rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
7430,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,250,D,0,1,D0IP11,"Based on record review and staff interview the facility failed to ensure that social services was provided for the mental and psychosocial well being of one (1) resident (D) on a sample of thirty-six (36) residents. Findings include: Record review revealed resident D was admitted (January 2012) with depression and suicidal ideation. A Nurses Note dated 01/23/12 at 6:00 a.m. documented the resident was being monitored every 15 minutes for safety and that the resident had not mentioned any suicidal ideations. There was no documentation prior to 01/23/12 as to why the safety checks were being done. Interview with a Licensed Practical Nurse (LPN) SS on 01/22/12 at 12:58 p.m. revealed that it was reported to her by the Nurse Supervisor earlier that day that resident D had expressed feelings of wanting to do self-injury. LPN SS informed the nurse supervisor that resident D wanted to hurt him/herself. When she spoke to the resident about this all he/she told her was that he/she was depressed but did not mention anything about wanting to hurt himself. She stated they did 15 minutes checks to monitor the resident afterwards. Review of the resident record revealed the physician was called and an order received on 01/22/12 to monitor the resident mood and location every 15 minutes, which was done for the next three days according to nurses notes and the Resident Focus Reports. Interview with the resident on 02/22/12 at 1:55 p.m. stated he/she remembered the weekend that he/she was so depressed. He/she stated he/she did tell the nurse at that time that he/she want to kill himself. There was no documentation in the resident's record that the Social Worker (SW) had been made aware of this incident. The only SW documentation was of a social history for the resident but no progress notes whatsoever. Interview with the current SW on 02/22/12 at 2:48 p.m. revealed she was a recent employee and knew nothing regarding resident D beyond what is in the clinical record. Interview with the administrator on 02/23/12 at 8:02 a.m. revealed that Resident D should have been followed by the SW.",2017-04-01
7431,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,253,B,0,1,D0IP11,Based on observation the facility failed to maintain the cleanliness of one (1) of two (2) fans used in resident rooms. Findings include: Observation during initial tour and for the four (4) days of the survey revealed a floor fan in room C-12 to be placed between the two residents residing in that room. The fan was observed to be on from 8:00 am-3:30 p.m. on 02/20/12 through 02/23/12. Observation of the fan revealed a thick coating of dust covering the fan with one (1) inch tendrils visible on the grating. One (1) of the two (2) residents in the room used oxygen as needed. Interview on 2/23/12 at 10:30 a.m. with the Housekeeping Supervisor confirmed it was a housekeeping responsibility to clean fans and that the fan needed to be cleaned.,2017-04-01
7432,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,278,D,0,1,D0IP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that two (2) residents on a sample of thirty six (26) residents were accurately assessed for health care needs. Resident #113 was not assessed related to a contracture and resident # 94 was not assessed accurately related to pressure sores. Findings include: 1. Review of the current Minimum Data Set (MDS) assessment dated ,[DATE] assessed resident # 94 as having two (2) stage II pressures sore and two (2) stage III pressure sores. Review of the documentation of both the resident's coccyx and the left hip documented there were stage IV pressure sores on both of these locations. During interview on 02/21/12 at 3:30 p.m. with the Hospice Registered Nurse BB who does the dressing changes and documentation of the residents pressure sores revealed the pressure sores on the left hip and the coccyx had always been stage IV. Observation on 02/21/12 at 3:32 p.m. of the pressure sore to the left hip revealed that the pressure sore was a stage IV. Interview with MDS Nurse on 02/22/12 at I:58 p.m. confirmed them MDS assessment dated [DATE] incorrectly assessed the resident as having 2 stage III pressure sore when the pressure sores are actually stage IV to the left hip and coccyx. 2. Minimum Data Set (MDS) assessment dated [DATE] assesses resident # 113 with no contractures of the upper extremities. Interview with Minimum Data Set (MDS) Coordinator LL on 02/21/12 at 2:30 p.m. revealed staff reported that the resident did not have a contracture of the right hand and this is the information used for the initial assessment. He state a review of the original nursing assessments did not indicate a right hand contracture. Review of admission Nursing assessment dated [DATE] revealed contracture of the right hand and fingers. Review of Preliminary Plan of Care dated 12/05/11 revealed that a contracture of the right hand was identified. Interview with Assistant Director of Nursing (ADON) and LPN FF on 02/21/2012 at 10:00 a.m. revealed that staff were aware of resident's contracture of the right hand. Observation of resident # 113 on 02/20/12 at 2:30 p.m. revealed the resident has a right hand contracture.",2017-04-01
7433,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,309,D,0,1,D0IP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that physician orders [REDACTED].#111) on a sample of thirty-six (36) residents. Findings include: Review of a Physician's Telephone Order dated 01/22/12 at 11:30 a.m. documented resident # 111 was to be checked every fifteen (15) minutes for his/her mood and location for three (3) days. Further review of a physician's telephone order dated 01/26/12 at 9:30 am documented to discontinue the focus sheets. Review of the Resident Focus Reports dated 01/22/12 beginning at 12:00 noon, 01/23/12 and 01/24/12 ending at 6:45 a.m. documented that the resident should be visually monitored every 15 minutes on all shifts for his own safety. There was no documentation on a Resident Focus Report that the resident was monitored on 01/25/12 and 01/26/12 . Interview with the Director of Nurses on 02/22/12 at 1:12 p.m. confirmed that there was no evidence that the resident was monitored for safety on 01/24/12 and 01/25/12 as indicated on the physician's orders [REDACTED].>",2017-04-01
