cms_GA
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2019-02-14 | 656 | G | 0 | 1 | PXEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Care Planning - Interdisciplinary Team the facility failed to follow the care plan for one resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a [MEDICAL CONDITION] (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. Additionally, the facility failed to develop a care plan for one Resident (R#94) for the use of a travel pillow for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Care Planning - Interdisciplinary Team reviewed on 3/1/18 noted: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS (Minimum Date Set)); 2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team. The policy did not include additional information regarding the development and implementation of resident care plans. 1. Review of the clinical record for R#49 revealed that the resident had the following [DIAGNOSES REDACTED]., [MEDICAL CONDITION] (left eye) and depression. Review of the Annual MDS, for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing requiring two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of the Fal… | 2020-09-01 |
| 2 | 2 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2019-02-14 | 688 | D | 0 | 1 | PXEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Resident Mobility and Range of Motion the facility failed to assess and provide treatment for one Resident (R), (R#94) for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion reviewed on 2/1/18 revealed 3. Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in range of motion; 4. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .5. Therapy will evaluate/reevaluate the resident's mobility on a routine basis to determine the need for range of motion exercises. Review of the clinical record for R#94 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] with documented [DIAGNOSES REDACTED]. Continued review of the MDS revealed R#94 was severely cognitively impaired and exhibited no behaviors during the assessment period. The resident required extensive to total assistance of one to two staff persons for all Activities of Daily Living (ADLs). During this assessment period, R#94 received Occupational Therapy (OT), passive range of motion (ROM), and splint/brace assistance. Review of the Task tab for R#94 printed from the electronic record on 1/31/19 revealed the resident required total assistance for eating; required two-person total dependence for bathing, bed mobility, and dressing. These tasks were to be completed by the Certified Nursing Assistants (CNAs). Further review revealed Restorative staff was to provide the resident with passive ROM to the left hand six times per week for 15 minutes for each treatment and was to apply a splint/brace to her left hand for up to six hours - six times per week. The Task tab did not list the use of a travel neck pillow to be used… | 2020-09-01 |
| 3 | 3 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2019-02-14 | 689 | G | 0 | 1 | PXEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Fall Policy the facility failed to provide supervision during a bed bath to prevent an avoidable fall for one Resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a [MEDICAL CONDITION] (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. The sample size was 26 residents. Findings include: Review of the facility's policy titled, Fall Policy reviewed 3/1/18 revealed The facility will identify each resident who is at risk for falls and will plan appropriate care and implement interventions to assist in fall prevention. The facility will attempt to decrease falls with injury by providing an environment that is free from potential hazards. Review of the clinical record for R#49 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. and depression. Review of the Annual Minimum Data Set (MDS), for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing and required two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of a handwritten statement dated 12/21/18 written by Certified Nursing Assistant (CNA) FF documented the following: On 12/15/18 at 10:45 a.m., I (CNA FF) entered room [ROOM NUMBER]. I began washing R#49's upper body and during the process she was fighting. She was yanking on the face towe… | 2020-09-01 |
| 4 | 4 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2019-02-14 | 880 | D | 0 | 1 | PXEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility policy titled, Handwashing/Hand Hygiene the facility failed to ensure food was served in a sanitary manner for six of 41 residents (R), R#63 and five unsampled resident) residing on the secured unit. Findings include: Review of the facility's document entitled Handwashing/Hand Hygiene policy (undated) noted the following: 6. Wash hands with soap and water for the following situations: a. When hands are visibly soiled; b. After contact with a resident with infectious diarrhea .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; .i. After contact with a resident's intact skin; .l. After contact with objects in the immediate vicinity of the resident; .o. Before and after eating or handling food; p. Before and after assisting a resident with meals. Review of the clinical record for R#63 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS dated [DATE] revealed the resident required the limited assistance of one staff person for eating and required the extensive assistance of one staff person for personal hygiene. During the lunch meal observation in the north dining room of the facility's secured unit on 1/28/19 at 1:07 p.m. an unsampled resident was seated at a dining table waiting to be served her lunch meal. The resident's left shoe was off of her foot and the resident was having difficulty putting her shoe back on. At this time, the Activity Director (AD) was passing out utensils wrapped in cloth napkins to all of the resident in the dining room and when the AD approached this unsampled resident, the AD set the tray of utensils down on the table and then assisted the resident by putting her shoe on for her. After the resident's shoe was on, the AD picked up the tray an… | 2020-09-01 |
| 5 | 5 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2017-03-23 | 247 | D | 0 | 1 | 6QM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with facility staff, review of the electronic records, and review of the policy titled Room Change/Roommate Assignment, revised (MONTH) 2006, the facility failed to ensure that written notification of room change was provided before moving a resident from the third floor to the fourth floor for one of 32 sampled residents (R) (R#194). Findings include: Review of a Social service assessment dated [DATE]; the resident is coded as independent for decision making skills and understanding the need for placement and participated in the placement decision. Review of the Room Change/Roommate assignment policy, revised in (MONTH) 2006 includes in part; Prior to changing a room or roommate assignment all parties involved in the change assignment (e.g.) Residents and their representatives (sponsors) will be given a 2-day advanced notice of such change. The notice of a change in room or roommate assignment may be oral or in writing, or both, and will include the reason(s) for such change. On 3/20/2017 at 1:00 p.m., R#194 was interviewed and he reported that he was very upset at the time that he was moved to this room from the third floor. He stated this happened about three months ago and no one prepared him for a room change. The resident said, they came to me after I finished my breakfast and moved me the same day. The resident stated, They told me I had to be moved because I no longer needed therapy and I became long term care. If they do it again I will speak up for myself because that really upset me. Review of the Shift Charting Notes dated 1/16/2017 at 9:49 a.m., the resident was transferred to (a room on the fourth floor) per staff. Medications and personally belongings transferred, report given as well. Review of a General Social Services Note dated 1/12/2017 at 3:18 p.m, documents the resident is to remain for long term care. MSW left a message on voice mail of his daughter to discuss room change to the 4th floor- traditional… | 2020-09-01 |
| 6 | 6 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2017-03-23 | 328 | D | 0 | 1 | 6QM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review and staff interviews, the facility failed to ensure residents received proper [MEDICATION NAME] treatment and care by not capping the sterile end of an intravenous (IV) tubing nor removing air from syringes and intravenous tubing. This had the potential to affect one of two residents (R) (R#37) currently receiving IV medications in a universe of 32 sampled stage 2 residents. Failure to cap the sterile end on an IV could result in a resident infection and failing to remove air from syringes or intravenous lines could result in an air [MEDICAL CONDITION] (a blood vessel blockage caused by air bubbles in the circulatory system). Findings include: Observation in R#37's room on 3/23/17 from 9:30 a.m. - 10:00 a.m. revealed Licensed Practical Nurse (LPN) (LPN KK) verbalized intention to flush R#37's right hand intravenous (IV) catheter using a 10 cc syringe of sterile normal saline (NS), However, as she moved toward the IV with the syringe, she had not expelled the visualized air from the syringe. Surveyor stopped the procedure requesting she expel the air. She held the syringe horizontally expelling liquid while the air bubble remained. She turned to resume flushing and again was asked to remove the air from the syringe, requesting LPN KK hold it vertically, syringe tip up, to examine and expel the air bubble. LPN KK did remove the air, shaking her head, offering that she was nervous being watched but can do this as she flushed the IV extension tube with the NS. LPN KK then opened the sterile IV tubing package and connected a 100 cc bag NS with 1 gram of [MEDICATION NAME] (an Antibiotic) to the IV tubing. She ran the solution through the tubing without closing clamp or turning filter upside down. LPN KK then strung the tubing through the medication pump (used to regulate the time and amount of solution administered). The pump began beeping when it was turned on. It was noted there were multiple air bubb… | 2020-09-01 |
| 7 | 7 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2017-03-23 | 371 | F | 0 | 1 | 6QM511 | Based on observation, staff interview, anonymous interviews, review of dish washer temperature log, and review of the Dish Machine Temperatures policy, revised 1/2016, and the Uniform Dress Code policy dated 1/2016, the facility failed to ensure the high temperature dishwasher wash temperature was maintained at 160 degrees Fahrenheit (F) and final rinse temperature was maintained at 180 degrees (F), or higher, The facility failed to have test strips for the dishwasher and attach the test strips to the dishwasher log as required by facility policy, and failed to ensure that staff wore hair and beard restraints while in the kitchen. This failure had the potential to effect 128 residents that received food from the kitchen. Findings include: Observation on 3/21/17 at 10:37 a.m. of the electronic dishwasher monitor screen revealed that it was red and had a tringle with an exclamation point (!) in it. In an interview at this time Dietary Aide DD stated that the dishwasher monitor screen was red and had an exclamation point in the triangle, because the water temperature in the dishwasher was too low. Dietary Aide DD stated that the dishwasher was a hot water dishwasher, the wash water temperature is supposed to be 160 degrees F and the rinse is supposed to be 180 F, but the water temperature has been fluctuating. Continued observation on 3/21/17 from 10:37a.m. to 10:45 a.m. revealed that the Dietary Aide DD continued to wash the dishes and the monitor continued to be red with an exclamation point inside a triangle. The wash water temperatures on the electronic monitor fluctuated from 132 to 157 degrees F and the rinse temperature fluctuated from 177 degrees F to 192 degrees F. Further observation revealed Dietary Aide DD never verified the water temperature fluctuation with a test strip attached to a dish. In an interview at this time the Dietary Aide stated that he had washed about 10 racks of dishes and the other staff member put them on the storage rack. In further interview, Dietary Aide DD stated that his supervis… | 2020-09-01 |
| 8 | 8 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-01-25 | 584 | D | 0 | 1 | 4HRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility documents the facility failed to maintain a safe/clean/comfortable homelike environment for the residents in six rooms (out of 24 rooms) on one unit (out of five). Specifically, six rooms on Unit 300 had significant areas of bare walls where the paint had been scratched, scuffed or peeled off. The documents reviewed included the Daily Housekeeping Room Checklist, Housekeeping Review, Work Order Logs and the Call In Work Orders listing. Findings include: A tour of Unit 300 was conducted with the Maintenance Director (MD) beginning on 1/25/19 at 10:35 a.m. The following areas were confirmed with the MD including: room [ROOM NUMBER]: Multiple areas on one of four walls where paint is scuffed, scratched and peeling, missing; room [ROOM NUMBER]-A: Multiple areas on the wall behind the head of the bed where paint is missing; room [ROOM NUMBER]-A: Multiple areas on the wall behind the head of the bed where paint is missing; room [ROOM NUMBER]: A line of multiple scratched, scuffed areas where paint is missing approximately four feet from floor (waist high) on two of four walls; room [ROOM NUMBER]: Multiple areas on one of four walls where paint is scuffed, scratched and peeling, missing above the cove base; room [ROOM NUMBER]: An area on the entry wall five feet in length approximately three feet from floor (waist high) where paint is missing, scratched, scuffed. During an interview conducted on 1/25/19 at 9:57 a.m. with Maintenance Tech CC revealed that he receives work orders from the maintenance office to complete specific painting tasks. He could not confirm if there was any type of regular scheduled inspection of the rooms for routine maintenance. An interview with the Administrator was conducted on 1/25/19 at 10:15 a.m. revealed that the facility is currently undergoing a renovation by unit. She could not confirm when Unit 300 was scheduled for renovation but stated that even though they… | 2020-09-01 |
| 9 | 9 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-01-25 | 656 | D | 0 | 1 | 4HRK11 | **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 administering medications as ordered for one Resident (R) (R#114). The sample size was 49 residents. Findings include: Review of the medical record revealed that R# 114 had the [DIAGNOSES REDACTED]. Record review revealed a care plan for the potential for medication side effects related to [MEDICAL CONDITION] medication. This care plan documented an intervention to administer medications as ordered. Further record review revealed a Physician order, with a start date of (MONTH) 1, (YEAR), for [MEDICATION NAME] 0.25 milligrams (mg) to take one tablet twice daily as needed (prn) for 60 days for agitation. Review of the Medication Administration Record [REDACTED]. Interview on 1/24/19 at 9:40 a.m. with Licensed Practical Nurse (LPN) II confirmed that the PRN [MEDICATION NAME] 0.25 mg order was started in (MONTH) (YEAR) and should have ended (MONTH) 1, 2019. Interview with the Registered Nurse (RN) Unit Manager on 1/24/19 at 9:45 a.m. revealed that they typically get a report from the pharmacy when a medication needs to be stopped and the pharmacy consultant sends a monthly report. The Unit Manager revealed that a report had been received from the pharmacy consultant on 1/22/19, but she had not reviewed or followed up on the recommendations yet. | 2020-09-01 |
| 10 | 10 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-01-25 | 657 | D | 0 | 1 | 4HRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled Comprehensive Person -Centered, the facility failed to update and revise a comprehensive care plan to reflect the vascular site and monitoring of the site for one resident out of five sampled residents (R#133) receiving [MEDICAL TREATMENT] services. Findings include: Record review of policy titled Care Plans Comprehensive Person-Centered stated It is the intent of Magnolia Manor facilities to develop and implement a person-centered plan of care for each resident that include goals for admission, discharge and desired outcomes. 3. (B) Incorporate risk factors (s) associated with the identified problems(s). (D) reflect treatment goals and objectives in measurable goals. B. Reflect the resident's specified goals for admission and desired outcomes. B. Reflect the resident's specified goals for admission and desired outcomes. F. Enhance the optimal functioning of the resident utilizing rehabilitative program as indicated. (5). Care plan are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. The resident has the right to participate in the process and to approve any changes to the plan of care. Record review revealed that R#133 had a Physician order dated 8/20/18 for an AV Fistula (ateriovenous fistula) shunt and attended [MEDICAL TREATMENT] two days a week on Monday and Friday. The Minimum Data Set ((MDS) dated [DATE] section C revealed a Brief Interview Mental Status (BIMS) score of 15 (a score of 15 out of 15 indicates cognitive intact) and a section O revealed a coding for [MEDICAL TREATMENT]. Review of [MEDICAL TREATMENT] care plan dated 10/16/18 (last reviewed on 1/2/19) revealed that there was not any interventions in place to monitor the vascular site or checking the site for bruit and thrill. Interview on 1/24/19 at 3:24 a.m., with the Director of Nursing (DON) revealed that staff should check every shift for bruit a… | 2020-09-01 |
| 11 | 11 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-01-25 | 758 | D | 0 | 1 | 4HRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to assure that PRN (as needed) medications were taken as ordered for one Resident (R) #114. The sample size was 49 residents. Findings include: Review of the medical record revealed that R#114 had the following [DIAGNOSES REDACTED]. Record review of the chart revealed an order, with a start date of (MONTH) 1, (YEAR), for [MEDICATION NAME] 0.25 milligrams (mg) with one tablet taken by mouth twice daily as needed for 60 days for agitation. Review of the Medication Administration Record [REDACTED]. Interview on 1/24/19 at 9:40 a.m. with Licensed Practical Nurse (LPN) II confirmed that the [MEDICATION NAME] PRN order started in (MONTH) and should have ended (MONTH) 1, 2019. It was reported that typically orders on the rehab unit are not written this way and that the pharmacy notifies when there is a hard stop on an order. Interview with the Registered Nurse (RN) Unit Manager JJ on 1/24/19 at 9:45 a.m. revealed that she had received a report from the pharmacy consultant on Tuesday but she had not reviewed or followed up on the recommendations yet. | 2020-09-01 |
| 12 | 12 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2017-01-26 | 280 | D | 0 | 1 | DVCB11 | Based on staff interview and record review, it was determined that the facility failed to revise a plan of care to include a pressure ulcer for one resident (#194) from a total sample of 22 residents. Findings include: A review of Resident (R) #194's clinical record revealed the resident had a stage two pressure ulcer to the left elbow since 10/31/16. During an interview on 1/24/17 at 10:12 a.m., Licensed Practical Nurse (LPN) AA confirmed the resident had a stage two pressure ulcer to the left elbow, identified on 10/31/16. There was a plan of care in place, dated 10/26/16, that R#194 was at risk for pressure areas related to incontinence and decreased mobility. Although interventions were implemented to address the pressure ulcer, the plan of care was not revised to include the presence of the pressure ulcer to the left elbow, until 1/25/17, after surveyor inquiry. During an interview on 1/26/17 at 1:49 p.m., Registered Nurse (RN) BB confirmed that the plan of care had not been revised and stated it was an oversight. | 2020-09-01 |
| 13 | 13 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2018-02-01 | 761 | D | 0 | 1 | 0R9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Medication Administration Procedural Guidelines and interviews the facility failed to ensure that the medication cart was locked during medication administration on one of four medication carts observed during medication administration. Findings include: Observation on 01/31/18 at 4:42 p.m. during Medication Administration with Licensed Practical Nurse (LPN) LPN AA on Unit 1 medication cart. revealed that LPN AA parked the medication cart outside along the opposite wall from room [ROOM NUMBER] on Unit 1 and at 4:21 p.m. and returned to the medication cart to remove medications to administer to the other resident in room, 125 A bed. At 4:24 p.m. LPN AA was observed to remov medications from the cart that was against the wall on the other side of the hall on Unit 1 that was not in direct view of the nurse in the residents room [ROOM NUMBER] [NAME] LPN AA then left the medication cart unlocked going into room [ROOM NUMBER] A leaving the door open however, the LPN's back was to the medication cart the entire time she was in the room. LPN AA then came out of the room and called for assistance to help reposition the resident in the bed, not realizing that the medication cart remained unlocked. LPN AA then went back into room [ROOM NUMBER] A continuing to leave the medication cart unlocked. After repositioning the resident with assistance and administering the residents medication the surveyor observed by standing right out side of residents door. LPN AA came out of the room at 4:35 p.m. Interview with the LPN AA, at this time revealed that she had not received any training here at the facility and did not have a preceptor here before starting on the floor, LPN AA also reported she was an agency nurse and started on the medication cart two months ago and comes two times a week. Interview on 2/1/18 at 11:00 a.m. with the Director of nursing reported that the licensed nursing staff do a skills check off list and Lif… | 2020-09-01 |
