all night. Review of the Action Taken section of the complaint… | 2017-09-01 |
| 6887 | 6887 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2013-02-14 | 282 | D | 0 | 1 | P02P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow the care plan related to reviewing recent bowel elimination patterns and reporting any negative findings to the physician for one (1) resident (#265), and failed to follow the care plan related giving diabetes medications as ordered for one (1) resident (Q). The sample size was thirty-three (33) residents. Findings include: 1. Review of resident #265's Potential for Constipation care plan revealed an Approach to review recent bowel elimination patterns, and report any negative findings to the physician. Review of resident #265's physician's orders [REDACTED]. Review of the facility's BM (Bowel Movement) Report 8/12 from 01/29/13 to 02/11/13 revealed that they had eight watery liquid stools, as well as more than one stool on ten days during this time. During interview with CNA HH on 02/13/13 at 2:50 p.m., he stated that resident #265 had frequent loose BM's ever since they were admitted to the facility, and had to be changed several times a shift. During interview with Registered Nurse (RN) Unit Manager DD at 3:45 p.m., she verified the frequency and consistency of the BM's, and that the resident received a nightly laxative. Cross-refer to F 329. 2. Review of resident Q's Diabetes care plan revealed an Approach for meds as ordered. Review of resident Q's physician's orders [REDACTED]. Further review of this sliding scale order revealed it did not specify how much insulin to give for a blood sugar over 353. Review of the MAR between 12/17/12 and 02/14/13 revealed the resident's blood sugar exceeded 353 on 12/19/12, 01/16/13, and 02/09/13, and the resident was given insulin without an order. This was verified during interview with RN Unit Manager DD on 02/14/13 at 8:40 a.m., who stated the nurse should have contacted the physician when the blood sugar exceeded 353, as there was no order for insulin coverage above that. Cross-refer to F 309. | 2017-09-01 |
| 6888 | 6888 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2013-02-14 | 309 | D | 0 | 1 | P02P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain an order for [REDACTED]. Findings include: Review of resident Q's physician's orders [REDACTED]. Further review of the order revealed it did not specify for how much insulin to give once the FSBS exceeded 353. Review of resident Q's Medication Administration Records (MAR) revealed the following: -On 12/19/12 at 9:00 p.m., the FSBS result was 398. The nurse administered 7 units of insulin. -On 01/16/13 at 9:00 p.m., the FSBS result was 369. The nurse administered 8 units of insulin. -On 02/09/13 at 4:30 p.m., the FSBS result was 466. The nurse administered 10 units of insulin. During interview with Registered Nurse (RN) Unit Manager DD on 02/14/13 at 8:40 a.m., she verified that there was no documentation in the physician's orders [REDACTED]. Upon further interview, she stated that the nurse that did the FSBS should have contacted the physician when the blood sugar exceeded 353, as there was no order for insulin coverage above that. | 2017-09-01 |
| 6889 | 6889 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2013-02-14 | 314 | D | 0 | 1 | P02P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide timely assessments to pressure ulcers and provide treatment according to physician orders [REDACTED].#270) and failed to assess the effect of a device which had the potential to cause pressure and conduct timely assessments for a pressure area for one (1) resident (Q) on a sample of thirty-three (33) residents. Findings include: Review of the medical record for Resident #270 revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted to the facility with a soft non-removable cast in place on the right leg. Review of the Daily Nurses Notes indicated the resident went to the physician's office on 2/8/13. Further review indicated the cast on the right foot was removed at the physician's office and a removable boot was applied. The resident returned to the facility with orders to for skin care to the right ankle, foot and calf to be performed twice daily. There was no evidence in the medical record of an assessment of the right foot and leg upon return from the physician's office on 2/8/13. In addition, there was no evidence skin care or treatment had been performed to the leg as ordered by the physician. Review of the Daily Skilled Nurses Notes dated 2/9/13 indicated the resident complained of pain to the ankle. The boot was removed and a reddened area was noted to the inside ankle and outside bone of the right ankle. A dark area was noted to the top of the foot. The note indicated the boot was loosened and notation was made that area was to be monitored. Review of the medical record indicated no evidence of any additional assessment of the areas on the right foot and ankle and no evidence any type of treatment was performed to the area until 2/11/13. Review of the Skin Notes dated 2/11/13 indicated the boot was removed from the right leg and pressure areas were noted. The lateral area of the fifth toe ha… | 2017-09-01 |