7434,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,318,D,0,1,D0IP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, chart review and staff interview, the facility failed to provide care to prevent worsening of a contracture for one (1) resident (E) from a sample of thirty-six (36) residents. Findings include: Observation of resident E on 02/20/12 at 2:30 p.m. revealed that the resident had a right hand contracture. Interview with the resident at that time revealed he rolls up a wash cloth and places it in the right hand himself. Resident E stated facility staff knows about the contracture but he does not receive and splints or therapy to the hand. Review of admission Nursing assessment dated [DATE] documented a contracture of the right hand and fingers. Further review revealed that the areas for restorative nursing and therapy were blank. Review of Preliminary Plan of Care dated 12/05/11 documented a contracture of the right hand, however, no further plan of care, assessment, evaluation or treatment to prevent worsening of contracture was put in place. Review of current Care Plan revealed no care plan interventions to address the contracture of resident E right hand. Interview with Assistant Director of Nursing (ADON) and LPN FF on 02/21/2012 at 10:00 a.m. revealed staff were aware of resident's contracture of the right hand, and there is no care plan or therapy in place to prevent worsening of contractures.",2017-04-01
7435,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,323,E,0,1,D0IP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that siderails fit the mattress properly to prevent potential entrapment for two (2) residents (# 55 and A) from a sample of thirty-six (36) residents. Findings include: 1. On 02/23/12 at 7:12 a.m., an observation was made of resident # 55 in their bed. There were siderails on each side of the top of the bed, one-fourth to one-half in size, and they were shaped like a T. The upper end of the siderail, especially on the resident's left side, had a gap of approximately nine to ten inches between the bottom part of the rail and the mattress. Additionally, there was a gap of approximately eighteen inches from the center bar of the siderail to each end. At 10:45 a.m., the Director of Nurses (DON) verified the above observations. She stated the resident could not move in bed by themselves. At this time, it was noted that the siderail on the resident's left side was freely movable away from the mattress that created a large gap, as well as an up and down movement without having to depress any mechanism on the bed to release it. The siderail on the resident's right side was loose as well, but not as much. Review of resident # 55's clinical record revealed that they had [DIAGNOSES REDACTED]. A care plan was developed on 09/05/11 for potential for injury related to a history of falling, and updated to include 1/4 siderails X 2 to define the parameters of bed. In addition, there were care plans for combative behavior and impaired thought processes related to mental retardation. A Siderail assessment dated [DATE] noted a history of falls or risk for falls; mental dysfunction which made the resident at risk for falling out of bed. The siderails were assessed as enablers, and noted the resident was not able to transfer independently. The Annual Minimum Data Set ((MDS) dated [DATE] noted the resident had short-term and long-term memory problems and severely impaired decision making. Bed Mobility was assessed as total dependence with two or more staff to assist. On 02/23/12 at 12:47 p.m., the MDS Coordinator stated the resident was able to wiggle somewhat in the bed. At 12:55 p.m., Licensed Practical Nurse (LPN) FF stated that the resident was able to move in bed because when turned to their side by staff, the resident always wiggled until they were on their back again. 2. During observation on 02/23/12 at 11:41 a.m. revealed that resident A had one 1/4 side rail on his bed that was leaning out away from the mattress and very loose. Review of the current February 2012 physician's orders [REDACTED]. Interview with the resident on 2/23/12 at 11:45 a.m. revealed that he/she has seizures and that is why the side rail was put on the bed. The resident further revealed he/she had not had a seizure in a while and has never fallen from the bed. The resident revealed he/she felt the side rail when raised were safe because it is loose that he/she could fall in between the rail and the bed if a seizure did occur. Interview with Registered Nurse DD on 02/23/12 at 11:56 a.m. confirmed that the side rail on the resident's bed needed to be repaired. Interview with Maintenance staff IIon 02/23/12 at 12:15 p.m. revealed that his staff does weekly monitoring of side rails to ensure they are not loose or in need of repair. No documentation was maintained regarding this monitoring of side rails.",2017-04-01