| 14 | 14 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2018-02-01 | 812 | E | 0 | 1 | 0R9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility's policy for food and nutrition the facility failed to maintain sanitary resident nourishment refrigerators in unit pantries, failed to store food items properly in resident nourishment refrigerator and failed to dispose of expired food items in a timely manner in resident nourishment pantry on three of five units. Findings include: Observation on [DATE] at 8:14 a.m. of resident nourishment pantry on Unit 3 revealed thickened sweet tea dated as expired on [DATE]. Confirmed as expired by Licensed Practical Nurse (LPN) A[NAME] Observation on [DATE] at 9:39 a.m. of resident nourishment pantry on Unit 1 revealed five cartons of Impact Advanced Reconstituted Nutritional Drink dated expired [DATE]. Confirmed by Registered Nurse (RN) BB as expired. Observation on [DATE] at 9:44 a.m. of resident nourishment refrigerator in the pantry on Unit 5 revealed two unlabeled/undated frozen food items in a take-out container in the freezer. Confirmed by LPN CC. LPN CC stated that the food items that were in the freezer had been brought in for a resident but she was unsure for which resident or when they were brought in. Observation on [DATE] at 9:55 a.m. of resident nourishment refrigerator in the pantry on Unit 4 revealed a large spill of brown liquid in the bottom of the refrigerator. Observation also revealed that the refrigerator contained the following an unlabeled/ undated open coke can, covered loosely by a paper towel, an open unlabeled/undated two- liter grape [MEDICATION NAME] beverage, an unlabeled/undated personal cup, a plate of food with staff signature of SH, LPN and dated [DATE]. The previously listed food items were intermingled with resident nourishment items. A separate employee refrigerator was provided for employee food and was labeled employee. LPN DD confirmed the previous findings. Interview with LPN DD revealed that all staff were responsible for upkeep of the resident nourishm… | 2020-09-01 |
| 15 | 15 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 656 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that medication for pain was administered for one of 12 residents(A) and failed to provide wound care for one of 12 residents (B) as care planned. Findings include: 1. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waits until her pain medication runs out to order more. Record review revealed that RA had a care plan since 2/819 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration. The care plan included an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed that there was a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. Record revealed that on 5/24/19 a physician's orders [REDACTED]. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. Therefore, the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. Cross refer to F697 2. Record review revealed that RB had a care plan problem, dated 4/2/19, for receiving treatment with an antibiotic for bilateral [MEDICAL CONDITION]. The care plan problem was updated on 4/29/19 to include the use of an intravenous antibiotic and an intervention for nursing staff to provide wound care as ordered. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left la… | 2020-09-01 |
| 16 | 16 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 684 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that wound treatments were provided as ordered by the physician for one of 12 residents (R B). Findings include: Record review revealed that Resident (R) B had [DIAGNOSES REDACTED]. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., with Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes dared 5/10/19 confirmed that RB reported the use of silver dressings to her lower extremity wounds. During an interview on 6/7/19 at 12:55 a.m., with the Director of Nursing (DON) revealed that she expected licensed nursing staff to obtain a physician's orders [REDACTED]. | 2020-09-01 |
| 17 | 17 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 697 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility policy titled, Obtaining and Receiving Medications from Pharmacy the facility failed to ensure the medication for pain was obtained timely for one of 12 residents (R A). Findings include: The facility had an Obtaining and Receiving Medications from Pharmacy policy. The policy documented that medications that must be reordered by the nurse included controlled substance medications. The policy further documented that Schedule II medications such as [MEDICATION NAME] and [MEDICATION NAME] products required a signed prescription by the physician and should be reordered at least seven days in advance. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waited until her pain medication ran out to order more. Record review revealed that RA had a care plan since 2/8/19 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration with an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed a Physician's order since 2/15/19 for [MEDICATION NAME] 10-325 milligrams (mg) to be administered every six hours for pain. There was also a physician's order since 2/13/19 for [MEDICATION NAME] 10-325 mg to be administered every six hours as needed for pain. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. On 4/23/19 a Physician's order was obtained to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when it was available. 2) Administer [MEDICATION NAME] 10-325 mg every six hours, scheduled and discontinue when the [MEDICATION NAME] became available. 3) Keep the order for [MEDICATION NAME] 10-325 mg every six hours as needed for pain. A review of the (MONTH) 2019 M… | 2020-09-01 |
| 18 | 18 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2018-07-19 | 656 | G | 0 | 1 | 9U3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, the facility staff failed to follow the comprehensive care plan for Resident (R #40) on how to safely transfer the resident from one surface to another. On 7/5/18, R#40 was transferred improperly, without the use of a Hoyer lift, resulting in R#40 sustaining two fractured ribs on the left side. The sample size was 46 residents. Findings include: Record review revealed that R #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#40's most recent comprehensive Minimum Data Set (MDS), a five-day scheduled assessment with an Assessment Reference Date (ARD) of 4/25/18 coded R#40 as cognitively moderately impaired, requiring cues/supervision with decision making and requiring extensive assistance of two people for bed mobility and totally dependent of two people for transfers. Review of the Comprehensive care plan dated 12/13/17 with an Approach: Transfer with the help of one person and updated on 4/15/18 to 4/18/18 to reflect dependent Extensive, related to weakness, need total assist with Activities of Daily Living (ADL) and Hoyer lift by two persons under the Goal section. A hand written note at the bottom of the care plan dated 4/18/18: (MONTH) use Hoyer lift prn (as needed) during transfers related to weakness. The care plan was updated on 7/10/18 under Approach: Transfer-two person Hoyer lift. A review of the facility document Nurse Aide's Information Sheet also referred to by the facility staff as the ADL sheet (a communication tool used by the Certified Nursing Assistants (CNA) to determine a resident's ADL needs, including transfers) documented that R#40 needed assistance of one staff member to place from bed into the wheelchair. An update was made on 7/9/18 for use of Hoyer lift by two persons for transfers. Review of the facility investigation statement, written by CNA BB, revealed that the CNA had never worked with R#40 prior to this incident and had tran… | 2020-09-01 |
| 19 | 19 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2018-07-19 | 689 | G | 0 | 1 | 9U3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family and staff interviews and records review, the facility staff failed to ensure that the correct information regarding safe transfer techniques for Resident (R#40) was accurate on the Certified Nursing Assistants (CNAs) care communication tool, the Activities of Daily Living (ADL) sheet. Between 4/18/18 and 7/5/18 R#40 was documented throughout the clinical record as being totally dependent for transfers and requiring a Hoyer lift for safe transfers. On 7/5/18 Certified Nursing Assistant (CNA) BB transferred R#40 without assistance of another staff member and without using a Hoyer lift. Following the transfer R#40 was documented as having increased pain on the left side and an X-Ray completed later that day documented that R#40 had acute fractures of two ribs on the left side resultling in the resident being transferred to the hospital for evaluation. The sample size was 46 residents. Findings include: Observation of R#40 on 7/16/18 at 9:30 a.m. revealed the resident was lying in her bed with her family at the bedside. An interview in R#40's room was conducted with a family member who stated that their mother was doing okay but that a couple of weeks ago she had been transferred from her bed to her recliner by an aide (CNA BB) and was found to have two fractured ribs following the transfer. When asked how the fractured ribs occurred the family of R#40 stated that the aide (CNA BB) had transferred the resident without assistance and did not use a Hoyer lift, which was how she was normally transferred. The family member further stated that the facility had reported the incident to the State and it was their understanding that the facility had investigated the incident. Review of R#40's clinical record revealed the resident's [DIAGNOSES REDACTED]. A review of R#40's most recent Comprehensive Minimum Data Set (MDS), a five-day assessment with an Assessment Reference Date (ARD) of 4/25/18, coded R#40 as being cognitively … | 2020-09-01 |
| 20 | 20 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2019-11-15 | 585 | D | 0 | 1 | O88D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review and review of facility policies, the facility failed to make prompt effort to file a grievance for one resident (R) #25 who verbally reported to staff she was missing her lower denture. The sample size was fifty-seven residents. Findings include: Review of an undated policy titled Dental Policy revealed 3. Nursing staff to report missing dentures, notify social service, and fill out concern forms. Review of the policy titled Complaint (Grievance) Policy revised date of (MONTH) (YEAR) revealed Such complaints may include those related to his or her treatment, medical care, missing clothing or other complaints regarding their stay. Record review of the Minimum Data Set (MDS) significant change assessment dated [DATE] revealed R#25 had a Brief Interview for Mental Status of nine indicating moderate cognitive impairment. An interview and observation was conducted on 11/12/19 at 11:50 a.m. with R#25 who responded to interview questions appropriately. The resident was asked about dentures. The resident revealed she is missing her bottom denture. Observation of only top dentures in the resident's mouth. The resident also revealed she reported to the staff and the dentist that she was missing her lower denture. The resident revealed the lower denture has been missing for a couple of months. An interview was conducted on 11/15/19 at 3:25 p.m. with the Certified Nursing Assistant (CNA) CC. The CNA revealed R#25 had reported to the staff during mealtime in the dining room a month ago that she was missing her bottom denture. Record review of R#25's dental notes dated 9/10/19 revealed Patient states her lower denture has been lost. An interview was conducted on 11/15/19 at 9:44 a.m. with the Social Service Director (SSD). The SSD was asked how the facility handles residents missing items. The SSD revealed when a person reports (verbally or in writing) a missing item a grievance form is com… | 2020-09-01 |
| 21 | 21 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2019-11-15 | 732 | C | 0 | 1 | O88D11 | Based on observation and staff interview the facility failed to categorize licensed and unlicensed nursing staff directly responsible for resident care per shift and failed to make certain staffing information was accurate and current. The facility census was 163. Findings include: An observation on 11/12/19 at 10:15 a.m., of the nurse staff information posted on the A/B hall near the treatment nurses office revealed a census of 161. The staffing posting consisted of 4 pages of staff names, staff assigned rooms, staff assigned breaks, staff assigned task, and total employee hours. The staff posting did not include the facility name or the number of licensed and unlicensed staff per unit. The posting appeared to be a facility schedule that listed all staff assigned to work for that day. The information included all licensed and unlicensed staff, as well as staff that do not provide direct care. Further review revealed that the nightshift CNA's assignment did not list the rooms assigned, but instead listed see book. It was difficult for a visitor or resident to know which staff (licensed or unlicensed) was assigned to provide care. An interview on 11/12/19 at 10:46 a.m., with the staffing coordinator, she revealed the A/B hall nursing station was the only place in the facility where the daily staffing is posted. An observation on 11/13/19 at 9:15 a.m,. of the nurse staff information posted on the A/B hall revealed a census of 161 which was not correct due to the actual census being 163. | 2020-09-01 |
| 22 | 22 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2019-11-15 | 812 | F | 0 | 1 | O88D11 | Based on observation, policy review and staff interviews, the facility failed to ensure opened food items in the dry storage area were securely covered, labeled and dated; failed to discard food items by expiration date; failed to maintain sanitary conditions in the kitchen by not stacking wet cookware and ensuring the cleanliness of kitchen equipment and not changing gloves during puree process. The facility also failed to maintain proper holding temperatures for cold food items at 41 degrees Fahrenheit (F) or below during meal service. There are 161 residents that receive an oral diet. Findings include: 1. Observation during initial tour on 11/12/19 from 10:05 a.m. to 10:31 a.m. with Certified Food Service Manager (CFSM), revealed in the dry storage area one opened/unsealed 12 ounce box of raisins with no open date; one 16 ounce opened/unsealed box of dry rice with no open date. In the walk in cooler, a large clear storage container with cooked chili with use by date of 11/3/19; one clear container with gravy with use by date of 11/5/19; one clear container of macaroni and cheese with use by date of 11/3/19; one clear storage container with red food substance, unlabeled with no use by date (identified by staff as stewed tomatoes); a large clear storage container of food substance, unlabeled with no use by date (identified by staff as green beans) and one stainless steel container of dinner rolls with use by date of 11/5/19. Interview on 11/12/19 at 11:15 a.m. with Certified Food Service Manager (CFSM) stated that the kitchen staff know that foods are to be dated and discarded after three days. She further stated that she has had many discussion with the dietary staff about not saving the leftover food, because they rarely use it. She verified the concerns identified during the initial tour. 2. Observation during initial tour on 11/12/19 from 10:05 a.m. to 10:31 a.m. with Certified Food Service Manager (CFSM), revealed food slicer on the back table with dried food debris on the blade and the slide tray; wet nest… | 2020-09-01 |
| 23 | 23 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2019-11-15 | 840 | D | 0 | 1 | O88D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide documentation of a written agreement or contract with the company providing out patient [MEDICAL TREATMENT] services for one resident (R) (#44) of 3 residents receiving [MEDICAL TREATMENT] services. Findings include: A review of the clinical record revealed R#44 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of three, indicating severe cognitive impairment. Section: O revealed the resident was receiving [MEDICAL TREATMENT] while a resident in the facility. Review of the physician's orders [REDACTED]. Review of the Facility Resident Census and Conditions of Residents Form dated 11/12/19 revealed the facility had three residents receiving [MEDICAL TREATMENT] at an outside certified end-stage [MEDICAL TREATMENT] facility. Interview on 11/13/19 at 4:56 p.m., with the Assistant Administrator revealed the facility had been trying for months to obtain a [MEDICAL TREATMENT] agreement from the [MEDICAL TREATMENT] center but has not had any luck. She stated she would call again to speak with someone who understood the importance of having this information on file. During an interview on 11/14/19 at 12:05 p.m., the Administrator stated the facility had made several attempts to get a contract from the [MEDICAL TREATMENT] center. He reported and confirmed that when R# 44 was admitted , he was not made aware that there was not a [MEDICAL TREATMENT] contract. He further stated that he had made several attempts to get an agreement with the [MEDICAL TREATMENT] provider but had not been successful until today. | 2020-09-01 |
| 24 | 24 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2019-11-15 | 908 | F | 0 | 1 | O88D11 | Based on observations and interview, the facility failed to ensure that essential equipment in the kitchen was in working order as evidenced by, ice build up inside and around the door frame of the walk-in freezer observed on four of four days during the survey. There are 161 residents that receive an oral diet. Findings include: During the initial tour on 11/12/19 at 10:05 a.m. with the Certified Food Service Manager (CFSM) the surveyor inspected the walk-in freezer. During the inspection, the inside door frame, ceiling and floor inside door opening, had visible ice formation. Additional observations during follow-up visits to the kitchen, revealed continued ice buildup on the walk-in freezer door frame, ceiling and floor during all four days of the survey. Interview on 11/15/19 at 4:00 p.m. with the CFSM, stated that staff scrape off the ice in the walk-in cooler everyday. She stated that she has not reported the issue to the maintenance department. She further stated there were no policies related to maintenance of the walk-in freezer. | 2020-09-01 |
| 25 | 25 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2017-02-09 | 278 | D | 0 | 1 | OC5011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to accurately assess pressure ulcers for one resident (R) (R#5) and failed to accurately asssess the oral/dental status for one resident (R#90) who had missing and broken teeth. The sample was 27 residents. Findings include: 1. R#5 was admitted to the facility on [DATE]. Further review of the record revealed the resident did not have pressure ulcers present on admission to the facility. A significant change MDS assessment was conducted on 3/23/16 and the resident was coded as having no pressure sores. On a quarterly MDS dated [DATE], the resident was coded as having an unstageable pressure sore to both heels which were present upon admission and present on the prior assessment. Review of the clinical record revealed the resident had unstageable pressure sores on her bilateral heels which developed in the facility. In addition, a quarterly MDS assessment was conducted on 9/9/16 and again the resident was coded as having the pressure sores present on admission. Review of a quarterly MDS dated [DATE] indicated the resident had a Stage 3 pressure sore upon admission and present on prior assessment. During an interview on 2/9/17 at 6:40 p.m., the MDS Coordinator confirmed she completed the assessments and further stated the resident's pressure sores her on bilateral heals were acquired in-house and both MDS assessments dated 6/23/16 and 12/2/16 were not coded correctly. 2. Review of records revealed R#90 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Observation of R#90 on 2/07/17 at 10:43 a.m. revealed the resident had several teeth missing in the upper and lower gums and several teeth, broken with caries. Review of a Clinical Health Status assessment completed for R#90 on 4/26/16 revealed under the section, Oral/Respiratory, that the resident had broken, loose, or carious teeth. Review of the latest Clinical Health St… | 2020-09-01 |
| 26 | 26 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2017-02-09 | 280 | D | 0 | 1 | OC5011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the comprehensive care plan to reflect the addition of [MEDICATION NAME] (an antipsychotic) to the medication regimen for one resident (R) (R#59) from a sample of 27 residents. Refer F329 Finding include: Review of the physician orders [REDACTED]. Review of section N of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed antipsychotic medications were documented as administered each day of the seven day look back period. Further review revealed the comprehensive care plan dated revised 12/1/16 indicated there was not a care plan developed to address the use of the antipsychotic medication. During an interview on 2/9/17 at 6:40 p.m., the MDS Coordinator confirmed the care plan was not revised to include [MEDICATION NAME] after the quarterly MDS was conducted in (MONTH) (YEAR). | 2020-09-01 |
| 27 | 27 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2017-02-09 | 282 | D | 0 | 1 | OC5011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policy and procedures, the facility failed to routinely implement care plan interventions related to behavior monitoring for one resident (R) (R#90) being treated with an antipsychotic medication from a sample of 27 residents. Refer F329 Findings include: Review of records revealed R#90 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment for R#90 with reference date of 12/19/16 revealed in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) score of 10 which indicates the resident has a moderate cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. Review of the resident's Annual MDS assessment with a reference date of 5/3/16 revealed that [MEDICAL CONDITION] drug use and behavioral symptoms triggered on Section V - Care Area Assessment (CAA) Summary - and the decision was made to complete a plan of care for these areas. Review of the policy titled Behavior Management Guideline dated 11/1/16 revealed that each resident's drug regiment will be free from unnecessary drugs, defined as a drug when used without adequate monitoring. A care plan is developed for residents exhibiting negative behaviors or those on an antipsychotic medication, and a monitoring system is established for targeted behaviors and medication side effects and effectiveness. Review of the Plan of Care for R#90, last revised 10/28/16 revealed a focus area related to the potential for drug-related complications associated with the use of antianxiety and antipsychotic medications, physical and verbal altercations with roommates and staff, and refusal of medications. The goal was for staff to monitor for psychiatric drug complications through the next review date. Interventions included: monitoring and reporting side effects to the attending physician; monitoring and documenting target beha… | 2020-09-01 |