| 6890 | 6890 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2013-02-14 | 325 | D | 0 | 1 | P02P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide interventions to address a significant weight loss of 10.7 percent (%) in one month for one (1) resident (#270) on a sample of thirty-three (33) residents. Findings include: Review of the medical record for resident #270 revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident had an admission weight of 200.8 pounds. Further review of the weight record indicated the resident had a weight of 190 pounds on 12/25/12 which indicated a significant weight loss of 5.1% since admission. In addition, the resident had a weight of 179.2 pounds on 1/12/13 which indicated the resident with at significant weight loss of 21.6 pounds or 10.7% in one month. The resident had an Admission Minimum Data Set (MDS) assessment dated [DATE] which indicated the resident had no weight loss or gain prior to admission. Review of the Weight Progress Notes Form revealed an entry dated 12/27/12 which identified a weight loss of 10.4 pounds since admission. A snack at 3:00 p.m. each day of milk and a sandwich was added as an intervention. An interview on 2/13/13 at 3:30 p.m. Licensed Practical Nurse AA stated the intervention to address the weight loss was a nursing intervention and confirmed the physician was not notified of the significant weight loss. Review of the facility's policy for the Weight Monitoring Program indicated if significant weight loss is identified the Weight Loss/Gain Checklist is completed, the resident would be added to the Colored Napkin Program and weekly weight team documentation would be performed and the resident would be evaluated for possible interventions to address the weight loss. Further review of the Weight Progress Note Form and the Nutritional Progress Notes revealed no evidence the additional weight loss of 11.2 pounds had been addressed and there was no evidence of additional interventions to address the weight loss.… | 2017-09-01 |
| 6891 | 6891 | OAKS - SCENIC VIEW SKILLED NURSING, THE | 115393 | 205 PEACH ORCHARD ROAD | BALDWIN | GA | 30511 | 2013-02-14 | 329 | D | 0 | 1 | P02P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to consult with the physician regarding continued use of a laxative for one (1) resident (#265), who was having intermittent loose stools. The sample size was thirty-three (33) residents. Findings include: Review of resident #265's physician's orders [REDACTED]. Review of the facility's BM (Bowel Movement) Report 8/12 from 01/29/13 to 02/11/13 revealed the following: 01/29/13: Had one extra-large watery liquid stool, and one large soft-formed stool. 01/30/13: Had two large soft-formed stools. 01/31/13: Had one large soft-formed stool. 02/01/13: Had one large watery liquid stool. 02/03/13: Had an extra-large soft-formed and an extra-large watery liquid stool. 02/04/13: Had a medium and a large soft-formed stool. 02/05/13: Had a small watery liquid stool. 02/06/13: Had a small and a medium soft-formed stool. 02/07/13: Had a large soft-formed and an extra-large watery liquid stool. 02/08/13: Had a medium, large, and extra-large watery liquid stool. 02/09/13: Had two large, soft-formed stools. 02/10/13: Had a medium watery liquid, and one large soft-formed stool. 02/11/13: Had a medium and large watery liquid stool, and one medium soft-formed stool. During interview with the Registered Nurse (RN) Unit Manager DD on 02/13/13 at 2:20 p.m., she stated that the Certified Nursing Assistants (CNA) documented in the computerized system once a shift as to whether or not the resident had a BM. Upon further interview, she stated that if there was more than one type of BM consistency per shift, that meant the resident had more than one stool that shift. RN Unit Manager DD added that she didn't know if the computerized system captured multiple BM's of the same consistency per shift. During interview with CNA HH on 02/13/13 at 2:50 p.m., he stated that resident #265 had frequent loose BM's ever since they were admitted to the facility, and had to be changed several times a shift. Upon further int… | 2017-09-01 |