| 28 | 28 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2017-02-09 | 329 | D | 0 | 1 | OC5011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to monitor two residents (R) for behaviors, that received antipsychotic medication (R#59 and R#90). The sample was 27 residents. Findings include: 1. Review of the physician orders [REDACTED]. Review of the Behavior Flow Sheet for (MONTH) (YEAR) revealed no evidence of behavior monitoring for hallucinations and wandering on the following dates and times: 2/3/17 on night shift 2/4/17 on night shift 2/5/17 on night shift 2/7/17 on night shift 2/8/17 on day, evening and night shift Further review of the medical record revealed no evidence of behavior monitoring for the months of October, November, and (MONTH) (YEAR) and (MONTH) (YEAR). An Interview on 2/9/17 at 7:55 p.m. with the Unit Coordinator DD confirmed there was no evidence of behavior monitoring for the dates noted in (MONTH) (YEAR). She further stated, in the past, the documentation of behaviors had been stored in a notebook, however, the notebook could not be located. 2. Review of the policy titled Behavior Management Guideline dated 11/1/16 revealed that each resident's drug regiment will be free from unnecessary drugs, defined as a drug when used without adequate monitoring. A care plan is developed for residents exhibiting negative behaviors or those on an antipsychotic medication, and a monitoring system is established for targeted behaviors and medication side effects and effectiveness. Review of records revealed Resident (R) #90 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Physician orders [REDACTED].; and an Abnormal Involuntary Movement Scale (AIMS) to be completed quarterly. Review of the most recent quarterly Minimum Data Set (MDS) assessment for R#90 with a reference date of 12/19/16 revealed in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) score of 10 which indicates the resident has a moderate cognitive impairment. Section [NAME] - Behavior - of the same … | 2020-09-01 |
| 29 | 29 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2017-02-09 | 514 | D | 0 | 1 | OC5011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of policy and procedure, the facility failed to maintain accurate clinical records for two residents (R), (R#77) related to [DIAGNOSES REDACTED].#59) related to inaccurate documentation of gastric tube feedings from a sample of 27 residents. Findings include: Review of facility policy titled Medication Review - Admission/ReAdmission revealed Medication review is intended to eliminate prescribing medication errors at care transitions by generating a complete and accurate list of resident medications. The second medication review will include review of admission orders [REDACTED]. 1. Review of the clinical record for R#77 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Continued review revealed R#77 was a male. Review of the hospital clinical record for R#77 revealed he had been admitted on [DATE] and discharged to the facility on [DATE] and had not had surgery during his hospital admission. Transfer orders from the hospital for R#77, dated 12/27/16, included an order for [REDACTED]. Facility admission orders [REDACTED]. Review of the December, (YEAR) and January, (YEAR) MAR for R#77 revealed [MEDICATION NAME] 250 mg had been initialed as administered at 9:00 a.m. on 12/28/16, 1/2/17, 1/3/17 and 1/4/17. Interview 2/9/17 at 11:45 a.m. with the Director of Nurses (DON) revealed the [DIAGNOSES REDACTED]. The DON acknowledged the order for [MEDICATION NAME] had been transcribed incorrectly and recorded as administered incorrectly. The DON revealed the process for avoiding transcription errors for newly admitted residents is to review the MAR/TAR and compare with the admission orders [REDACTED]. The DON revealed she had compared the admission and transfer orders with the MAR for R#77 but had not noticed there was only one space to sign out [MEDICATION NAME] 250 mg on the MAR and that the spaces for 12/29/16, 12/30/16, and 12/31/16 had been crossed out. The DON revealed she also had n… | 2020-09-01 |
| 30 | 30 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 584 | E | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in nine resident rooms (rooms 3 B, 5 B, 11 B, 14 B, rooms 12, 20, 23, 30 and room [ROOM NUMBER]) on two of two halls. The facility census was 61. Findings include: Observation on 12/3/18 at 11:19 a.m., revealed in room [ROOM NUMBER] B, residents bedside tabletop fan, with dust build-up on the fan grill and blades. Observation on 12/3/18 at 11:48 a.m., revealed in room [ROOM NUMBER] B, scratched and peeling paint along the wall close to bathroom doorway. Observation on 12/3/18 at 2:47 p.m., revealed in room [ROOM NUMBER], electrical phone plate loosely hanging on wall, at the head of bed between bed A and bed B. Observation on 12/4/18 at 8:58 a.m., revealed in room [ROOM NUMBER], window curtain has circular stains in three different spots, approximately three by three inches. Window sill has dust build up with cob webs in low corner. Observation on 12/4/18 at 9:37 a.m., revealed in room [ROOM NUMBER] B, wall to the right of bed B, scuffed paint approximately four feet in length. Observation on 12/6/18 at 11:15 a.m., revealed in room [ROOM NUMBER] B, a large hole in the wall on the window side of the room, near the floor baseboard, window curtain noted with multiple brown stains, resembling liquid spill on curtain. Also, patch of peeling paint at head of bed B. Observation on 12/6/18 at 12:00 p.m., revealed in room [ROOM NUMBER], window curtain noted with multiple brown stains, resembling liquid spill on curtain. Observation on 12/6/18 at 2:31 p.m., revealed in room [ROOM NUMBER], window curtains with multiple red colored stains, appearing to be blood stains. Also, cob webs noted in left lower corner of window. Observation on 12/6/18 at 2:31 p.m., revealed in room [ROOM NUMBER], floor length window curtains stained with red and blue substance splattered on bottom of floor length curtains. Interview on … | 2020-09-01 |
| 31 | 31 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 636 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and policy titled Resident Assessment Instrument process, the facility failed to assess the resident (R) #24 on the Minimum Data Set (MDS) assessment for depression. Sample size was 37. Findings include; R#24 was admitted on [DATE]. [DIAGNOSES REDACTED]. During an unnecessary medication record review on 12/4/18 at 1:46 p.m. a review of R#24 medications include but not limited to [MEDICATION NAME] 10 mg 1 tab daily by mouth (po) for depression, [MEDICATION NAME] .5mg po for agitation at hour of sleep, (hs) and [MEDICATION NAME] 5mg daily for dementia. Further record review revealed Pharmacy Consultant reviewed R#24 record on 10/17/18 and made a recommendation to attempt a gradual dose reduction (GDR) for [MEDICATION NAME]. On 10/29/18 the Physician documented a GDR was contraindicated for this resident and declined the pharmaceutical recommendation. Continued review of R#24 record offers evidence resident was receiving psychiatric services and was last seen on 11/26/18. The review of records revealed a Nurse Practioner assessed resident on 11/12/18. The active problem list included a [DIAGNOSES REDACTED]. Review of several of R#24's most recent MDS did not assess the resident as having depression. MDS reviews included an annual dated 12/2/17 and quarterly's dated 2/7/18, 4/24/18, 7/10/18, and 9/19/18. Review of care plan revealed the resident is care planned for review of [MEDICAL CONDITION] medications. An interview with the Director of Nursing (DON) on 12/6/18 at 10:00 a.m. revealed the facility has been without a fulltime MDS Coordinator for more than 30 days. DON continued to state that corporate personnel and staff members from other facilities have been filling the positions. A telephone interview on 12/6/18 at 11:23 a.m. with, Regional Nurse Resident Assessment Consultant (RAC) revealed the MDS Coordinator is responsible for reviewing all MDS's in the facility. In clinical morning meetings what sh… | 2020-09-01 |
| 32 | 32 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 655 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review and policy title Baseline Care Plan, the facility failed to develop a baseline care plan for one resident (R) [NAME] Sample size was 37. Findings include; Resident A was admitted on [DATE]. [DIAGNOSES REDACTED]. Medications ordered included but not limited to; fleet oil enema (mineral oil),insert 133 milliliters (ml) rectally every 24 hours(hrs.) as needed(prn) for constipation may self-administer, senna tablet 8.6 milligrams (mg) (sennosides) give two tablets by mouth (po) at bedtime (hs) for laxatives, [MEDICATION NAME] powder (polyethylene [MEDICATION NAME] 3350) give 17 grams (gms) po at hs for constipation, [MEDICATION NAME] capsule 100 mg ([MEDICATION NAME] sodium) give one capsule po prn for constipation. An interview on 12/3/18 at 1:51 p.m. with R A stated hasn't had a BM in nine days. Continued to state has told the Certified Nursing Assistant (CNA) and the charge nurse. An interview with R A on 12/4/18 at 5:08 p.m. stated had bowel movement (BM) and is feeling much better. Stated they administered an enema and now is ready to go home. Record review on 12/5/18 on 8:19 a.m. evidenced a nurse's note dated 12/4/18 at 2:10 p.m. Medical Doctor (MD) at bedside this shift to assess and review medications; new orders to discontinue (d/c) [MEDICATION NAME], start [MEDICATION NAME] 50mg prn; Fleets Enema prn, and give senna and [MEDICATION NAME] every (q) hs; orders noted; Enema administered this shift with results; large loose stools noted. Resident states to writer, It's just what the doctor ordered. States, I feel much better. Further review of medical record on 12/5/18 at 9:32 a.m. revealed that two nursing skilled documentations dated 12/2/18 and 12/3/18 revealed the resident was assessed for being constipated. Review of resident record revealed there was no baseline care plan in place to address the resident's issue with constipation. An interview on 12/5/18 at 10:13 a.m. with Director of Nursing … | 2020-09-01 |
| 33 | 33 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 656 | E | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to develop a plan of care to address activities of daily living (ADL's) for one resident (R#38), Oxygen usage for two resident (R#3, R#29) and failure to implement care plan intervention for one resident (R #55) related to Restorative Nursing for Range of Motion (ROM) and one resident (R #214) for ADL care. The sample size was forty residents. Findings include : Review of the clinical record for R#3 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had no known drug allergies and elected full code status. Review of the physician's orders [REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact; a Mood Total Severity Score of 0, indicating she was not depressed; and displayed no behaviors. Continued review of the same assessment documented R#3 as using oxygen while a resident. Review of the care plan, updated 11/28/18, did not include a care plan for oxygen to include goals and interventions. Observation and interview with R#3 on 12/03/18 at 12:25 p.m. revealed R#3 was wearing O2 via NC at 4.5 LPM. When asked if she knew what her O2 liter flow was supposed to be, she stated she believed her physician order [REDACTED]. She stated she was in no respiratory distress. Observation and interview with R#3 on 12/04/18 at 1:14 p.m., she was alert, oriented and pleasant sitting up in her wheelchair in her room. She was wearing O2 at 3 LPM via NC using a portable E-cylinder. She stated she was in no respiratory distress. Observation of R#3 on 12/04/18 at 4:49 p.m., noted she was asleep wearing O2 via NC at 3 LPM. She was in no apparent respiratory distress. Observation and interview of R#3 on 12/05/18 at 8:40 a.m., R#3 was seated upright in her bed wearing O2 via NC at 3 LPM. She stated she had just finished b… | 2020-09-01 |
| 34 | 34 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 677 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for two dependent residents (R) R#38 and R#214 related to nail care. The sample size was 40. Findings include: 1. A review of the clinical record for R #38 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated mild cognitive impairment. Section G revealed that the resident was assessed for total dependence for dressing, toilet use and personal hygiene. Review of updated care plan for R #38, dated 8/1/18, did not have evidence that R #38 had a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Observation on 12/3/18 at 1:49 p.m., 12/4/18 at 3:05 p.m., and 12/5/18 at 9:06 a.m., revealed that fingernails on both hands have dark brown material underneath and are untrimmed. 2. A review of the clinical record for R #214 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #214 is a new admission and entry tracking Minimum Data Set ((MDS) dated [DATE] is only MDS available, therefore, no data available at this time. Observation on 12/3/18 at 12:48 p.m., 12/4/18 at 11:02 a.m., and 12/5/18 at 10:09 a.m., and 12/6/18 at 8:30 a.m. revealed that nails are untrimmed and dirty underneath on both hands. Resident stated he would like for them to be trimmed. Interview on 12/6/18 at 8:34 a.m. with Certified Nursing Assistant (CNA) AA stated she is assigned 1-12 residents each day. She provides daily care consisting of bathing, shaving, brushing teeth, assisting with eating (meal set-up) and dressing, and feeding if they need help. If the residents are bed bound, she stated that she turns them every two hours. When asked about providing nail care, she stated that she ch… | 2020-09-01 |
| 35 | 35 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 684 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Interviews and record reviews, the facility failed to ensure quality care and services in accordance with professional standards for one resident (R#55) for the provision of Restorative Nursing for Range of Motion (ROM). The sample size was 40. The Findings: Review of resident (#55) medical record revealed the resident was admitted to the facility on (MONTH) 13, (YEAR) with [DIAGNOSES REDACTED]. Further review of resident (#55) medical record revealed his Minimum Data Set (MDS) quarterly assessment dated (MONTH) 3, (YEAR) indicated that resident (#55) has impairments to one side on the upper extremities and has impairments of both legs on the lower extremities. Additionally, according to resident MDS he is receiving Restorative Services for 6 weeks with splinting devices. Review of resident physician orders [REDACTED].#55) to have splinting brace on left elbow extremity and left resting hand splint with digit separator for first eight hours with skin checks. The program was scheduled for six days a week for six weeks. Observation made on 12/04/18 at approximately 10:38 a.m revealed resident R#55 left hand contracted while in bed asleep without splinting device in place. At the time of the observation the splint was observed lying on his dresser beside him. Observation made on 12/05/18 at approximately 01:34 p.m revealed resident R#55 in his bed asleep with the splinting device lying on top of the dresser beside him. Observation made on 12/05/18 at approximately 02:44 p.m revealed resident R#55) in his bed awake with splinting device on his dresser. Review of resident restorative log for the month of (MONTH) (YEAR) through (MONTH) (YEAR) indicated there were no documented refusals of resident (#55) refusing to wear splinting devices. Additionally, there were no documented times to show when restorative aids applied splinting devices on and off R(#55). On (MONTH) 5, (YEAR) at 02:15 PM an interview was conducted with Certif… | 2020-09-01 |
| 36 | 36 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 695 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to maintain resident [MEDICAL CONDITION], medication nebulizer and oxygen equipment in a sanitary manner for three of seven sampled residents, Resident (R)#29, R# 38 and R#3. Findings include: 3. The facility failed to maintain resident [MEDICAL CONDITION], medication nebulizer and oxygen equipment in a sanitary manner for three of seven sampled residents, Resident (R)#29, R# 38 and R#3. Findings include: 3. Review of the clinical record for R#3 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had no known drug allergies and elected full code status. Review of the physician's orders [REDACTED]. 1. Oxygen (O2) at two liters per minute (LPM) via nasal cannula (NC). 2. Change O2 tubing every Tuesday and when visibly soiled. 3. Pulse oximetry every shift 4. Check and clean (O2) concentrator filter every month and as needed. Observation of the O2 concentrator for R#3 on 12/03/18 at 12:25 p.m. revealed the equipment in good working order but the washable dust filter was covered with a thick, pale gray layer of dust. Observation of the O2 concentrator for R#3 on 12/04/18 at 1:14 p.m., revealed the washable filter was covered with a thick, pale gray layer of dust. Observation of the O2 concentrator for R#3 on 12/04/18 at 4:49 p.m., revealed the washable filter was covered with a thick, pale gray layer of dust. Observation of the O2 concentrator for R#3 on 12/05/18 at 8:40 a.m., revealed the washable filter was clean. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact; a Mood Total Severity Score of 0, indicating she was not depressed; and displayed no behaviors. Continued review of the same assessment documented R#3 as using oxygen while a resident. In an interview with R#3 on 12/5/18 at 8:40 a.m. regarding maintenance of the O2 concentrator, she stated she did n… | 2020-09-01 |
| 37 | 37 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 757 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview, the facility failed to ensure that one residents drug regimen was free from unnecessary medication with duplicated drug therapy for one resident (R) #17. The sample size was 40. Findings include: Review of facility policy titled Physician order [REDACTED]. Procedure receiving a written or faxed order number two: The licensed nurse receiving the order verifies the order to ensure it is complete and that it includes resident name, room/bed, date of order, time of order, Physician signature and date, Physician name, Medication name, accurate dosage, accurate frequency, duration of order, if applicable, accurate route if applicable and medical indication for medication or reason for use. Observation of medication administration on 12/4/18 at 8:25 a.m. with Licensed Practical Nurse (LPN) EE revealed she administered multiple medications to R#17. The following observations were made: Calcium + vitamin D3 (a medication given as a supplement) 600/400 milligram (mg) tablet one time a day, Duloxetine (a medication used to treat depression) 60 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) 300 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat hypertension) 25 mg two times a day (bid), [MEDICATION NAME] (a medication used to treat fluid retention) 20 mg two times a day (bid), [MEDICATION NAME] (a medication used to treat acid reflux) 20 mg two times a day (bid) and [MEDICATION NAME] (a medication used to treat pain) 10 mg three times a day (TID), Aspirin (a medication used as a blood thinner) 81 mg one time a day, Senna (a medication used as stool softener) 8.6 mg two tablets one time a day, Isorbide (a medication used to treat hypertension) 30 mg one time a day and Polyethylene [MEDICATION NAME] (a medication used to treat constipation) 17 grams (gm) one time a day. During reconciliation with review of R#17 printe… | 2020-09-01 |
| 38 | 38 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 759 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to ensure it was free of a medication error rate greater than five percent by not ensuring medications were given as ordered by physician for two residents (R) R#17 and R#54. A total of 29 medication opportunities were observed, and there were four errors for two of three residents (R) R#17 and R#54, by one of two nurses observed during medication pass, for a medication error rate of 13.79%. The census was 61 and the sample size was 40. Findings include: Review of the facility policy titled Medication Administration revised (MONTH) 2008 revealed under procedure number: 2: Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength and route. Section C: Report any discrepancies to the pharmacy. Do not administer the mediation until the discrepancy is resolved. Observation of medication administration on 12/4/18 at 8:04 a.m. on side one, cart one, with Licensed Practical Nurse (LPN) EE revealed she administered multiple medications to R#54. The following observations were made: [MEDICATION NAME] (a medication used to hypertension) 25 milligram (mg) tablet, [MEDICATION NAME] (a medication used to treat acid reflux) 150 mg tablet, [MEDICATION NAME] (a medication used to treat depression) 10 mg tablet, [MEDICATION NAME] (a medication used to treat hypertension) 5 mg tablet, Calcium + vitamin D3 (a medication given as a supplement) 600/400 mg tablet and vitamin D3 (a medication given as a supplement) 1000 units, two tablets. After all of the R #54's 9:00 a.m. medications had been prepared, LPN EE counted the number of medications to be given, and verified during interview that what she prepared was all of the medications R#54 received for that time of day. During reconciliation with review of R#54 printed physician orders for the month of (MONTH) (YEAR) revealed the following orders: [MEDICATION NAME] 25 mg two… | 2020-09-01 |
| 39 | 39 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 761 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure that all drugs and biological's were discarded prior to expiration date. The facility census was 61. Findings include: Review of the facility policy titled Medication Storage in the facility dated ,[DATE], revealed the policy as medications and biological's are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. Procedure letter H revealed outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. Observation on [DATE] at 2:53 p.m. of medication storage room/Central Supply room, with Administrator and Clinical Director of Health Services, revealed medications neatly arranged on multiple shelves. Observation of random bottles of medication revealed a 16 ounce bottle of Mineral Oil with expiration date of ,[DATE] and a 16 ounce bottle of [MEDICATION NAME] Cough syrup with expiration date of ,[DATE]. Interview on [DATE] at 2:53 p.m. with Administrator, stated that Central Supply Clerk is responsible for keeping the medications stocked and checked for expiration dates. She was not sure of how often she checks the medications/supplies. Interview on [DATE] at 9:10 a.m. with Central Supply Clerk, stated that she checks the medications in the supply room for expiration dates once per month. She stated that when she finds medications that are expired, she gives them to the Director of Nursing (DON). She stated she was not aware of the two bottles of expired liquids in the supply room. | 2020-09-01 |
| 40 | 40 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 880 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to utilize proper technique while providing [MEDICAL CONDITION] care for one resident (R) R#38. The facility census was 61 residents. Findings include: Observation on 12/3/18 at 11:16 a.m. revealed in room [ROOM NUMBER] B, un-bagged and unlabeled urinal on the floor behind the toilet and an unlabeled bar of soap on the sink ledge, in a bathroom shared by two male residents. Observation on 12/3/18 at 11:20 a.m. revealed in room [ROOM NUMBER] B, four unlabeled and unbagged bath basins, in a bathroom shared by two female residents. Observation on 12/3/18 at 11:27 a.m. revealed in room [ROOM NUMBER] A, un-bagged and unlabeled nebulizer mask sitting on bedside nightstand. Observation on 12/3/18 at 11:34 a.m. revealed in room [ROOM NUMBER] B, bar of hand soap sitting on sink ledge in bathroom shared by two male residents. Also, un-bagged nebulizer mask sitting on bedside nightstand. Observation on 12/3/18 at 11:46 a.m. revealed in room [ROOM NUMBER] B, labeled but un-bagged urinal in bathroom. Enteral feeding bottle hanging from pole at bedside to bed B, dated 12/1/18. No resident currently residing in bed B. Observation on 12/6/18 at 9:01 a.m. [MEDICAL CONDITION] care performed by Licensed Practical Nurse (LPN) EE for Resident (R) #38. Nurse EE gathered supplies and entered R #38 room. She washed her hands and donned clean gloves. Nurse EE removed soiled [MEDICAL CONDITION] dressing from stoma site. Moderate amount of brown drainage noted on dressing. No odor detected. Nurse removed gloves and applied clean gloves. She did not wash her hands or use hand sanitizer. She [MEDICAL CONDITION] kit and cleanse around [MEDICAL CONDITION] with normal saline. She placed drain sponge on residents chest and resident had a coughing spell and drain sponge was propelled off chest… | 2020-09-01 |
| 41 | 41 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 883 | D | 0 | 1 | 46UW11 | Based on resident interviews, staff interviews record review and policies titled Immunizations: Influenza (Flu) Vaccination of Residents and Staff and Standing Orders for Administering Pneumococcal Vaccines to Adults; the facility failed to document rationale of resident (R)#24 refusal of Flu and provide vaccine information statement (VIS) and offering of Pneumococcal vaccine and VIS to R# B. Sample was 2 of 5. Findings include; During review of facility's infection control processes on 12/6/18 at 11:41 a.m. unable to locate documentation for R#24 regarding refusal of flu vaccine. Also, unable to locate documentation that education via the VIS as recommended by the Center for Disease Control (CDC) was provided to resident and /or family member. Further review of R#24's minimum data set (MDS) which a is part of the United States federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes; assessed R#24 with a Brief Interview for Mental Status (BIMS) of two. BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A score of 00-07 indicates severe cognitive impairment. R#24 has family member who is the responsible party (RP). An interview with Director of Nursing (DON), with Corporate representative present, Director of Clinical Services, on 12/6/18 at 12:00 p.m. revealed that the electronic medical record (EMR) should show that the resident and /or RP was provided the VIS education. DON attempted to evidence the education had been given. Upon continued review of the R#24's record DON was unable to confirm the VIS education was provided; Nor was there evidence of a nurse's note indicating VIS education had been provided or discussed. On 12/6/18 at 12:55 p.m. Corporate representative, Director of Clinical Services provided a document dated 12/6/18 indicating the resident's RP had been contacted to discuss administration of the flu vaccine. The RP refused however; the reason for refusal not documented nor was it cle… | 2020-09-01 |
| 42 | 42 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2016-11-10 | 278 | D | 0 | 1 | M6O611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to accurately assess the dental status for one (1) resident (R #30) who had missing and broken teeth and failed to accurately assess the swallowing/nutritional status for one (1) resident (R) (R #72) that exhibited signs and symptoms of possible swallowing disorder by coughing during meals. The sample was thirty six (36) residents. Findings include: 1. Record review for R#30 revealed a Nursing Admission Evaluation and Initial Plan of Care dated 9-8-14 and 10/03/2016, in the oral status section questions #79 and #81 was not checked to indicate the resident had missing and broken teeth. Review of the Minimum Data Set (MDS) assessment for R#30 dated 10/10/2016 did not indicate in Section L- Dental Status that the resident had missing and broken natural teeth. Observation conducted on 11/9/2016 at 12:23 p.m., revealed the R#30 sitting in the dining hall waiting for lunch. Missing and broken broken teeth noted during this observation. During an interview with the R#30 on 11/10/2016 at 9:29 a.m., it was observed that he was missing several teeth on the top and bottom of his gums. There were a few teeth on the left bottom gum that was visible when the resident opened his mouth. R#30 revealed he does not have any trouble eating and that he had not talked with anyone about receiving dental services. R#30 further stated that he had gingivitis in the past that resulted in some of his teeth coming out. Interview on 1/10/2016 at 11:54 a.m. with the MDS Coordinator DD confirmed that the MDS assessment for R#30 dated 10/10/2016 did not indicate the resident had broken or missing natural teeth. DD said R#30 would be re-assessed to verify if there are any missing or broken teeth. Subsequent interview with the MDS Coordinator DD conducted on 11/10/16 at 12:15 p.m. confirmed that after re-assessment, R#30 did have missing and broken teeth. DD further confirmed the dental status for R#30 wa… | 2020-09-01 |
| 43 | 43 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2016-11-10 | 279 | D | 0 | 1 | M6O611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to develop a care plan for one (1) resident (R) (#86) related to missing/broken teeth. The sample was thirty-six (36) residents. Findings included: On 11/07/2016 at 2:32 p.m., R#86 was observed to have missing, broken, and discolored teeth. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented in Section L- Dental Status that the resident had obvious or likely cavity or broken natural teeth. Section V- Care Area Assessment (CAA) triggered Dental Status with the decision to be care planned. A review of the medical record for R#86 revealed no evidence of a care plan related to the resident's dental status. During an interview with MDS Coordinator DD on 11/9/2016 at 3:53 p.m. she stated that she has been working at the facility since (MONTH) 2013. She confirmed that when a resident is assessed to have likely cavity or broken natural teeth, the MDS staff will create a care plan related to dental. She confirmed that there was no dental plan of care in place for R#86. DD stated that the reason the care plan was not created was pure human error'. She had addressed the impairments in the CAA and stated, At this point, it is just human error. | 2020-09-01 |
| 44 | 44 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2016-11-10 | 323 | D | 0 | 1 | M6O611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policy and procedure, the facility failed to conduct neurological assessments (Neuro Checks) for one (1) resident (R) (R#134) after an unwitnessed fall. The sample was thirty six (36) residents. Findings Include: Review of the facility's Fall Prevention Protocol documented: Action (Step 4) After an incident of a fall, complete the Post Fall Risk Assessment, notify MD and Responsible Party, start Neuro check if there is a suspected head injury or for an unwitnessed fall as per facility Protocol: Record review for R#134 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 6, indicating severe cognitive impairment. R#134 was assessed for wandering 1 out of 3 days to a potentially dangerous place. Section G: Functional Status: Activities of Daily Living (ADL) resident requires supervised oversight encouragement or cueing with one person physical assist with bed mobility and transfer. Resident requires limited assistance with one person assist with walk-in room, walk-in corridor, locomotion on unit and locomotion off unit. A Nurse's progress note of 6/24/16 at 11:18 p.m., documented that the resident had a fall in her room resulting with injuries to include a skin tear to her right elbow, and a laceration to her right cheek,secondary to the resident attempting to turn off her light in her bedroom. R#134 confirmed to the staff she fell beside her bed while trying to turn off a light. Staff encouraged the resident to use her call light button when she needed something, staff placed non-skid socks on resident for added safety. Review of the Fall Assessment Note dated 6/25/16 at 02:55 revealed (unwitnessed fall) R#134 had intermittent confusion 1-2 falls in the last 3 months Ambulatory/Continent Adequate (with or without glasses). No noted d… | 2020-09-01 |
| 45 | 45 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2016-11-10 | 363 | E | 0 | 1 | M6O611 | Based on observation and staff interview the facility failed to follow recipes for the preparation of pureed stewed tomatoes and puree navy bean soup. This deficient practice had the potential to effect eleven (11) residents receiving pureed consistency from a total of ninety three (93) residents receiving an oral diet. Findings include: Review of the General Food Preparation and Handling policy revealed food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of injurious organisms and substances. Review of the facilities menu for Wednesday, week five supper meal revealed puree diet was to receive pureed navy bean soup, stewed tomatoes with okra, cornbread, margarine, citrus gelatin, and milk. Observation on 11/09/16 at 1:40 p.m. of BB dietary aide preparing the food items for the puree supper meal. BB opened a one hundred two (102) ounce can of stewed tomatoes, placed contents inside a large blender bowl, added twelve (12) slices of white bread and turned blender machine on to pureed. Once the stewed tomatoes were pureed BB placed the contents in a stainless steel pan that was five (5) inches in length, 12 inches in width and six (6) inches in depth, covered with a lid then placed in refrigerator. Further observation revealed BB puree the navy bean soup for the supper meal. BB opened a 6 pound 6 ounce can of navy beans, placed the contents in the large blender bowl, turned blender machine on, stirred, and added water. Once the beans were pureed BB placed the contents in a stainless steel pan that was 5 inches in length, 12 inches in width, and 6 inches in depth. The dietary aid placed a lid on the top of the pan then placed in the refrigerator. Review of the recipe for Stewed [NAME]toes revealed the ingredients were to consist of chopped onions, melted margarine, crushed canned tomatoes, granulated sugar, and celery powder. The method for preparation 1) Saute onions in the margarine until golden brown. 2) Add remaining ingredients to onions. Mix well, bring to bo… | 2020-09-01 |
| 46 | 46 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2016-11-10 | 364 | E | 0 | 1 | M6O611 | Based on observation and staff interview the facility failed to prepare puree food in a manner to conserve nutrient value by prolonged re-heating. This deficient practice had the potential to effect eleven (11) residents receiving pureed consistency from a total of ninety three (93) residents receiving an oral diet. Findings include: Review of the General Food Preparation and Handling policy revealed food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of injurious organisms and substances. Review of the Meat and Vegetable Preparation policy revealed vegetables: Avoid overcooking and long holding times. Observation on 11/09/16 at 12:30 p.m. of the steam table revealed the pureed mixed vegetable had a dark orange brown color and the puree scalloped potatoes and puree chicken were light brown in color. Interview on 11/09/16 at 12:30 p.m. with the Dietary Manager (DM) revealed she knew the pureed food items were being held for a long period of time. When asked why the pureed foods were being held for a long period time the DM revealed that the ovens under the stove top are not working properly and if was difficult to get food items re-heated at the proper temperature in a timely manner. The DM revealed she had dietary staff puree food items early and put in oven in order to get up to the proper temperatures. Interview on 11/09/16 at 1:30 p.m. with BB, dietary aide revealed they wanted to clarify the process of the pureed food items prepared for the lunch meal today. BB revealed she began re-heating the pureed food items in the oven at 9:30 a. m. The dietary aide revealed the oven had not been working properly for the past two (2) weeks and in order to get the puree food items re-heated to the proper temperature she had start the process early. Interview on 11/09/16 at 1:35 p. m. with the registered dietitian (RD) revealed she expects the facility to re-heat the pureed food items no earlier than 1 hour before the meal is to be served. The dietitian was not aware th… | 2020-09-01 |
| 47 | 47 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2016-11-10 | 371 | F | 0 | 1 | M6O611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and documentation review the facility failed to follow manufactures recommendations for sanitizing dishware in the three (3) compartment sink to prevent foodborne illness; failed securely wrap opened food items in the dry storage area as well in one (1) of 3 refrigerators for two (2) of four (4) days of the survey; failed to prevent wet nesting of stainless steel food pans to prevent bacterial growth; failed to ensure the stand-up mixer was cleaned after usage to prevent contamination; failed to ensure the inside ice slide to the ice machine was clean and free from debris. This deficient practice had the potential to effect all ninety three (93) residents receiving an oral diet. Findings include: Observation on 11/07/16 at 11:30 a.m. of AA, dietary aide, wash several cooking utensils in the 3 compartment sink revealed AA took the cooking utensils from the rinse sink compartment, then swished them all in the sanitizing solution compartment for a couple of seconds then placed on a shelf area to dry. Further observation revealed a poster was hung on the wall above the 3 compartment sink which indicated to submerge items for one to two (1-2) minutes. Observation on 11/07/16 at 11:35 a.m. of the first reach-in refrigerator revealed a stainless steel pan, five (5) inches in length, twelve (12) inches in width, and six (6) inches in depth containing a block of sliced American cheese that was eight (8) inches in length and four (4) inches in width and depth opened and not securely wrapped, the top of the cheese was exposed to the air. Observation on 11/07/16 at 11:40 a.m. of the stand-up mixer revealed under the mixing arm was an off white substance that was splattered around in several different areas. Observation on 11/07/16 at 11:45 a.m. of an inverted stack of three stainless steel pans ten (10) inches in length, 12 inches in width and 6 inches in depth, located under the food preparation table near the ov… | 2020-09-01 |
| 48 | 48 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2016-11-10 | 431 | D | 0 | 1 | M6O611 | Based on observation, record review and staff interviews, the facility failed to ensure that expired medications were disposed of properly in one (1) of two (2) medication storage rooms. (Unit A). Findings include: Review of the facility's policy titled Storage of Medications and Biologicals with revision date 10/20/2016 revealed on number five (5): The facility should ensure the Medications, Biologicals, Syringes and Needles are monitored for expiration dates, secured and stored appropriately. Observation on 11/09/2016 at 11:45 a.m. of the medication room on A hallway revealed one (1) bottle of ASA 325mg with expiration date 10/2016, one (1) bottle of Fiber Laxative with expiration date of 09/2016 and one (1) bottle of Zinc Sulfate with expiration date 09/2016. Interview on 11/09/2016 at 11:50 a.m. with the Licensed Practical Nurse (LPN)/Charge Nurse HH revealed the nurses check their medication carts daily and check the medications in the storage room especially when they have to get a medication from the storage room for the medication cart. LPN HH confirmed that the medications were expired. Interview on 11/09/2016 at 12:00 p.m. with the Director of Nursing (DON) confirmed that the medications: [REDACTED]. Stated the the medication rooms are checked every Sunday and the nurses check all of the medications daily and as needed. Stated her expectations are for there to be no expired medications on the medication carts or in the medication storage rooms. | 2020-09-01 |
| 49 | 49 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2016-11-10 | 456 | F | 0 | 1 | M6O611 | Based on observation and staff interviews, the facility failed to maintain two (2) of three (3) ovens in the kitchen in optimal working condition in order to prepare resident meals. This deficient practice had the potential to effect all ninety three (93) residents receiving an oral diet. Findings include: Observation and interview on 11/09/16 at 12:30 p.m. with the Dietary Manager (DM) revealed the 2 ovens under the stove top were not functional and had not be working correctly for the past four (4) months. The DM revealed that sometimes the oven works and sometimes it does not. When asked what it meant, work, the DM revealed sometimes the oven gets hot and sometimes it does not. Continued interview with the DM regarding the interview conducted on 11/07/16 at 12:15 p. m. when she told surveyor there was no kitchen equipment under repair or out of service, the DM revealed the convention was working probably but failed to report the 2 standard ovens did not work at times. Further interview with the DM revealed the free standing convention oven is working properly however there is not enough room to cook food items and re-heat the pureed foods. Interview on 11/09/16 at 1:30 p.m. with the facilities registered dietitian (RD) revealed she was not aware the standard ovens had not been functioning properly for the past 4 months. The RD revealed she visits the facility at least once a month and goes into the kitchen but was not aware of the malfunctioning ovens until today. Interview on 11/09/16 at 2:15 p.m. with CC, Maintenance Assistant revealed he was not aware the dietary department had problems with the ovens. He revealed 2 weeks ago the natural gas to the entire building was shut off to run a new gas line to the back-up generator and all kitchen equipment was turned off. CC revealed he was in the kitchen 2 weeks ago to re-light the pilot on the stove and ovens and the DM did not revealed any concerns with any kitchen equipment. Interview on 11/10/16 at 9:55 a.m. with CC, Maintenance Assistant revealed he expects t… | 2020-09-01 |
| 50 | 50 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2016-11-10 | 514 | D | 0 | 1 | M6O611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure documentation for the use of a splint or refusal to use a splint for one (1) resident (R) (R#65) with a left hand contracture and failed to consistently document the urinary output for one (1) resident (R#93) with a urinary catheter. The sample was thirty six (36) residents. Findings include: 1. Record review for resident #65 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the [DIAGNOSES REDACTED]. Review of the care plan for R#65 dated 8/8/2016 indicated a left hand contracture [MEDICAL CONDITION] secondary to history of [MEDICAL CONDITION]. The goal of the facility is to minimize decline in left hand contracture. An intervention included to place splint as tolerated and maintain contracture and treatment prn as ordered. Review of restorative nursing care weekly notes dated 8/25/16 documented: range of motion active, transfer, dressing or grooming fair. The resident making fair progress towards goals. Continue with restorative nursing program. Observations of R#65 revealed a left hand contracture with no splint device in place on 11/09/2016 at 9:56 a.m. and 11/9/2016 at 12:00 p.m. An interview with R#65 on 11/9/2016 at 9:56 a.m. revealed the left hand contracture was the result of a past stroke. R#65 further stated she is unable to use her left hand to assist with any daily activity. Review of restorative CNA progress notes section dated 8/25/16 documented: range of motion active, training skill/practice: transfer/dressing or grooming progress is fair towards goals. Further review of the clinical record for R#65 revealed no evidence of documentation when the splint was placed or if the splint was tolerated by the resident. Further Record Review revealed no evidence of documentation related to (r/t) splint and/or refusal of splint wearing. Review of care plan revealed left hand contracture with intervention to splint as tolerated-no is… | 2020-09-01 |