| 6971 | 6971 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2013-02-14 | 225 | D | 0 | 1 | YKS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy and procedure, it was determined the facility failed to ensure that an allegation of neglect was immediately reported to the administrator and to the State survey and certification agency, and was thoroughly investigated for one resident (D) in a total sample of 29 residents. Findings include: The facility failed to ensure that resident D's allegation of a CNA refusing to provide requested care was reported immediately to the administrator of the facility and to state survey and certification agency. Although a licensed nurse was aware of the resident's allegation, there was no evidence that the facility had investigated the allegation and reported the results of the investigations to the administrator or his designated representative and to the state survey agency within 5 working days of the incident. However, the facility failed to identify an allegation of neglect made by resident D about CNAKK and immediately report it to the state survey and certification agency, and to thoroughly investigate to determine the validity of that allegation and to implement any corrective actions if needed. Resident D was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 2/11/13 at 1:11 p.m., resident D said that, 2 to 3 weeks ago when he/she was sitting in the hallway outside the bathroom door, Certified Nursing Assistant (CNA) KK walked by and he/she asked that CNA to help him/her onto the toilet. The resident said that CNA KK replied no but, licensed practical nurse (LPN) JJ walked by and offered to help him/her. The resident stated CNA KK told LPN JJ that she would not help resident D. The resident described the incident as having made him/her feel pretty rough, like nobody cared. The resident said that he/she was able to stand but it took one person to help get him/her from the wheelchair to the toilet. Resident D said that nurse JJ told him/her that she … | 2017-09-01 |
| 6972 | 6972 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2013-02-14 | 278 | D | 0 | 1 | YKS711 | **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 accurately code the section on vision impairment on a Minimum Data Set (MDS) assessment for one resident (#46) in a total sample of 29 residents. Findings include: Review of the 8/09/12 vision consultation report revealed that the physician had diagnosed resident #46 as having moderate to severe [MEDICAL CONDITION] that required removal as soon as possible, and mild [MEDICATION NAME] degeneration. However, a review of the 9/15/12 annual MDS assessment revealed that licensed staff had inaccurately coded the resident as having had no visual impairment. Review of the 10/11/12 consultation report revealed that the physician diagnosed the resident with visually significant [MEDICAL CONDITION]. However, a review of the 11/28/122 quarterly MDS assessment revealed that licensed staff had inaccurately coded the resident with no visual impairment. During an interview on 2/13/13 at 12:25 p.m., the MDS Coordinator and Director of Nurses (DON) said that they were not aware that the resident had had a vision consultation and that vision problems had been diagnosed . However, the annual and the quarterly assessments should have identified the resident as having had a vision impairment. The MDS Coordinator admitted that her assessment of a resident's vision was based on whether or not the resident could see the television. However that process did not follow the guidelines in the MDS manual for the assessment of residents' vision. | 2017-09-01 |
| 6973 | 6973 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2013-02-14 | 279 | D | 0 | 1 | YKS711 | **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 a comprehensive plan of care to address the range of motion and positioning needs of one resident (#13) and the vision needs of one resident (#46) in a total sample of 29 residents. Findings include: 1. Licensed staff coded resident #13, on the 9/19/12 and 12/12/12 Mimimum Data Set (MDS) assessments, as having decreased range of motion and limited mobility, chronic pain due to limited mobility and contractures in his/her upper and lower extremities. It was observed on 2/13/13 at 11:11 a.m., that first finger on the resident's right hand was contracted. There were not splinting devices in use. On 2/13/13 at 1:22 p.m., licensed practical nurse (LPN) PP said that three people had to assist the resident to get dressed because the resident's legs would not bend. She said that since the resident was on hospice services, they did not use splints. During an interview on 2/13/13 at 4:00 