| 51 | 51 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2018-12-06 | 580 | D | 0 | 1 | Q9R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the physician of a change in condition for one sampled Resident (R) #72 out of a total of 34 residents. Findings include: Resident #72 was admitted to the facility on [DATE] and re-admitted on [DATE] with current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#72 revealed the resident's cognition was intact, with the Brief Interview for Mental Status (BIMS) score of 15/15. The care plan dated 10/22/18 revealed the problem statement, I have an actual impairment to skin integrity r/t (related to) fistula which created an abdominal abscess to my LLQ (left lower quadrant). I have an ostomy bag in place for drainage. Interventions included: Staff will follow facility protocols for treatment of [REDACTED]. Treatment nurse and WC (wound care) will observe on rounds/document location, size and treatment of [REDACTED]. to MD. During resident observation and interview on 12/3/18 at 2:38 p.m., R#72 stated that a few weeks ago, she had a [MEDICAL CONDITION] done. I had a bump on my belly (pointed to her lower left abdomen), and had nurses look at it, but they never did anything about it until it turned into a bump, and I complained of that knot there, and they looked at it, but just said it will go away, or that I need to get 'cleaned out' (have a bowel movement). Then it formed a head, and then they had the doctor look at it, and he said it was a cyst, and opened it. It went down about 1-1/2 inches into my colon. So, they did this [MEDICAL CONDITION] . Review of the Nurses' Notes revealed: 8/21/2018 18:58 Nurses Note: C/O (complained of) stomach hurting all day. Said it hurt more than usual. Will continue to monitor. (No follow up documentation was noted by nursing for this change of condition until 8/25/18) 8/25/2018 16:55 Nurses Note: C/O stomach hurting. Resident stated she felt something on her left side of her abdomen. I felt he… | 2020-09-01 |
| 52 | 52 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2018-12-06 | 641 | B | 0 | 1 | Q9R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately reflect the number of falls since admission/entry or prior assessment on the Minimum Data Set (MDS) at the time of the assessment of one Resident (R) (#35) out of thirty-four (34) sampled residents. Findings include: Interview with R #35 on 12/03/18 3:44 p.m. in his room revealed that he fell about three months ago and cracked a bone. Review of the Progress Notes dated 6/24/18 revealed that R #35 was heard yelling out I need help at 2:00 a.m. The aide arrived first in the room and alerted nurse that he was sitting on the floor. Nurse noted resident to be sitting on bottom with legs stretched out apart from each other. Resident stated that he rolled out of bed. Wheelchair noted to be rolled away from resident with brakes unlocked. Medical Doctor (MD) notified and family notified. Review of the Quarterly Minimum Data Set (MDS) for R #35 dated 7/10/18 revealed in Section: A- Re-entry from acute hospital on [DATE] C- Brief Interview Mental Status (BIMS)-14 cognitively intact J- No falls Review of the Quarterly MDS Assessment for R #35 dated 10/5/18 revealed in Section: A- Reentry 7/3/18 from an acute hospital. C-BIMS- 15 cognitively intact J- No falls Interview with the current MDS Coordinators (II and JJ) in the conference room on 12/06/18 at 4:00 p.m. revealed there was no reference to R #35's falls on the (MONTH) 10, (YEAR) or (MONTH) 5, (YEAR) MDS assessments. They stated that they were aware that R #35 had fallen as a Care Plan for his falls was written. They stated that a correction would be made to the MDS. | 2020-09-01 |
| 53 | 53 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2018-12-06 | 657 | D | 0 | 1 | Q9R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to revise care plans to address the current care needs of two sampled Residents (R#'s 72 and 55) out of 34 residents. Findings included: The facility provided the policy titled, Resident Assessments, dated 11/28/17 which directed, Resident assessments will be completed upon admission, quarterly, annually, and with a significant change in status. The resident's comprehensive assessment is not only for the purpose of understanding a resident's needs, but to understand their strengths, goals, like history and preferences . 1. R#72 was admitted to the facility on [DATE] and re-admitted on [DATE] with current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] R#72 revealed the resident's cognition was intact, with the Brief Interview for Mental Status (BIMS) score of 15/15. The care plan dated 10/22/18 revealed the problem statement, I have an actual impairment to skin integrity r/t (related to) fistula which created an abdominal abscess to my LLQ (left lower quadrant). I have an ostomy bag in place for drainage. Interventions included: Staff will follow facility protocols for treatment of [REDACTED]. Treatment nurse and WC (wound care) will observe on rounds/document location, size and treatment of [REDACTED]. to MD. During resident interview on 12/3/18 at 2:38 p.m., in the resident's room R#72 stated that a few weeks ago, she had a [MEDICAL CONDITION] done. R#72 further stated, Staff never comes in to check my [MEDICAL CONDITION] bag, I have not told them not to check it, they just don't. When I think it's full, I call them, and they empty it. Last Saturday, I misjudged, and the bag broke; it was such a mess. During an interview with R#72 on 12/4/18 at 9:35 a.m., in the resident's room, the resident stated, Nobody on last evening or night shifts checked my [MEDICAL CONDITION] bag. On 12/4/18 at 4:18 p.m. in the 100 hall nurse's station… | 2020-09-01 |
| 54 | 54 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2018-12-06 | 658 | D | 0 | 1 | Q9R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy it was determined the facility failed to the ensure resident's electronic Medication Administration Record [REDACTED]. Findings include: Review of facility policy and procedures titled Medication Administration General Guidelines Section 7.1, Nursing Care Center Pharmacy Policy & Procedure Manual -dated 2007 indicated the following: - The person who prepares the dose for administration is the person who administers the dose - The individual who administers the medication dose, records the administration on the resident's MAR (medication administration record) immediately following the medication being given. - The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that for that specific medication dose administration and time. Initials on each MAR/TAR are verified with a full signature in the space provided or on the nursing care center's master employee signature log. Medication pass observation revealed on 12/3/18 at 10:27 a.m., Licensed Practical Nurse (LPN) KK administer the following medications to R#83: [MEDICATION NAME] 0.5 (anti-anxiety) milligrams (mg) one tablet PO (by mouth); Aspirin 81mg (blood thinner use to prevent [MEDICAL CONDITION] or stroke) one tablet PO; [MEDICATION NAME] 6.25 mg (medication for blood pressure and heart failure) one tablet PO; [MEDICATION NAME] 75mg (anti platelet) one tablet PO; [MEDICATION NAME] 40 mg (blood pressure) one tablet PO; [MEDICATION NAME] 150 mg (antidepressant) tablet PO [MEDICATION NAME] 5 mg (bladder spasms) one tablet PO; Duo Neb ([MEDICATION NAME]-[MEDICATION NAME]) 0.5 mg-3 mg(2.5 mg base)/3 mL nebulization solution used for nebulizer treatment ( a combination of [MEDICATION NAME][MEDICATION NAME] used to treat and prevent symptoms (wheezing and shortness of breath). A review of the eMAR during the medication reconciliation f… | 2020-09-01 |
| 55 | 55 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2018-12-06 | 684 | D | 0 | 1 | Q9R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess for positioning for Resident (R) #55 during meals. The sample included 34 residents. Findings included: R#55 admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. R#55's Quarterly Minimum Data Set ((MDS) dated [DATE] recorded staff evaluated R#55 as severely cognitively impaired. The MDS noted R#55 required extensive assistance of staff for bed mobility, transfers, dressing, eating and toilet use, and was totally dependent on staff for personal hygiene, locomotion and bathing. Review of the Activities of Daily Living (ADLs) care plan dated 11/6/18 directed staff: Anticipate my needs. BATHING: I require total staff participation with bathing. BED MOBILITY: I require total x (times) 2 staff participation to reposition and turn in bed. CODE STATUS: DNR (do not resuscitate). DRESSING: I require total x1 staff participation to dress. EATING: I require total assist x1 staff participation to eat. Heel boots as tolerated. PERSONAL HYGIENE/ORAL CARE: I require total staff participation with personal hygiene and oral care. Promote dignity by ensuring my privacy. SIDE RAILS: 3/4 Side rails up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN (as needed) to avoid injury. Staff to keep in mind that my level of assistance may fluctuate r/t (related to) my significant impairments in cognition and mobility. Document amount of assistance required. TOILET USE: I require total assist x2 staff participation to use toilet. TRANSFER: I require total assist x2 staff participation with transfers. SKIN INSPECTION: I require for staff to observe my skin for changes/alterations during ADL (Activities of Daily Living) care. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Observations of R#55 on 12/3/18 at 1:18 p.m., revealed the resident's Broda c… | 2020-09-01 |
| 56 | 56 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2017-12-14 | 550 | D | 0 | 1 | 4OSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations record review, review of the facility policy titled Social Service- Dignity Policy, resident and staff interviews, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity and respect. Specifically, three of 29 sampled residents (R B, R A and R C) stated that they are undressed and naked in the shower room while other residents are present. (Refer F583) Findings include: Review of the facility policy titled Social Service- Dignity Policy revised (MONTH) (YEAR) documented: According to federal regulations, the facility must promote care for residents in a manner, and in an environment, that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Dignity means that their interactions with the resident, staff carries out activities which assist the resident to maintain or enhance his/her self-esteem and self-worth. 1. Record review for R B revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. The resident required extensive assistance with bathing and personal hygiene. Interview on 12/11/17 at 2:39 p.m. with R B revealed that staff undress and re-dress her in front of other resident's in the shower room. Resident B further stated that when she is finished with her shower, the staff transport her from the shower stall to the area where they dress everyone with only a small towel covering her. Resident B stated that this has been going on for so long that she has had to just turn it into a funny thing so that it's not an embarrassing thing and will tell herself Well, here comes (name!). R B further stated That's just the way it is! Interview on 12/14/17 at 10:29 a.m. with Certified Nursing Assistant (CNA A) who was actively providing care in the shower room revealed that they always have two residents in th… | 2020-09-01 |
| 57 | 57 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2017-12-14 | 561 | D | 0 | 1 | 4OSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the policy titled Resident Rights Policy, resident and staff interviews, the facility failed to ensure one of 29 sampled residents (R B) right to self-determination. Specifically, R B was told by staff that she was not allowed to have a peanut butter sandwich for a snack unless there was jelly on it. R B stated she told the staff she does not like jelly and she should be allowed to eat what she wants. Findings include: Review of the policy titled Resident Rights Policy revised 8/22/17 documented that the resident has the right to self-determination. The resident has the right to exercise his or her rights as a resident of the facility. Record review for R B revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. Resident B was assessed as not having a swallowing disorder or dental conditions. Section F- Preferences for Customary Routine and Activity assessed that it is very important to R B to have snacks between meals. During an interview with R B on 12/11/17 at 3:10 p.m. she stated that she loves peanut butter sandwiches but the staff always put jelly on it. Resident B stated that when she asks the Certified Nursing Assistants (CNA), they tell her they cannot just make a peanut butter sandwich. Resident B stated they tell her they have to put jelly on it. Resident B stated she has told the staff she does not like jelly and they put way too much on it! Resident B stated that she should get to eat what she wants and what she likes. Interview on 12/13/17 at 1:50 p.m. with the Dietary Supervisor (DS) revealed the dietary staff deliver pre-made sandwiches to the resident pantry three times a day for snacks. She stated typically they always have peanut butter and jelly, pimento cheese, bologna, ham, and turkey sandwiches for snacks. The DS stated that if a resident asks for just a peanut … | 2020-09-01 |
| 58 | 58 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2017-12-14 | 583 | D | 0 | 1 | 4OSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy titled Resident Rights Policy, and resident, family, and staff interview, the facility failed to provide privacy of their persons during showers to three residents (A, B, and C) from a sample of 29 residents. Findings include: 1. Review of the policy titled Resident Rights Policy, last revised 8/22/17, the resident has a right to a dignified existence and the right to personal privacy. Review of the Annual Minimum Data Set (MDS) Assessment for Resident (R) A dated 10/13/17 revealed the resident has a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident is cognitively intact. The resident was also assessed on the annual assessment as needing the support of one person with bathing and dressing. During interviews conducted on 12/11/17 3:26 p.m. and on 12/14/17 at 1:50 p.m., Resident A said she received showers on Mondays and Thursdays, and the staff takes as many as five or six residents in at a time into the shower area. Only two residents at a time can be showered in the two curtained shower stalls. However, the other residents wait right outside the curtained areas, sometimes wearing simply a towel. Afterwards, the two residents receiving a shower at any one time are taken into another curtained drying area to be toweled off and dressed in clean garments. She feels embarrassed at such times - while waiting outside the shower stall and while being dressed. She complained to the facility, at least once before, about having to sit undressed among several other residents. The facility addressed her concern, and the situation got better for a while, but it has deteriorated again to where staff are taking five or more residents in to the shower room at the same time. Observation of the vacant shower room on the resident's hall on 12/12/17 at 8:15 a.m. revealed the shower room consisted of two curtained shower stalls and an open area just in front of these stalls. To the right, when fa… | 2020-09-01 |
| 59 | 59 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2018-02-08 | 578 | D | 0 | 1 | G4GK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to determine whether or not the resident wanted to formulate an Advanced Directive, for five residents (R) observed. R# 11, R# 72, R#255, R# 84 and R#254. The sample size was 22 residents. Findings include: 1. Medical Record review revealed that Resident (R) #72 review of the medical record for R#72 revealed that there was not any evidence that an Advance Directive was completed. Further review of the admission file for R#72 revealed that the form, Responsible/Legal Guardian & Advanced Directive Checklist (no date) was incomplete. No response were checked for choice and there was not any evidence that an Advance Directive checklist was documented. 2. Medical Record review for R #255 reveals that there was not any evidence that the resident had an Advance Directive. Further review of the Acknowledgement of Receipt of Admission for Rehabilitation form reveals that there is not a check mark next to the Georgia Advance Directive for Healthcare. 3. Medical Record review for R #84 reveals that there was not any evidence that the resident had an Advance Directive. Further review revealed that R #84 does have a completed Acknowledgement of Receipt of Admission for Rehabilitation Information form in the resident's Admission Folder. 4. Medical Record review for R # 254 revealed that there was not any evidence that the resident had an Advance Directive on their medical record or in their admission folder. Further review of theAcknowledgement of Receipt of Admission for Rehabilitation information form revealed that R#254 does not have a check mark next to Georgia Advance Directive for Healthcare. 5. Medical record review for resident R#11 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated no cognitive impair… | 2020-09-01 |
| 60 | 60 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2018-02-08 | 641 | D | 0 | 1 | G4GK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one resident (R) #9 for the use of injectable's and insulin. The sample size was 22 residents. Findings Include: Record review revealed R#9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as three, which indicates cognitive impairment. Section I-Active [DIAGNOSES REDACTED]. Review of MDS dated [DATE], section N-Medications, N0300 Injections: indicated that resident received 0 injections in last 7 days; NO350 Insulin was left blank. Review of a care plan initiated on 2/8/18, revealed that resident has potential for hyperglycemic or hypoglycemic episodes secondary to diabetes: resident uses insulin. Interview on 2/8/18 at 3:11 p.m., with MDS Coordinator, stated she gets information for the MDS assessments by having a face to face interview with the residents and information is obtained from the direct care staff caring for the residents. She stated information about medications is obtained from the electronic Medication Administration Record [REDACTED]. She verified that the 8/1/17 MDS did not reflect that the resident has received insulin injections 7 out of 7 days. She further stated that she would go ahead and modify the MDS assessment to indicate resident received insulin injections 7 out of 7 days. | 2020-09-01 |
| 61 | 61 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2018-02-08 | 656 | D | 0 | 1 | G4GK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to follow the care plan for one resident (R) #47 related to not placing a fall mat at the bedside post fall on 1/9/18. The sample size was 22 residents. Findings include: A review of the clinical record for R#47 revealed resident was admitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as two, which indicated cognitive impairment. Review of the care plan dated 1/9/18, revealed that R#47 had impaired physical mobility related to a fall from the bed. Interventions to be implemented included bed in low position and fall mat at bedside. Observation on 2/7/18 at 12:05 p.m., 2/8/18 at 9:19 a.m. and 2/8/18 at 4:11 p.m. revealed no fall mat at bedside, nor stored in the closet or under the bed. A review of facility policy titled Fall Management Program with effective date (MONTH) 25, 2010, revealed that the date and time of each fall and new intervention will be added to the care plan. Interview on 2/8/18 at 2:51 p.m., with Licensed Practical Nurse (LPN) AA, revealed that the procedure for when residents have a fall is to do a complete head to toe assessment, assessing for any injuries. She then notifies the Shift Supervisor, the residents Physician and family member. The residents nurse and the Supervisor discuss possible interventions and collaborate together what intervention is best suited for the situation. Supervisor inputs the intervention into electronic medical record (EMR) and the floor nurse is responsible for follow-up on implementation. She further stated the residents are observed for 72 hours post fall. She stated she did not know why R#47 didn't have a fall mat at the bedside. Interview on 2/8/18 at 4:06 p.m., with Assistant Director of Nursing, revealed that she and the floor Charge Nurse confer together discussing possible interventio… | 2020-09-01 |
| 62 | 62 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2018-02-08 | 758 | D | 0 | 1 | G4GK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to indicate the need to extend orders for as needed (PRN) antianxiety medications for two residents (R#31 and R#25) beyond 14 days, and failed to document the reason for the extension or the period during which the extended order should be in effect. The sample size was 22 residents. Findings include: Review of the clinical records for Resident (R) #31 revealed she was admitted to the facility with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment of 11/21/17 revealed the resident had evidence of mood symptoms, behaviors directed at others occurred 1-3 days during the assessment period, had active [DIAGNOSES REDACTED]. Review of the most recent physician order [REDACTED]. Further review of the clinical records for R#31 revealed no documentation that the PRN anxiolytic should continue beyond 14 days, the period during which it should be continued, or a rationale for its continued use. Interview with the Medical Director on 2/08/18 at 2:37 p.m. revealed the resident has had significant trauma in recent months and was placed on hospice soon after admission due to declining health. The resident has since been discharged from hospice, but continues to experience anxiety and needs the antianxiety medication on an as needed basis. He was not aware that he should have documented the ongoing need for this medication, but will do so going forward. 2. Review of clinical record for Resident (R) #25 revealed he was admitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicates no cognitive impairment. Review of (MONTH) (YEAR) Physician order [REDACTED].#25 was prescribed Klonopin 0.5 milligrams (mg) at bedtime as needed (PRN) for anxiety, with original order date of 8/8/17. Further review of the PO did not indicate that… | 2020-09-01 |
| 63 | 63 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2018-02-08 | 761 | D | 0 | 1 | G4GK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure medications were dated appropriately when opened to determine the discard date, in one of two medication carts; and failed to discard expired biological's and medical supplies prior to expiration date in one of two medication storage rooms. The sample size was 22 residents. Findings include: 1. Observation on 2/6/18 at 4:25 p.m., third floor medication cart revealed one opened and used [MEDICATION NAME] respiratory inhaler. The inhaler had a sticker from the pharmacy that indicated the medication should be discarded 90 days after opening. The inhaler did not have a date when opened. Further observation, on the same medication cart, was [MEDICATION NAME] Propionate liquid, approximtely 1/2 of 16 ounce bottle, with expiration date of 12/17. 2. Observation on 2/6/18 at 4:25 p.m., in the third floor medication storage room revealed two catheter irrigation trays with expiration date of 1/18. 3. During medication pass on 2/7/18 at 12:28 p.m., with Licensed Practical Nurse (LPN) AA, revealed an opened multiple-dose vial of [MEDICATION NAME] Insulin with opened date of 1/2/18. A label on the vial read discard after 28 days. Review of the facility policy titled, Pharmacy Services and Procedures policy, revised (MONTH) 2013, indicated that the facility should ensure that medications and biological's have an expiration date on the label and have not been retained longer than recommended by the manufacturer or supplier. The policy further indicated the facility should record the date opened on the medication container when the medication has a shortened expiration date once opened. Review of the policy titled, Recommended Minimum Medication Storage Parameters, revised (MONTH) 29, (YEAR), indicated that multiple-dose vials for injection, are to be dated when opened and discard unused portion after 28 days or in accordance with manufacturer's recommendations. The parameters fo… | 2020-09-01 |
| 64 | 64 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2019-02-28 | 578 | D | 0 | 1 | 952S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately document the Advance Directive status for one Resident (R) R#18 from a sample of 17 residents reviewed for Advance Directives. Findings include: Review of the record for R#18 revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. A review was conducted of the physician orders [REDACTED]. Review of the facility form titled, Order Summary Report for R#18 documented Advanced Directive: CPR, order date [DATE]; order status active and documented active orders as of [DATE]. Review of the resident's care plan, provided by MDS Coordinator A for R#18, documented two Advance Directive (AD) code status determinations. The care plan focus area reflects a code status as Full Code with a date initiated of [DATE], revision on [DATE]. Another care plan focus area reflects a code status as Do not Resuscitate (DNR) with a date initiated of [DATE], revision on [DATE]. Further record review for R#18 revealed a form titled, Physician order [REDACTED]. The POLST was signed by the resident and dated [DATE]. The section for discussion and signatures was blank for the physician's name and signature. The POLST was found at the front of the record in a clear document sleeve with a bright orange DNR sticker positioned at the top of the clear plastic document sleeve. On [DATE] at 10:38 a.m. an interview was conducted with the Social Worker (SW), she explained that the process to obtain Advance Directive information for a resident begins in admission; they work with the long-term care and rehab residents. Those residents receive an admission packet that starts with an Advance Directive checklist where residents can choose options. If they can sign for themselves, they must have a good BIMS sco… | 2020-09-01 |
| 65 | 65 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2019-02-28 | 604 | D | 0 | 1 | 952S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review the facility failed to ensure that one resident (R), # 296 out of 2 residents reviewed was free from restraints from a sample of 39 residents. Findings include: Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#296 with a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was cognitively impaired. Further review of R#296 MDS provided evidence that R#296 required two-person extensive assistance with transfers and no documented evidence for use of restraint. Further review of resident R#296 clinical records shows that resident (R#296) was not assessed for the use of restraints. Additionally, there were no Physician order, plan of care or progress notes to show the needed use of restraints. Multiple observations were made of resident R#296 with a seatbelt around his torso area while sitting in his wheelchair. On 2/26/19 at 1:00 p.m., observed resident in the garden room involved in activities. Resident in wheelchair while seatbelt around his torso area. On 2/27/19 at 12:45 p.m., observed resident in dining room area eating his lunch, resident in a wheelchair with a seatbelt fasten around his torso currently. On 2/27/19 at 2:02 p.m. an interview was conducted with Registered Nurse FF, she stated that R#296 has a seat around him while he is in the wheelchair because he has problems with [MEDICAL CONDITION] activity and the seatbelt is being used to keep him for falling out wheelchair. On 2/28/19 at 3:05 p.m. an interview was conducted with the Director of Nursing (DON), she stated that R#296 should not have a seatbelt around his torso. The DON stated she believes that the daughter brought the wheelchair for R#296 to have but at this time the resident does not have a Physician order for [REDACTED]. | 2020-09-01 |
| 66 | 66 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2019-02-28 | 656 | G | 0 | 1 | 952S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and review of the facility documents the facility failed to follow the care plan/ Nursing Kardex related to two staff assistance for transfers for one resident (R) #67 of two residents reviewed. Actual harm was identified when R#67 sustained a left arm fracture from an improper transfer. Findings include: Record review revealed that R#67 was admitted to the facility on [DATE], current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe impaired cognition. Continued review of the MDS revealed the resident required extensive assistance with bed mobility and extensive assistance with transfers requiring two plus person physical assist. Review of the significant change MDS dated [DATE] revealed R#67 had a BIMS score of 10 which indicates the resident's cognition was moderately impaired. Section G revealed that the resident was assessed for total dependence assist by two plus persons for transfer. Review of the care plan, revision on, 2/6/19 with a problem onset dated 9/24/18 impaired physical mobility related to fall. Interventions for R#67 requires two persons with all transfers and mechanical lift transfer as needed. Review of the MDS 3.0 Nursing Kardex dated 10/8/18 revealed under transfer that R#67 requires the assist of two plus person. A phone interview was conducted on 2/27/19 at 12:45 p.m. with Certified Nursing Assistant (CNA) EE, regarding the incident with R#67. The CNA revealed the resident refused to use the lift to get up. She asked the resident if she could she stand and pivot to the wheel chair and the resident said yes. The CNA revealed the resident was sitting on the side of the bed and had both her feet on the floor. The resident was assisted to a standing position and pivot to the wheel chair and the resident's left arm went up. The CNA revealed she felt pressure f… | 2020-09-01 |
| 67 | 67 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2019-02-28 | 689 | G | 0 | 1 | 952S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and family interviews, and review of the facility documents the facility failed to ensure a safe and secure environment related to accidents, for one of two residents (R) reviewed for falls. Actual harm was identified on 1/11/19 when R#67 was transferred improperly by one Certified Nursing Assistants (CNA) when the resident required assistance of two staff resulting in a fracture to the left arm. Findings included: Record review revealed that R#67 was admitted to the facility on [DATE], current [DIAGNOSES REDACTED]. On 1/16/19 [DIAGNOSES REDACTED].#67 [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe impaired cognition. Continued review of the MDS revealed the resident required extensive assistance with bed mobility and extensive assistance with transfers requiring two plus person physical assist. Review of the significant change MDS dated [DATE] revealed R#67 had a BIMS score of 10 which indicates the resident's cognition was moderately impaired. Section G revealed that the resident was assessed for total dependence assist by two plus persons for transfer and toilet use. The resident was assessed as total dependence for care. Review of the care plan, revision on, 2/6/19 with a problem onset dated 9/24/18 revealed impaired physical mobility related to fall. Interventions for R#67 requires two persons with all transfers and mechanical lift transfer as needed. Review of the MDS 3.0 Nursing Kardex dated 10/8/18 revealed under transfer that R#67 requires the assist of two plus person. Review of the progress note dated 1/11/19 at 10:40 a.m. revealed: Writer was notified by Certified Nursing Assistant (CNA) during transferring of resident from bed to wheel chair, resident knees gave out and was going down. CNA broke fall by supporting her arm under resident left armpit and ease her into wheel ch… | 2020-09-01 |
| 68 | 68 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2017-03-30 | 278 | D | 0 | 1 | U5BR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (R#109) taking a diuretic out of a total sample of 35 residents. Findings include: Resident #109 was admitted [DATE] with a [DIAGNOSES REDACTED]. Record review of the Admission MDS assessment dated [DATE] revealed in section N: medications that resident received two of the seven days of a diuretic in the last seven days. Review of the (MONTH) (YEAR) Physician order [REDACTED]. Interview with the MDS Coordinator on 3/30/17 at 12:30 p.m. confirmed that the MDS was miscoded during that time | 2020-09-01 |
| 69 | 69 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2017-03-30 | 282 | D | 0 | 1 | U5BR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to follow the care plans related to the monitoring of blood glucose levels and the treatment of [REDACTED].#17) from a total sample of 35 residents. Findings include: Record review for resident (R) #17 revealed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the care plan dated 1/9/17 stated R#17 has the potential for hypoglycemic and hyperglycemic episodes secondary to DM with the goal to provide relief of hypo/hyperglycemic episodes within 30 minutes of interventions. Continued review revealed to monitor blood sugar (glucose) levels per physician's orders [REDACTED]. Review of the Physician order [REDACTED].-300, give five (5) u, 301-350, give seven (7) u; greater than 351, give 10 u. Review of the Medication Record for (MONTH) (YEAR) revealed no evidence of blood glucose (bg) level documentation at bedtime for 1/6/17, 1/7/17, 1/8/17, and/or 1/24/17. Review of the The Medication Record for (MONTH) (YEAR) revealed no evidence of BG level documentation for 3/18/17. During interview with the Director of Nursing (DON) on 3/30/17 3:20 p.m., she confirmed that the care plan was not followed regarding blood sugars. 2.) During observation on 3/30/17 at 7:00 a.m. with Registered Nurse (RN) EE, she cleaned the pressure ulcer to the sacral wound with Dakins solution, then applied an oil [MEDICATION NAME] dressing to the wound bed and applied the calcium alginate to the tunneling area. Continued observation revealed that a sponge was applied to the site and a new canister applied to the wound. Review of the care plan for R#17 dated 1/9/17 revealed that resident has a pressure ulcer and the intervention included to treatment per current physician orders. Review of the (MONTH) (YEAR) Physician order [REDACTED]. Interview with the Assistant Director of Nursing (ADON) on 3/30/17 at 10:30 a.m., revealed that wound care for th… | 2020-09-01 |
| 70 | 70 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2017-03-30 | 309 | D | 0 | 1 | U5BR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interviews, the facility failed to follow physician's orders for the administration of insulin per sliding scale. Findings include: Record review for R#17 revealed that the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Physician Orders dated 1/20/17 revealed an order for [REDACTED]. Review of the Medication Record (MR) for (MONTH) (YEAR) revealed one incorrect dose of insulin administered at bedtime (HS) on 1/21/17, which was documented at 212. During further review, the MR revealed that four u of insulin were given; however, two u ordered. Review of the Physician Orders for (MONTH) (YEAR) revealed order for [MEDICATION NAME] 100 u/ml per sliding scale for BG greater than 160 mg/dl; give via subcutaneous injection before meals and at bedtime at 7:00 a.m., 12:00 p.m., 5:00 p.m. and 9:00 p.m. Continued review revealed that the sliding scale is as follows: 161-200, give one u, 201-250, give three u, 251-300, give five u, 301-350, give seven u; greater than 351, give 10 u. Review of the MR for (MONTH) (YEAR) revealed a total of seven (7) occasions when insulin coverage had no evidence of documentation for the following dates: 7:00 a.m. administration: 2/6/17 BG=174, 2/12/17 BG=162; bedtime administration: 2/4/17 BG=198, 2/5/17 BG=176, 2/11/17 BG=213, 2/12/17 BG=189, and 2/18/17 BG=187. Review of the (MONTH) (YEAR) MR revealed four (4) incorrect doses given, which includes the following: on 3/2/17 at 5:00 p.m. the BG was 232, and the resident was given two u instead of five units. Then on 3/8/17 BG=380, five u given, not 10 u as ordered; and on 3/13/17 BG=262-three (3) u given, instead of five (5) units. Review of the (MONTH) (YEAR) Physician Orders continued the same sliding scale insulin orders as (MONTH) (YEAR). Interview with Licensed Practical Nurse (LPN) DD on 3/29/17 at 11:15 a.m., she stated that inservices are held for all n… | 2020-09-01 |
| 71 | 71 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2017-03-30 | 314 | D | 0 | 1 | U5BR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and staff interviews, the facility failed to ensure that one resident (R#64) pressure ulcer measurements were completed weekly from a total sample of 35 residents. Findings include: Review of the Documentation section of the facility's Pressure Ulcer Treatment policy and procedure revealed that following wound care, the wound appearance, including wound bed, edges, and presence of drainage should be documented. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound should be documented. Review of R #64's clinical record revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his Admission Minimum Data Set ((MDS) dated [DATE] noted that he had one Stage 2 pressure ulcer which was present on admission. Review of an impaired skin integrity care plan developed on 2/24/17 revealed that R #64 had a Stage 2 abrasion to his left buttock. Review of his Braden Scale (a tool used to predict pressure ulcer development) dated 3/10/17 revealed a score of 14 (moderate risk for development of a pressure ulcer). Review of an [MEDICATION NAME] lab test dated 3/13/17 revealed a result of 1.5 (normal 3.5-5.0). Review of R #64's Wound Evaluation Form revealed that he had a Stage II pressure wound to the left buttock. On 2/24/17, the wound was measured as 1.5 cm (centimeters) long by 0.1 cm wide. On 3/3/17, the wound measurements were recorded as 1.0 cm long by 0.5 cm wide. On 3/10/17, the wound was measured as 0.5 cm long by 0 cm wide. Further review of all three of these wound assessments revealed that the depth was left blank in the Size sections of the form. During interview with the Assistant Director of Nursing (ADON) on 3/30/17 at 1:19 p.m., she stated that the nurse that measured and described the wound should have recorded the depth on the Wound Evaluation Form. During further interview, the ADON verified that thi… | 2020-09-01 |
| 72 | 72 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2017-03-30 | 328 | E | 0 | 1 | U5BR11 | Based on observations, record review, policy and procedure review, and staff interviews the facility failed to maintain clean inlet filters on oxygen concentrators for five residents (R) receiving oxygen therapy ( R#80, R#182, R#181, R#111, R#96). The sample size was 7 residents receiving oxygen therapy via oxygen concentrators. Findings include: 1. Observation on 3/28/17 at 2:47 p.m. revealed R # 182 lying in bed awake receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen at 3 liters by nasal cannula every shift. Observation on 3/29/17 at 9:47 a.m. revealed R # 182 lying in bed awake receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 2. Observation on 3/28/17 at 3:22 p.m. revealed R # 181 lying in bed with eyes closed receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen 2 - 5 liters as needed by nasal cannula to keep oxygen level above ninety (90) percent. Observation on 3/29/17 at 9:48 a.m. revealed R # 181 lying in bed with eyes closed receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 3. Observation on 3/28/17 at 3:35 p.m. revealed R # 111 seated in recliner chair at bedside receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen continuously at 3 liters by by nasal cannula at night and 3 liters as needed during the day. Observation on 3/29/17 at 10:26 a.m. revealed R # 111 asleep in bed, private sitter at bedside. R # 111 is receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concen… | 2020-09-01 |
| 73 | 73 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2016-07-28 | 226 | D | 0 | 1 | 44GN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to ensure the abuse policy and procedure was followed to ensure 1 of 1 allegations of abuse was thoroughly investigated for 1 of 1 residents reviewed for abuse. (Resident #45) Findings include: On 7/25/16 at 3:30 PM, the Executive Director provided a policy titled Verification of Investigation of Alleged Mistreatment, Abuse, Neglect, Injuries of Unknown Source and Misappropriation of Resident Property Guideline, dated 3/2002 and revised 2013, and indicated the policy was the one currently used by the facility. The policy indicated .In the event of an alleged violation .involving mistreatment, neglect, abuse, injuries of unknown source or misappropriation of property, the center investigates the alleged violation thoroughly and reports the results of all investigation to the Executive Director as well as to state agencies as required by state and federal law. Investigation is conducted per the nursing policy Reporting Alleged Violations and documented on the Verification of Investigation form. Documentation reflects resident assessment; record reviews and sufficient employees/individuals were interviewed to derive at conclusion findings .Event Investigation: .The Executive Director, Director of Nursing or designee will initiate an event investigation immediately after the occurrence .2. Interview all people involved in the event. Discuss the event with associates involved, but DO NOT take written statements .8. Determine what recommendation or interventions have been or will be taken to prevent recurrence On 7/27/16 at 8:58 [NAME]M., record review indicated Resident # 45 was originally admitted to the facility on [DATE] with the most recent readmission on 7/15/16 with [DIAGNOSES REDACTED].diabetes mellitus type II, obesity, [MEDICAL CONDITION] and [MEDICAL CONDITION] A quarterly MDS (Minimum Data Set) assessment, completed on 5/11/16, indicated the resident … | 2020-09-01 |
| 74 | 74 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2016-07-28 | 253 | E | 0 | 1 | 44GN11 | Based on observation, interview, record, and facility vendor service agreement review, the facility failed to maintain dining areas and two (2) resident rooms on the Magnolia Wing in clean and sanitary condition. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. - - Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. 1. On 7/26/16 at 9:19 AM, Resident #117 room was observed standing near her bed. Residents ' bed control was lying on the bed spread. The bed control had exposed wires and there was some type of black sticky substance all over the back of it. 2. On 7/25/16 at 10:12 AM, Resident #143's bathroom was observed to have several dried splattered brown stains on the wall and on the outside of the toilet. Resident #143 stated We share with people in the other room also. 3. At 11:00 am during observation of the Magnolia Wing dining areas, there was a buildup of dirt in the corners and along the base boards of both dining areas. Residents were sitting in the dining area after participating in an activity. At 11:10 AM the Environmental Manager (EM) was queried about cleaning of the dining areas, particularly the floors. EM stated We have two people here on the 3 to 11 PM shift. One person is in laundry and the other person is doing the floors. On 7/27/16 at 9:25 AM, an interview was conducted with the… | 2020-09-01 |
| 75 | 75 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2016-07-28 | 254 | D | 0 | 1 | 44GN11 | Based on observation, interview, and review of the Vendor's Master Service Agreement the facility failed to provide four (4) sampled residents (Residents #3, #117, #143 and #213) out of 31 residents sampled with clean bed linen, mattresses and pillows in good condition. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. -- - Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. 1. Observation and interview on 7/25/16 at 5:19 PM revealed Resident #3's pillow cover cracked and in disrepair. Resident #3 stated I don't like it. 2. During observation and interview with Resident #213 on 7/25/16 at 5:57 PM the resident stated that his bed pillow and mattress were filthy. Observed the resident's stained malodorous pillow and soiled malodorous mattress. Resident #213 stated the mattress was uncomfortable to him. 3. On 7/26/16 at 9:19 AM, entered Resident # 117's room. Resident #117 ' s bed was observed to be made up with a blanket that had a large tear in it. When asked to see the linen on the bed, the resident pulled back the blanket and there were multiple brown, yellow and green stains on the sheet. Resident removed the pillow case and the pillow had multiple brown stains all over it. CNA MM entered the resident ' s room and when asked how often the linen was changed. CNA MM replied CNA on night shift gets some… | 2020-09-01 |