p.m., the Director of Rehabilitation services provided therapist reports dated 12/07/11 and 12/14/12 which noted that the resident was to continue to wear Prevalon heel floating boots. There was a recommendation for an abduction wedge to keep the resident's legs separated. There was documentation on the 3/06/12 interdisciplinary team collection form about the resident's decreased mobility and hospice status. Documentation on the form noted that the resident would benefit from an abduction wedge and floating heel boots. The team documented at that time that the resident's legs were scissored. However, staff did not develop a plan of care to address the resident's range of motion and positioning needs See F318 for additional information regarding resident # 13. 2. Review of an 8/09/12 vision consultation report revealed that the physician diagnosed resident #46 as having moderate to severe [MEDICAL CONDITION] that required removal as soon as possible, and mild … | 2017-09-01 |
| 6974 | 6974 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2013-02-14 | 282 | D | 0 | 1 | YKS711 | **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 implement planned interventions to promote skin integrity for one resident (#46) and to arrange for needed dental services for one resident (C) in a total sample of 29 residents. Findings include: 1. Resident #46 had [DIAGNOSES REDACTED]. There was a care plan since 10/22/10 to address his/her risk for alteration in skin integrity due to incontinence and a history of frequent skin tears and bruising due to involuntary movements. There were interventions to keep the resident's bed side rails padded and to encourage him/her to reposition frequently. However, staff failed to pad the resident's side rails as planned. See F323 for additional information regarding resident #46. 2. Resident C had a care plan which had been reviewed on 12/12/12 to address his/her need for assistance with all activities-of-daily living (ADLs). There were interventions for staff to provide dental care after each meal and at bedtime, to report loose or ill-fitting dentures, and to offer dental services as needed. During an interview on 2/13/13 at 8:30 a.m., resident C stated that his/her gums and mouth were sore along the bottom on the right side. Although the resident stated that she had not reported the problem to nursing staff, documentation in the 1/05/13 Resident Council meeting minutes revealed that resident C had complained about his/her gums hurting. There was a note that Social Service staff would follow up, however, there was no evidence of any follow up having been done. Staff failed to implement their planned intervention. See F411 for additional information regarding resident C. | 2017-09-01 |
| 6975 | 6975 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2013-02-14 | 309 | D | 0 | 1 | YKS711 | **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 implement the facility's protocol for one resident (#6) that was constipated in a total sample of 29 residents. Findings include: The facility's BM (bowel movement) protocol, provided by the Director of Nurses (DON) on 2/14/13. The protocol was that if a resident had not had a bowel movement in 3 days then, the nursing staff was supposed to start with 30 mililters (ml) of Milk of Magnesia (MOM) suspension or 30 ml of [MEDICATION NAME] by mouth or gastrostomy tube. During and interview on 2/14/13 at 12 p.m., the DON stated that if nursing staff initiated the facility's BM protocol then, it would be documented on the resident's Medication Administration Record [REDACTED] Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Medication Administration Records (MARs) revealed that there was no documentation that the resident had had a bowel movement from 11/29/12 - 12/04/12 (6 days), from 10/22/12 - 10/26/12 (5 days), 10/12/12 - 10/15/12 (4 days), and from 9/18/12 - 9/21/12 (4 days). However, there was no documentation on the MAR indicated [REDACTED]. | 2017-09-01 |
| 6976 | 6976 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2013-02-14 | 318 | D | 0 | 1 | YKS711 | **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 provide treatment and services to address the range of motion and positioning needs for one resident (#13) from a total sample of 29 residents. Findings include: Resident #13 had [DIAGNOSES REDACTED]. Licensed staff coded resident #13, on the 9/19/12 and 12/12/12 Minimum Data Set (MDS) assessments, as having decreased range of motion and limited mobility, chronic pain due to limited mobility and contractures in his/her upper and lower extremities. During an interview on2/11/13 at 1:16 p.m., licensed practical nurse (LPN) PP stated that the resident