| 76 | 76 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2016-07-28 | 279 | D | 0 | 1 | 44GN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a written comprehensive care plan for 1 of 5 residents reviewed for unnecessary medications. (Resident #12) Findings include: On 7/28/16 at 9:40 [NAME]M., record review indicated Resident #12's [DIAGNOSES REDACTED].diabetes type II, major [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] and anxiety A significant change MDS (Minimum Data Set) assessment, completed on 6/20/16, documented Resident #12 had an active [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. The sliding scale orders were: 0-59 give 0 units, notify physician if blood sugar below 60 60-199 give 0 units 200-249 give 4 units 250-300 give 6 units, 301-349 give 8 units, 350-400 give 10 units, if blood sugar above 401 notify the physician. The [MEDICATION NAME]was originally ordered on [DATE] and the Humalog sliding scale insulin was ordered on [DATE]. On 7/28/16 at 11:00 [NAME]M., the care plans for Resident #12 was reviewed there was no care plan for the resident ' s [DIAGNOSES REDACTED]. During an interview, on 7/28/16 at 11:15 [NAME]M., Employee EE stated Resident #12 did not have a care plan in place for her [DIAGNOSES REDACTED]. During an interview, on 7/28/16 at 11:30 [NAME]M., the Director of Nursing stated the facility does not have a policy regarding the development of a care plan they go by the RAI (Resident Assessment Instrument) standards. During an interview, on 7/28/16 at 12:04 P.M., Employee FF stated Resident #12 was diagnosed with [REDACTED]. Employee FF indicated when the resident has a new [DIAGNOSES REDACTED]. The facility failed to develop comprehensive care plans for resident receiving insulin. | 2020-09-01 |
| 77 | 77 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2016-07-28 | 323 | D | 0 | 1 | 44GN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record, and facility policy review, the facility failed to provide adequate supervision for 1 sampled resident (Resident #61) from a sampled 31 residents. On 4/26/16 Resident #61 had expressed a desire to leave the facility, however the resident could not leave the facility unless accompanied by a family member. The facility was not aware the resident had left the facility unsupervised until 10 pm on 4/26/16. Findings include: Review of the facility's policy titled Elopement revised 2013 revealed the following information elopement is defined as that situation where a resident with impaired decision making ability , who is oblivious to his/her own safety, needs and therefore at risk for injury outside the confines of the living center, has left the living center without knowledge of staff. Review of Resident #61's active clinical record revealed the resident was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS), Medicare 30 day, indicated the resident was cognitively intact with a score of 13. -Quarterly MDS, dated [DATE] indicated the resident displayed no wandering behavior not exhibited and required supervision with all activities of daily living. Review of Care plans initiated on 3/11/16 revealed the following: Focus: - Resident #61 has impaired neurological status related to: Parkinson's disease, Dementia Focus: I forget things and can become anxious and it can create possible safety risks for me related to [DIAGNOSES REDACTED]. Review of the resident ' s progress notes revealed a late entry note dated 4/26/16 11:02Note Text: Resident noted to have left the faciity on this date without signing out. Resident's emergency contact person was called to determine if resident was picked up early for pending discharge. Family denies discharging resident early and stated that they were unaware of where resident may have gone. Resident was scheduled to be discharged to a PCH o… | 2020-09-01 |
| 78 | 78 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2016-07-28 | 328 | D | 0 | 1 | 44GN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review the facility failed to ensure 1 resident (Resident #128) of 31 residents sampled, received the prescribed amount of enteral nutrition within a 24 hour timeframe. Findings include: Review of the facility's policy titled Administration of Enteral Feeding last reviewed 11/02/15 indicated Procedure: to ensure all residents who receive enteral feeding receive the appropriate care and services. - check physician orders-formula, amount, rate, flushes, and residual parameters. -document the amount of formula administered, the amount of free water administered and any exceptions noted with the administration of enteral feeding to the resident. On 7/26/16 at 9:17 a.m., Resident # 128 was observed in bed asleep with the head of the bed (HOB) at 45 degrees. A full bottle (1500 milliliters) of Osmolyte 1.0 (liquid nutrition) dated 7/26/16 at 4:30 AM was hanging on a pole connected to an infusion pump. The pump was turned off and the tubing was capped and draped over the pole. At 12:00 PM CNA JJ was observed with Resident #128 lying flat in the bed, providing incontinence care. The pump remained turned off On 7/26/16 at 2:20 PM, Resident #128 was observed in bed, HOB at 45 degrees, tube feeding (TF) was infusing at 75 ml/hr., no flush bag hanging. On 7/27/2016 9:15 AM , Resident #128 was observed in hospital gown in bed with 1500 ml (full bottle) of Osmolyte 1.0, dated 7/27 at 5:15 AM hanging on infusion pump pole capped and not connected to resident, not infusing. At 10:23 AM Resident #128 remained in bed and TF, remained off. Review of the Physician order [REDACTED].) for 22 hours to provide 1650 kilocalorie's in 1650 ml of volume. Every 2 hours flush peg tube with 200 ml of water. On 7/27/16 at 11:14 AM LPN KK was queried about the infusion times for Resident #128 ' s tube feeding and how often did the resident receives a flush. LPN KK responded it should be up for 12 hours and off for 8 hours. … | 2020-09-01 |
| 79 | 79 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2016-07-28 | 431 | D | 0 | 1 | 44GN11 | Based on observation and interview, the facility failed to ensure expired medications were removed from 2 of 5 medication storage rooms, reviewed for medication storage. (Georgia and Dogwood) Findings include: On 7-27-2016 at 3:46 P.M., the policy entitled, Medication Storage in the Facility, Storage of Medications, was provided by the Assistant Administrative Director, and reviewed. The policy indicated, Procedures .H. Outdated, contaminated, or deteriorated medications .are immediately removed from inventory, disposed of according to procedures for medication disposal On 7-27-2016 at 10:02 [NAME]M., an observation of the medication storage room on Georgia Unit, was conducted with Employee G[NAME] A box labeled Heparin Lock Flush Solution, USP 10USP Heparin units/mL, was observed in the upper cabinet to the left of the locked medication storage refrigerator, and had an expiration date of (MONTH) 29, 2014. The box contained 13 preloaded and individually packaged Posi Flush Heparin Lock Flush Syringes. Each of the 13 individually packaged Heparin Flush syringes were labeled with the expiration date of (MONTH) 29, 2014. An interview at the time of the observation with Employee GG, indicated the out dated Heparin Lock Flush Solution, should have been removed from the medication storage room and discarded upon expiration. The employee indicated it was the responsibility of the nursing staff to look for and remove expired medications from the medication storage rooms. On 7-27-2016 at 10:28 [NAME]M., an observation of the medication storage room on Dogwood Unit, was conducted with Employee HH. 3 individual IV (intravenous) medications were observed in the locked medication storage refrigerator. Each of the 3 medications were labeled, Meropenem one gram (Merrem 1 GM) 100 ML IV infusion, and each had it's own stamped expiration date. The expiration dates were 6/08/2016, 6/13/2016, and 6/10/2016. An interview at the time of the observation with Employee HH, indicated the out dated Meropenem IV medication should have been … | 2020-09-01 |
| 80 | 80 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2016-07-28 | 441 | E | 0 | 1 | 44GN11 | Based on observation, interview, and review of the facility vendor service agreement, it was determined the facility failed to handle and transport linens to prevent cross-contamination between dirty and clean linen in the laundry room. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. During a tour of the laundry on 7/27/16 at 9:19 AM interview with the housekeeping and laundry director (AA) and observation of the physical layout of the laundry's clean and dirty areas revealed the laundry from the Magnolia wing that is adjacent to the laundry in delivered into a corridor outside the laundry. There is no direct access into the dirty laundry room. The laundry must be transported through the clean laundry room in close proximity to the front door of the dryers. Interview with AA (the Environmental Services Director) during the observation of the laundry revealed a door was needed between the hallway and the dirty laundry room to prevent cross contamination of clean clothing from the dirty laundry transported through the clean room. Additionally, a barrel containing mop heads and towels was observed at the junction between the clean and dirty rooms. AA stated the items in the barrel were clean but then instructed the staff to re-wash the mop heads and to… | 2020-09-01 |
| 81 | 81 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2016-07-28 | 456 | E | 0 | 1 | 44GN11 | Based on observation, interview and review of the vendor service agreement , the facility failed to keep the 3 (#1, #2, #3) of 4 laundry's washing machines in good working order. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. During tour of the laundry with AA (the Environmental Services Director) on 7/27/16 at 9:19 AM 2 (#1, #3) of 4 washing machines were observed leaking large pools of water onto the laundry room floor. The facility staff stemmed the flow of water with bedspreads. 07/27/2016 12:03 PM interview with the Regional Director for Environmental Services in the conference room revealed that AA had contacted the laundry washer manufacturer regarding the leaking washers and was waiting for documentation/call logs from the company. Follow-up interview with AA on 07/27/2016 4:25 PM in the day room revealed the technician from Laundry Equipment Sales responded to his call today and repaired the washers (#1 and #3). On 07/28/2016 at 12:52 PM observation and interview with AA revealed that the washing machines #1 was not leaking. However, new leaks were observed from washer #2 and washer #3. | 2020-09-01 |
| 82 | 82 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2018-11-01 | 604 | D | 0 | 1 | GW4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure that one (1) of 35 sampled residents (R) (R#44) was free from a physical restraint. While R#44 was seated in a high-back wheelchair, the resident's legs were strapped together for approximately three (3) hours, and the resident was unable to move her legs. The findings included: Review of R#44's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#44's Significant Change Minimum Data Set (MDS) assessment dated [DATE] and her Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired and had no physical behaviors. R#44 required extensive to total assistance for all activities of daily living (ADLs) and utilized a wheelchair for mobility. The resident had no falls during either assessment period. R#44 received no therapy services and no restraints or alarms were used during either assessment period. Review of R#44's ADL care plan dated 11/4/17 noted R#44 had an ADL self-care performance deficit related to (r/t) Alzheimer's and weakness. Goal for R#44 was to maintain current level of function in ADLs thru the review date. Interventions included: Dressing: receives total to extensive assist with one staff support; Bathing/hygiene - she receives shower 3 times per week with total assist from staff. Staff will trim her nails as needed (prn); encourage active participation in tasks; Bed mobility: requires total to extensive assistance by 1- to 2 (1-2) staff to reposition in bed and as necessary; Eating: requires extensive assistance with eating; Transfer: requires total assist by 1-2 staff to move between surfaces; Observe/document/report prn any changes any potential for improvement, reasons for self-care deficit, expected course, declines in function; Praise all efforts at self-care; physical therapy/occupational therapy (PT/OT) evaluation and treatm… | 2020-09-01 |
| 83 | 83 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2018-11-01 | 880 | D | 0 | 1 | GW4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to utilize proper hand hygiene prior to performing wound care for one of two residents, Resident (R) #15. Improper hand hygiene can promote the spread of infection in a facility. Findings include: R#15 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Wound Evaluation and Management Summary note dated 10/30/18 revealed the resident was admitted to the facility with the following wounds: Stage 4 pressure wound to the sacrum measuring 5.5 x 7.5 x 0.5 centimeters (cm). Stage 4 pressure wound of the right ischium measuring 1.8 x 3.5 x 1cm. Stage 4 pressure wound of the left ischium measuring 3 x 4.5 x 2.5 cm. The Wound Evaluation and Management Summary stated that the dressings were to be changed daily. Review of the facility policy titled Hand Hygiene dated 2012 stated Using an alcohol-based hand rub is appropriate after contact with inanimate objects in the patient's environment. Review of the facility policy titled Artificial Finger Nails stated the following: I. Length of nails: Fingernails should be kept clean, healthy, and short (1.4 inch or less beyond the tip of the finger.) II: Artificial nails: Artificial nails or nails enhancements should not be worn by any person whose responsibilities include handling of sterile supplies and/or direct hands-on resident contact. III. Nail polish: If used, nail polish should not be chipped. Studies have demonstrated that chipped nail polish may support the growth of organisms on the fingernails. If nail polish is worn, it should not be worn for more than 4 days. At the end of 4 days, nail polish should be removed and freshly reapplied. During an observation of wound care on 10/31/18 at 11:00 a.m. Licensed Practical Nurse (LPN) AA set up supplies to change R#15's dressing on the left ischium. She was observed to have long nails with chipped and worn polish and confirmed that they were artificial.… | 2020-09-01 |
| 84 | 84 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 272 | D | 0 | 1 | FY6A11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to accurately assess dental status for one resident (#46). Sample size was 35 residents. Findings include: Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) annual reassessment dated [DATE] was completed by staff. Review of this MDS assessment, including the accompanying Care Area Assessments (CAA's), revealed the facility staff failed to accurately assess this residents dental status. During interview on 11/3/2017 at 4:47 p.m., MDS nurse AA confirmed that R #46 was not accurately coded on the Annual Reassessment MDS or included in the CA[NAME] She stated that reassessments are done by face to face visits. She further stated that she may be confusing this resident with another. If she is made aware of a miscoding by staff or herself, then she will make a modification. She could not find a dental assessment on his record. | 2020-09-01 |
| 85 | 85 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 281 | D | 1 | 1 | FY6A11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of the Georgia Practice Act for Registered Nurses (RN) and Licensed Practical Nurses (LPN), staff and family interviews the facility failed to ensure that resident vital signs were monitored per the Physician orders [REDACTED].#_), that Physician orders [REDACTED].#6) that received [MEDICATION NAME] injection, that nurses were conducting narcotic reconciliation per the facility's policy for one resident (R#201) reviewed for use of injectable [MEDICATION NAME] and that nurses were confirming that the pharmacy label for medications corresponded with the physician's orders [REDACTED].#201 and R#137). The resident sample was 35. Findings include: Review of the Georgia Practice Act for Registered Nurses 2.2.2: Standards Related to Registered Nurse Responsibility for Nursing Practice Implementation. [NAME] Implements treatments and therapy, including medication administration, delegated medicals and independent nursing functions. Review of the Georgia Practice Act for Licensed Practical Nurses 2.3.2: Responsibilities for Nursing Practice Implementation. [NAME] Implements appropriate aspects of client care in a timely manner. 1. Provides assigned and delegated aspects of client's health care plan. 2. Implements treatments and procedures. 2. Administers medications accurately. K. Documents care provided. 1. Review of the Controlled Substance Accountability Sheet for R#6 revealed a pharmacy medication label with an original date of 5/23/17 for [MEDICATION NAME] INJ 2MG/ML (2 milligrams per milliliter) [MEDICATION NAME]- Inject 0.5ML (0.25ML). Review of the Physician order [REDACTED]. Review of the MAR indicated [REDACTED]. Interview on 11/3/17 at 1:50 p.m. with the DON and the Consulting Pharmacist (CP) confirmed that R#6 does not have an order for [REDACTED].#6, they should have notified the nursing supervisor and an order for [REDACTED]. 2. Review of the policy titled Controlled Drugs dated (MONTH) 2005 … | 2020-09-01 |
| 86 | 86 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 323 | D | 0 | 1 | FY6A11 | Based on observation and interview, the facility failed to assure electrical safety in five rooms on two of five units where an electrical power strip was used to provide electricity to multiple medical devices. The sample size was 35 residents. Findings include: 1. Observation on 11/1/2017 at 11:04 a.m., on the Magnolia Unit, revealed room 117 a with a power strip sitting on the floor at the head of the bed. The power strip was not affixed to the wall but plugged into an electrical outlet to the right of the hospital bed. Connected to the power strip and supplying electrical current was a hospital bed. 2. Observation on 11/1/2017 at 11:14 a.m., on the East Unit, revealed three resident rooms (103 b, 106, and 121 c) with power strips affixed to the wall and plugged into an electrical outlet. Connected to the power strips and supplying electrical current were hospital beds, feeding pump and oxygen concentrators. 3. Observation on 11/1/2017 at 11:14 a.m., on the East Unit, revealed room 120 d with two power strips connected to each other and affixed to the wall. Connected to the power strips and supplying electrical current was a hospital bed and oxygen machine. 4. Observation on 11/1/2017 at 11:32 a.m., on the Georgia Unit, revealed a power strip in use in the dining room. The power strip was supplying electricity to the communal television and was noted to be hanging from the television and plugged into outlet in the wall. Interview on 11/3/2017 at 10:35 a.m., with Environmental Supervisor, stated he knows that powers trips can be used for residents personal equipment such as personal fans, phone chargers, radios, and televisions. He further stated he was not aware that power strips could not be used with Medical equipment. | 2020-09-01 |
| 87 | 87 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 372 | F | 0 | 1 | FY6A11 | Based on observation and interviews, the facility failed to ensure that the surrounding area of one of one dumpster was maintained free of garbage and debris; and failed to secure two of three grease barrel lids to prevent insect and rodent infestation. Findings include: A tour of the dumpster area was conducted on 11/01/2017 at 11:08 a.m. revealed the following concerns: there was a pile of weathered garbage, containing paper trash and vinyl gloves, approximately three feet behind dumpster in a grass area; there was broken and damaged chairs stored behind the dumpster. Furthermore, three grease barrels are located beside the dumpster, and two of the three barrels had lids that were unsealed and ajar. On 11/2/2017 at 12:25 p.m. during an interview with the Corporate Dietary Manager, he stated that he was not aware the grease barrels were not able to be sealed. He stated that he would contact the company,[NAME]Industries, to order the locking rings that seal the barrels and lids. He also stated that the trash and debris around the dumpster was not the responsibility of the kitchen staff. On 11/3/2017 at 10:35 a.m., with Environmental Supervisor, stated that he orders a roll-off dumpster monthly to haul off the damaged furniture and equipment stored outside the dietary department. On 11/3/2017 at 11:04 a.m. during an interview with the Assistant Administration, he stated that there was no written policy or process related to the maintenance of the dumpster area. He stated that the Maintenance Department is responsible for the upkeep of the exterior grounds, including trash and debris around the dumpster. | 2020-09-01 |
| 88 | 88 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 425 | D | 1 | 1 | FY6A11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility's Dispensing Pharmacy failed to ensure an accurate dosage on the pharmacy medication label for one resident (R#201) that received Ativan liquid injection and failed to ensure that Physician orders [REDACTED]. orders [REDACTED].#137 and R#201). The resident sample was 35. Findings include: 1. Record review for R#137 revealed a physician's orders [REDACTED]. Review of the medication pharmacy label on the plastic bag containing vials of Ativan 2MG/ML, prescribed to R#137 indicated Inject Intramuscularly 1 vial every eight hours. Interview with the Consulting Pharmacist (CP) on 11/3/17 at 1:55 p.m. revealed she does conduct random audits and selects random medication carts. She stated she checks the control sheet for narcotics and ensures that the medication count matches what is on the control sheet. The CP further stated she does check the narcotics in the medication storage refrigerators but only to check for expiration dates and the correct amount of medication. She stated she does not check for the accuracy of the pharmacy label to ensure that it matches the facility's Physician order. Interview on 11/3/17 at 5:00 p.m. with the Dispensing Pharmacist (DP) revealed that narcotic medications orders have to be reordered after six months. He stated the order for Ativan 1 MG injection previously prescribed for R#137 on 3/28/17 could no longer be filled. He stated the pharmacy received an order directly from the physician's office on 10/27/17 for Inject Intramuscularly 1 Vial every 8 hours quantity five and five remaining. The DP stated the facility would have to call for the remaining five vials. The DP stated the prescription does not read PRN (as needed). The DP stated there are several dispensing pharmacist and per the system notes, the pharmacist called the facility and documented that the prescription was reported to LPN KK and two other staff names. The DP stated that no last names … | 2020-09-01 |
| 89 | 89 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 431 | E | 0 | 1 | FY6A11 | Based on observation, record review, review of the policy titled Controlled Substance and staff interviews, the facility failed to ensure that a controlled substance, Lorazepam (Ativan) liquid injection, was accounted for in two of four medication storage refrigerators (West Wing Medication Storage Room and Dogwood/Georgia Medication Storage Room). The resident census was 35. Findings include: Review of the policy titled Controlled Drugs dated (MONTH) 2005 and revised (MONTH) 2011 documented: To ensure that controlled drugs are inventoried and administered as required by State and Federal agencies: Maintain a declining inventory record by resident by drug on all controlled drugs. Reconcile the declining inventory record at the beginning and the end of each shift. Reconciliation is performed by a physical count of the remaining medication by two persons who are legally authorized to administer medications. 1. Observation of the West Wing medication storage room on 11/2/17 at 1:50 p.m. revealed a locked refrigerator that when opened by staff contained commonly used medications and a controlled substance, Lorazepam (Ativan) liquid injectable. Observation with Licensed Practical Nurse (LPN) CC revealed a plastic package with four vials of Ativan. The label read; two milligrams per milliliter (2 MG/ML), Inject 1 MG (0.25 ML) intramuscularly every four hours as needed, prescribed to R#201. Review of the Controlled Substance Accountability Sheet with LPN CC revealed the last dated entry of dispense was 10/31/17 with a remaining quantity of five vials. LPN CC and the Unit Manager, LPN DD looked in the refrigerator and were unable to locate the fifth vial of Ativan. Interview on 11/2/17 at 1:58 p.m. with LPN CC revealed she had not conducted a count of the Ativan in the West Wing medication storage refrigerator because the night shift nurse had to leave early due to an emergency. LPN CC stated that the second night shift nurse, LPN EE told her that they had counted narcotics prior to the nurse leaving early. LPN CC confir… | 2020-09-01 |
| 90 | 90 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 441 | C | 0 | 1 | FY6A11 | Based on a review of facility records, policy review, and staff interview, the facility failed to maintain an infection control program designed to provide a sanitary environment for its residents for the period beginning (MONTH) (YEAR) to (MONTH) (YEAR). The facility census was 205. Finding include: Review of the undated Infection Prevention Manual revealed the facility's infection prevention program should include: surveillance of infections; investigation of outbreaks; regular review of the policies and procedures of the program with updates in response to changes; staff education related to infection prevention; incorporation of infection prevention into the quality assurance process; and the utilization of an Infection Preventionist to carry out the daily functions of the infection prevention program. Further review of the Infection Prevention Manual revealed the infection prevention program should also include reporting and documentation mechanisms. The Infection Preventionist is expected to monitor line listings of infections and complete monthly report forms which are reported to the Quality Assurance (QA) Committee and other staff for feedback. The infection preventionist is also expected to monitor and document compliance with infection prevention practices. Review of the facility's infection control program documents revealed documentation that the infection control program was maintained, accordingly, for the periods prior to (MONTH) (YEAR) and after (MONTH) (YEAR). However, the infection control program documents for the period (MONTH) (YEAR) through (MONTH) (YEAR) consisted only of line listings of infections maintained on the individual units of the facility, and facility wide CAI/HAI sheets for the months of (MONTH) (YEAR) and (MONTH) (YEAR) with calculated percentages of infections identified in the facility during those months. Interview on 11/2/17 at 2:15 p.m. with Registered Nurse (RN), BB revealed, she assumed the role of infection preventionist for the facility in (MONTH) (YEAR). Any previou… | 2020-09-01 |
| 91 | 91 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 463 | D | 0 | 1 | FY6A11 | Based on observations, resident and staff interviews, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance in five rooms (M123, W127, W130, W142, and D214) on three of five units. The facility census was 205 residents. Findings include: Observations on 10/30/17 at 11:27 a.m., during initial tour of resident rooms revealed the following: 1. On the Magnolia Unit, Room 123 bed A, did not have a call light for resident use and the call light casing in the bathroom was loose and partially hanging on wall. 2. On West Unit, Room 127 bed B, Room 130 bed A and Room 142 bed C, the call light was not functioning on initial tour. 3. On Dogwood Unit, Room 214, the call light casing in the bathroom was loose and partially hanging on wall. Interview on 10/30/17 at 12:36 p.m., with the Maintenance Supervisor revealed he had repaired the call lights in rooms M123 bed A bathroom and obtained a functioning call light for 123 bed A; repaired the call lights in W127 bed B, W130 bed A, and W142 bed C; repaired the bathroom call light in D214. He reported that they were now functioning properly. | 2020-09-01 |
| 92 | 92 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 514 | E | 1 | 1 | FY6A11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to ensure that the administration, justification, and effectiveness of PRN (as needed) antianxiety medication ([MEDICATION NAME] injection) was consistently documented on the Medication Administration Record (MAR) for five residents (R#6, R#137, R#138, R#201 and R#228) and vital signs were not recorded weekly, for one resident (#11), from (MONTH) (YEAR) until (MONTH) (YEAR). The resident sample was 35. Findings include: 1. Review of the Controlled Substance Accountability Sheet for R#6 revealed a pharmacy medication label with an original date of 5/23/17 for [MEDICATION NAME] INJ 2MG/ML (2 milligrams per milliliter) [MEDICATION NAME]- Inject 0.5 ML (0.25 ML). Review of the Physician order revealed no orders for [MEDICATION NAME] matching the pharmacy medication label. Review of the MAR revealed no order for [MEDICATION NAME] matching the pharmacy medication label, therefor, there was no documentation or evidence that [MEDICATION NAME] 0.25 ML injection had been administered to R#6. Interview on 11/3/17 at 1:50 p.m. with the DON and the Consulting Pharmacist confirmed that R#6 does not have an order for [REDACTED]. The DON stated that the nurses should have noticed that there was no order for [MEDICATION NAME] and no order for [MEDICATION NAME] on the MAR. The DON further stated that the nurses should not have administered [MEDICATION NAME] to R#6, they should have notified the nursing supervisor and an order for [REDACTED]. The DON stated that the nurse receiving the telephone order is responsible for faxing the order to the pharmacy and entering the order into the electronic charting system, which in turn generates the order on the MAR. The DON stated she would have to find out who the nurse was that received the order. 2. Record review for R#137 revealed a Physician order for [REDACTED]. Review of the Controlled Substance Accountability Sheet for R#137 revealed that [MEDICAT… | 2020-09-01 |
| 93 | 93 | MILLER NURSING HOME | 115039 | 206 GRACE ST | COLQUITT | GA | 39837 | 2018-06-28 | 640 | E | 1 | 1 | KTS211 | > Based on record review and interview the facility failed to transmit resident Minimum Data Assessment (MDS) assessments timely for eight residents (R4, R2, R17, R20, R14, R7, R26 and R10). The facility census was 98. Findings include: Interview on 06/28/18 at 3:29 p.m. with Registered Nurse (RN) AA regarding the Minimum Data Assessments (MDS) revealed that a (MONTH) 10, (YEAR) batch of resident assessments were downloaded but was not uploaded and that it was that the facility's mistake. RN AA revealed that it is the responsibly of the facility to check to make sure that the assessments are uploaded and confirm that the assessments have been received. RN AA revealed that the 5/10/18 file was saved to Downloads, but was never exported, so there was not a receipt alerting her of the batch. Interview on 6/28/18 at 3:30 p.m. with the Director of Nursing (DON) and RN CC revealed that the MDS nurse in the facility is responsible for making sure the download of assessments is complete. The DON inquired with the MDS assessment nurses as to why the assessments were late. At this time, RN CC revealed that the QI data that is reported monthly is generated by reviewing the Resident Assessment Instrument (RAI) MDS schedule and reporting any assessments that haven't been completed by the RAI assessment due date. RN CC revealed that the 5/10/18 batch had been completed and sent to a zip file to be submitted to CMS, which caused the report to drop off the assessment due report however, it was never taken from the zip file and submitted and this caused the assessments to be sent in late. Interview on 6/28/18 at 3:32 p.m. with CC RN MDS revealed she made a file and uploaded the batch to the file and downloaded it to the site but apparently it did not go through. RN MDS CC revealed that when processing MDS assessments we save a zip file in the charting system and from there we must sign into the Quality Improvement and Evaluation System (QIES) submission website and attach the zip file to the state website; however, on 5/10/18, I … | 2020-09-01 |
| 94 | 94 | MILLER NURSING HOME | 115039 | 206 GRACE ST | COLQUITT | GA | 39837 | 2017-07-13 | 167 | D | 0 | 1 | TBPW11 | Based on observation and interview, it was determined that the facility failed to make the most recent survey results readily available to residents. Findings include: During an interview on 7/13/17 at 2 p.m., Resident (R) A stated she was unaware of the survey report. During an interview on 7/13/17 at 2:20 p.m., RB stated the he did not know where the survey results were kept. An observation on 7/13/17 at 2:40 p.m. revealed a sign posted on the large bulletin board, located across from the Unit 1 nurses station. The sign documented that the survey results were posted at the Nurses Station to be viewed at anytime. However, an observation of the nurses station revealed no visible survey results posted at that time. Registered Nurse (RN) AA was unable to locate the survey results. The Director of Nursing (DON) was able to locate the survey results in a folder in the drawer, behind the nurses station. She confirmed that the results were kept behind the nurses station. | 2020-09-01 |
| 95 | 95 | MILLER NURSING HOME | 115039 | 206 GRACE ST | COLQUITT | GA | 39837 | 2019-11-07 | 578 | E | 0 | 1 | C7SX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, and review of the facility's policy titled, Advance Directives the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Physician order [REDACTED].#55, R#42 and R#117). This deficient practice affected 3 of 7 residents reviewed for Do Not Resuscitate. Findings include: Review of Advance Directives Policy revealed: 2. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. POLST Additional Guidance for Health Care Professionals III. When a POLST form is signed by an Authorized Person (other than the patient's Health Care Agent) and Attending Physician: I. If Section A indicates Allow Natural Death - Do Not Attempt Resuscitation, this order may be implemented when the patient is a candidate for non-resuscitation as defined in Georgia Code Section 31-39-2(4). A concurring physician signature is Required per Georgia Code Section 31-39-4(c). 1. Review of the medical record for R#55 revealed a POLST with a verbal signature noted for Allow Natural Death with one Physician signature on 9/13/17. There was not any evidence of any documentation that R#55 had a power of attorney for healthcare nor was there a healthcare agent identified. During an interview on 11/5/19 at 4:00 p.m. with the facility's Long-Term Care (LTC) Director revealed that if a resident has a legal next of kin to sign the POLST only one Physician's signature has been gotten and was signed by an authorized person who is not the health care agent. The LTC Director further reported that if there was no legal next of kin two Physician signatures would be needed. The LTC Director reviewed the POLST for R#55 and she confirmed that there was only one Physician signature for R#55. Upon reading the POLST LTC Director acknowledged that a concurring physician's signatu… | 2020-09-01 |
| 96 | 96 | MILLER NURSING HOME | 115039 | 206 GRACE ST | COLQUITT | GA | 39837 | 2019-11-07 | 584 | D | 0 | 1 | C7SX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to ensure the resident fans on the vent unit were clean and free from dust build up for four of 15 rooms on Unit Two (Rooms: 20, 19, 22, 14). Findings include: The following observations were made: On 11/4/19 at 12:21 p.m. in room [ROOM NUMBER] there was a fan sitting on the table at the foot of Bed B that had a buildup of dust. On 11/4/19 at 1:13 p.m. in room [ROOM NUMBER] there was a fan at the end of Bed A with dust buildup. On 11/4/19 at 1:16 p.m. in room [ROOM NUMBER] at the end of bed A there was a fan with dust buildup On 11/5/19 at 8:09 a.m. in room [ROOM NUMBER] there was a fan with black dust buildup on the blades. On 11/5/19 at 3:10 p.m. in room [ROOM NUMBER] there was a fan with thick dust buildup. On 11/5/19 at 3:18 p.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/5/19 at 3:20 p.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/6/19 at 9:21 a.m. in room [ROOM NUMBER] there was dust noted on the fan by the sink. On 11/6/19 at 9:22 a.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/6/19 at 9:23 a.m. in room [ROOM NUMBER] there was dust build up on the fan. On 11/6/19 at 9:24 a.m. in room [ROOM NUMBER] there was dust noted on the fan. During a tour of Unit Two on 11/7/19 at 9:50 a.m. the Director of Nursing (DON) confirmed that in room [ROOM NUMBER] there was dust and buildup on the fan, in room [ROOM NUMBER] there was dust build up on the fan blade and the fan grille, in room [ROOM NUMBER] there was dust build up on the fan grille and, in room [ROOM NUMBER] there was dust build up on the fan and fan grille. During an interview with the DON on 11/7/19 at 9:58 a.m. revealed the Certified Nursing Assistants (CNAs) should clean fans when they are identified as having dust buildup. The DON further revealed that Maintenance should be notified when there is dust on the fan blades. The DON stated that CNAs should be wiping down the fans da… | 2020-09-01 |
| 97 | 97 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2018-08-23 | 583 | D | 1 | 1 | 07R411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to provide privacy of one resident's (R) body (R#25) during incontinence care and a shower. The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 9 (a BIMS score of 8 to 12 indicates moderate cognitive impairment); was extensive assistance for personal hygiene and toilet use; and needed physical help in part of bathing activity. On 8/20/18 at 4:13 p.m., Certified Nursing Assistant (CNA) BB was observed performing incontinence care for R#25 with her permission. CNA BB was observed to remove the resident's pants and incontinent brief, had the resident wipe herself with a washcloth, and then the CNA further cleaned the resident's perineal area and buttocks, before placing a clean brief back on her. Further observation revealed that R#25 was in a semi-private room in a bed closest to the window, and the bottom of the window blinds were raised approximately eight inches. Continued observation revealed that her room looked out to the front of the facility, and there was a car parked parallel to the building outside of her window. Further observation revealed that the door to the hallway had never been closed, and the privacy curtain between the two beds in the room had been not been pulled the entire length from wall to wall, leaving an opening of approximately 24 inches. On 8/22/18 at 7:25 a.m., R#25 was observed receiving a shower with her permission in the common shower room on the Mauve Hall by CNAs CC and DD. Continued observation revealed that R#25 pulled up on the grab bar just inside the shower room door, so that the CNA could remove her incontinent brief and pants, and then she sat back down on the shower chair (her shirt was still on). Dur… | 2020-09-01 |
| 98 | 98 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2018-08-23 | 689 | D | 1 | 1 | 07R411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to evaluate the risk of leaving one resident (R) (R#25) unattended while sitting on the side of the bed, resulting in a fall from the bed. The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 9 (a BIMS score of 8 to 12 indicates moderate cognitive impairment); she needed extensive assistance of two or more persons for transfers; was not steady, only able to stabilize with staff assistance for surface to surface transfer; had functional limitation in range of motion on one side of upper and lower extremities; and had one fall with no injury since prior MDS assessment. During interview with R#25 on 8/20/18 at 4:24 p.m., she stated that she had a fall today when staff was in the room with her. She further stated that she fell off the side of the bed onto the fall mat, and that the staff tried but were unable to catch her from falling. Observation at this time revealed that R#25 was in a bed lowered to the floor with an alarm, a bed rail up on both sides of the mattress, and she had a brace on her left leg. During interview with R#25 on 8/21/18 at 8:38 a.m., she stated that when she was receiving therapy in her room yesterday, the therapist sat her up on the side of the bed and then turned around, and she fell off the bed. During further interview, R#25 stated that she had left arm, back and right-sided facial pain after this fall. Review of incident reports revealed that R#25 had a fall from the wheelchair during a staff transfer on 11/25/17; unwitnessed falls from bed on 2/1/18, 3/30/18, and 6/26/18; and a fall from the bed during therapy on 8/20/18. During an observation of a transfer by Certified Nursing Assistants (CNA) CC and DD o… | 2020-09-01 |
| 99 | 99 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2018-08-23 | 690 | D | 1 | 1 | 07R411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to perform perineal care in a manner to prevent potential urinary tract infections [MEDICAL CONDITION] to the extent possible for one resident (R) (R#25). The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [MEDICAL CONDITION] (paralysis on one side of the body) following a stroke, urine retention, and a history of UTIs. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she was always incontinent of urine, and needed extensive assistance for toilet use. Review of R#25's urine cultures revealed infections with the following organisms: 11/14/17: Proteus mirabilis 3/20/18: Proteus mirabilis 5/10/18: [MEDICATION NAME] raffinosus During an observation of incontinence care with R#25's permission by Certified Nursing Assistant (CNA) BB on 8/20/18 at 4:13 p.m., the CNA was observed to obtain and place several wet washcloths on top of the resident's bed rail before removing her incontinent brief, which had a moderate amount of urine in it. Further observation revealed that the CNA asked R#25 if she wanted to wipe herself and she responded yes, and was given one of the wet washcloths. The resident was observed to wipe her right eye with the washcloth, and the CNA instructed her to wipe between her legs at which time she reached between her legs and wiped herself several times from the rectal area towards the urethra (back to front). Continued observation revealed that the CNA did not stop and instruct her the proper way to wipe. CNA BB was then observed to get another one of the wet washcloths on the bed rail, and cleaned the resident's perineal area properly from the front towards the back, and then turned her to her side and washed her buttocks with another wet washcloth from the bed rail. Further observation revealed that CNA BB did not dry the resident's skin before putting a… | 2020-09-01 |
| 100 | 100 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2018-08-23 | 812 | F | 0 | 1 | 07R411 | Based on observation, record review and staff interview, the facility failed to ensure that two foods served from the steam table were held at 135 degrees or higher; that a fan mounted over a drink preparation area was free of dust; and that the amount of sanitizer used in the low temperature dish machine was 50 parts per million (PPM) to prevent potential chemical contamination of food on two of two observations. There were 123 residents that consumed an oral diet. Findings include: 1. During the initial tour of the kitchen on 8/20/18 beginning at 12:00 p.m., a light to moderate build-up of dust was observed on the wall-mounted fan over the drink preparation area. This same observation was made on 8/21/18 at 3:50 p.m. During interview with the Dietary Manager on 8/23/18 at 9:03 a.m., she stated that Maintenance was responsible for cleaning the fans in the kitchen, and that they did so weekly or every other week. She verified during further interview that the wall-mounted fan over the drink preparation area had a light to moderate dust build-up, would contact Maintenance to clean it, and thought they last cleaned it on Friday (six days ago). During interview with Maintenance Technician II on 8/23/18 at 12:36 p.m., he stated that he cleaned the fan over the drink machine today per the Dietary Manager's request, and that he had no documentation of the last time the fan had been cleaned. 2. During observation of the preparation of pureed foods on 8/21/18 at 3:33 p.m., the food processor parts were observed to be washed in the low-temperature dish machine between and after foods prepared, which was connected to a container of sodium hypochlorite sanitizer. Dietary Aide GG was observed to check the chemical concentration of the final rinse water after running the food processor equipment through using a chlorine test strip, and she stated she would interpret the result as 75 (PPM). She stated during further interview that she was trained that the result should not be less than 50 (PPM). On 8/23/18 at 8:56 a.m., the Di… | 2020-09-01 |
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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 );