had contractures of his/her left hand and starting contractures of his/her right hand. During an observation on 2/13/13 at 11:11 a.m., the resident's first finger on his/her right hand was observed to be contracted. There were no visible positioning devices in use. On 2/13/13 at 1:22 p.m., LPN PP said that it took three people to assist the resident to get dressed and it was very hard because the resident's legs would not bend. She said that since the resident was on hospice services, they did not use splints. During an interview on 2/13/13 at 4:00 p.m., the Director of Rehab RR provided therapist reports dated 12/07/11 and 12/14/12 that noted the resident was to continue to wear Prevalon heel floating boots. There was a recommendation for an abduction wedge to keep the resident's legs separated. There was a 3/06/12 interdisciplinary team collection form that documented the resident's decreased mobility and hospice status. The form documentation noted that the resident would benefit from an abduction wedge and floating heel boots. The team documented that the resident had scissored legs at that time. However, staff had not developed care plan interventions to address preventive care related to the resident's limited range of motion and positioning needs. Although the interdisciplinary team had no… | 2017-09-01 |
| 6977 | 6977 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2013-02-14 | 323 | D | 0 | 1 | YKS711 | **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 implement interventions to address a potentially hazardous assistive device for one resident (#46) who had a history of [REDACTED]. Findings include: Resident #46 had [DIAGNOSES REDACTED]. Licensed staff coded him/her on the 11/28/12 Minimum Data Set (MDS) assessment as needing limited assistance for bed mobility. There was a care plan since 10/22/10 to address the resident's risk for alteration in skin integrity due to a history of having frequent skin tears and bruising because of his/her involuntary movements. There was an intervention for staff to keep the three side rails padded. However, during observations of the resident in bed on 2/11/13 at 2:00 p.m. and 2:55 p.m., and on 2/13/13 at 11:30 a.m., and 11:55 a.m., staff had not padded the three side rails. On 2/11/13 at 2:00 p.m., the resident's head was positioned against the metal side rail. During an interview on 2/13/13 at 12:25 p.m., the Director of Nurses (DON) and MDS Coordinator stated that the use of side rails was assessed on admission and then quarterly. They said that the staff just reviewed verbally and looked at the use of side rails. However, there was no documentation to verify that the side rails for the resident had been evaluated to assess the potential hazard from continued use. There was no evidence that staff had monitored the effectiveness of the side rails and the intervention for the use of the padding on those rails to prevent skin tears and bruising on the resident. | 2017-09-01 |
| 6978 | 6978 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2013-02-14 | 328 | E | 0 | 1 | YKS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to ensure that respiratory care equipment was stored in a sanitary manner and failed to ensure the equipment was properly maintained in five resident rooms (11, 17B, 21A, 4C and 23B) in use for three residents in three rooms (11B, 17B and 21A) in a total sample of 29 sampled residents. Findings include: 1. During observations on 2/11/13 at 11:35 a.m. and on 2/12/13 at 10:00 a.m., the nasal cannula at the 11B bed location was uncovered and wrapped around the handle of the oxygen concentrator. The filter on the right side of the concentrator was dirty, with the bottom half covered in a white lint-looking material. There was not a filter on the left side of the concentrator. The mask for the Continuous Positive Airway Pressure ([MEDICAL CONDITION]) machine on the bedside table of bed B was uncovered. Resident #24 was observed lying in bed (11A) on 2/13/13 at 7:50 a.m. with oxygen being administered through a nasal cannula from an oxygen concentrator. The oxygen concentrator that had previously been at his/her roommate's bedside on 2/11/13 and 2/12/13 had been moved to his/her bedside. The right air filter on the oxygen concentrator was dirty and the left filter was missing. The [MEDICAL CONDITION] mask was uncovered on the bedside table. 2. Resident #9 was observed lying in bed on 2/13/13 at 3:50 p.m. and 2/14/13 at 3:36 p.m. with a nasal cannula infusing oxygen from an oxygen concentrator. However, there was not an air filter on either side of the concentrator. 3. On 2/14/13 at 11:55 a.m., the oxygen concentrator in room [ROOM NUMBER]A was observed to have only one dirty air filter instead of the two filters that it was supposed to have. One air filter was missing. On 2/14/13 between 1:10 p.m. and 1:20 p.m., the following observations were made: 4. There was an uncovered nasal cannula draped over the oxygen concentrator in room [ROOM NUMBER]B. The front panel … | 2017-09-01 |
| 6979 | 6979 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2013-02-14 | 411 | D | 0 | 1 | YKS711 | Based on record review, interviews with staff and a resident, and observations, it was determined that the facility had failed to provide timely routine dental services for one resident (C) in a total sample of 29 residents. Findings include: Resident C had a care plan which had been reviewed on 12/12/12 to address his/her need for staff assistance with all of his/her activities-of-daily living (ADLs). The interventions included that staff would provide dental care after each meal and at bedtime, report loose or ill-fitting dentures, and offer dental services as needed. During an interview on 2/13/13 at 8:30 a.m., resident C stated that his/her gums and mouth were sore along the bottom on the right side. Although the resident said that he/she had not reported the problem to nursing staff, a review of the 1/02/13 Resident Council meeting minutes revealed staff documentation that Social Service would follow up on resident C's complaint about his/her gums hurting. However, there was no evidence that the staff had followed up on the resident's complaint. Staff failed to implement their planned intervention to offer dental services as needed. During an interview on 2/13/13 at 10:51 a.m., the Social Service Director (SSD) stated that the facility was in the process of getting a mobile dentist to come to the facility. She stated that, for now, if a resident complained of mouth or tooth pain then, the staff would report it to nursing or her. She said that then she called the doctor to see if it might could be a medical problem or if the resident needed an appointment with a dentist. She stated that the facility would then send the resident out to a dentist. On 2/13/13 at 11:06 a.m., the SSD said that she was unaware the resident C had ever complained about any dental problems. The SSD said that the nurses examined the resident's mouths on admission and assessed their dental needs and then the CNAs assessed the residents' mouths when they provided mouth care. On 2/13/13 at 11:35 a.m., the SSD stated that, when resident C … | 2017-09-01 |
| 6980 | 6980 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2013-02-14 | 431 | E | 0 | 1 | YKS711 | Based on observations and review of the facility's policy, it was determined that the facility failed to discard opened insulin timely to maintain viability and to discard expired medications in two medication carts (North and South halls) and/or in the medication room. Findings include: The facility's policy identified insulin as a medication with a shortened expiration date. The policy noted that the expiration date for an opened vial of insulin was 28 days. Vials would expire 28 days after being opened (or punctured) or having been removed from the refrigerator, whichever came first. However, observations in the medication carts and medication rooms revealed that nursing staff had not implemented that policy for insulin. Observations were made of the South hall medication cart and the medication room on 2/14/13 between 10:45 a.m.and11a.m. South hall medication cart with licensed pratical nurse (LPN) XX 1. There was documentation on a bottle of Lantus insulin that it had been opened on 12/24/12 with an expiration date of 1/22/13. 2. There was a bottle of Lantus insulin opened 12/26/12 with an expiration date of 1/24/13. 3. There was a bottle of Humalog insulin opened 12/26/12 with an expiration date of 1/24/12 and a reorder date of 2/12/13. The new bottle was observed to be unopened in the medication room refrigerator but, the opened vial was still on the cart. Per licensed nurse - all nurses on the medication cart try to keep check of medication expiration dates so can they can be reordered The Medication room and Stock medication cabinet with LPN XX 1. There was one bottle of Rugby brand chlorophyll tablets (100 count) that had expired 03/09. 2. There was one bottle of Major brand Banophen caplets (1000 count) that had expired 10/12. Observations of the North hall medication cart with LPN PP were done on 2/14/13 between 11:10 a.m. and 11:20 a.m. There was one bottle of Novolin R insulin with an opened date of 1/4/13 and an end date of 2/02/13. | 2017-09-01 |
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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 );