7436,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,328,D,0,1,D0IP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility failed to store oxygen equipment properly. Findings include: Observation during three (3) days of the survey revealed a Continuous Positive Airway Pressure ([MEDICAL CONDITION]) mask in room C-13 to be stored hanging on a hook above the bed uncovered. During observation of room C-12, there was an oxygen concentrator with a nasal cannula dangling uncovered from the concentrator. Interview with the Assistant Director of Nurses ( ADON) on 02/22/12 at 3:00 p.m., revealed the [MEDICAL CONDITION] mask should be stored in a bag. Interview with the Infection Control Nurse DD on 02/23/12 at 10:45 a.m., revealed it was facility policy to store the oxygen cannula in a bag. Review of Policy and Procedure for storing [MEDICAL CONDITION] masks and oxygen cannulas revealed they were to be stored in a plastic bag when not in use.",2017-04-01
7437,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,363,E,0,1,D0IP11,"Based on observation, record review, and staff interview, the facility failed to prepare a pureed meat in a manner to preserve the intended nutritional content for twelve (12) residents receiving a pureed and/or pureed meats diet. Findings include: On 02/21/12 at 2:59 p.m., Dietary employee GG was observed preparing pureed chicken cutlets. For each batch she prepared, she placed four whole slices of white bread and four breaded chicken breast patties into the food processor along with gravy, until the puree was at the desired consistency. She provided the recipe she used to prepare the food, and verified that she used one slice of bread per portion. Review of the facility's recipe for Puree Breaded Meats such as Chicken Patties revealed that one-half slice of bread per portion of meat was to be used. This was verified by the Dietary Manager at the time of the observation.",2017-04-01
7438,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,387,E,0,1,D0IP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to have initial physician progress notes [REDACTED].#23, #94, #65, #21, #98 and #53) from a sample of thirty-six (36) residents. Findings include: 1. Record review for resident #23 revealed an admission date of [DATE]. The only physician's progress note was dated 2/8/2012. No initial visit was in the clinical record. Interview on 2/22/12 at 3:10 p.m. with Licensed Practical Nurse AA revealed that she did not see any Physician's Progress Notes in the clinical record. Interview 2/22/12 at 3:15 p.m. with the Medical Record clerk revealed that after speaking with the primary physician's office manager, that no initial history and physical was ever sent to the facility for the resident's clinical records. 2. Record review for resident #94 revealed there was not indication in the physician's progress notes that the physician had made a visit to see this resident since admission on 9/01/11. Interview with director of Nursing (DON) at 2/2212 at 11:55 am revealed that the resident's physician had been sick since December 2011 and some visits had been missed. 3. Record review for resident #65 revealed there was no documentation in the physician progress notes [REDACTED]. Interview with the DON on 2/22/12 at 12:35 pm revealed the physician had not visited this resident except in September 2011 and February 2012. 4. Documentation in the clinical record for resident # 53 showed that the resident was admitted [DATE] with [MEDICAL CONDITION], paralysis aagitans, hypertension and [MEDICAL CONDITION]. According to the clinical record, the resident was not seen by a physician until 02/17/12. 5. Review of resident #21's clinical record revealed an unsigned physician Interim Rounds note dated 12/06/11. A Nursing Home Visits note prior to this was dated 09/13/11. 6. Review of resident #98's clinical record noted physician progress notes [REDACTED]. This was confirmed by the Director of Nurses (DON) on 02/23/12 at 10:45 a.m., who stated the physicians were supposed to visit and write notes at least every 2 months. She stated the physician actually saw resident #21 on 12/06/11, but got sick before she could sign it. She called the physician's office, and was told they did not have any progress notes between 09/13/11 and 12/06/11.",2017-04-01
7439,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,406,D,0,1,D0IP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to arrange for provision of specialized services for one (1) resident (# 21) with a history of severe mental illness per the Preadmission Screening and Resident Review (PASRR) recommendation. The sample size was thirty-six (36) residents. Findings include: On 02/20/12 at 12:11 p.m., resident #21 was noted in their bed and appeared anxious and had several somatic complaints. Review of the resident's clinical record revealed they were admitted to the facility on [DATE]. Per the Admission Nurse's Note, the resident was admitted from a with [DIAGNOSES REDACTED]. A Mood State/Psychosocial Care Plan dated 03/30/11 noted the resident had depression and anxiety disorder, and was at risk for adverse moods, signs and symptoms of depression and behaviors related to difficulty coping with long-term care placement and decline in health. Interventions included to use diversional activities during care, such as holding onto a pillow, stuffed animal or other personal item as needed. There were no interventions for referral to psychiatric services. On admission the resident was receiving [MEDICATION NAME] and [MEDICATION NAME] for depression; [MEDICATION NAME] for anxiety; and [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION]. The Georgia PASRR Psychiatric Evaluation and Medical History dated 03/17/11 noted that the resident had a chronic history of severe [MEDICAL CONDITION] with [MEDICAL CONDITION] and [MEDICAL CONDITION], generalized anxiety disorder and multiple medical problems. The PASRR Determination was that the resident had serious mental illness, met the Skilled Nursing Facility level of care criteria, and recommended specialized services for serious mental illness. Service Planning Recommendations included Crisis Services; Psychiatric Assessment/Care; Individual or Group Activity/Counseling; Case Management; and Day Supports. Rationale for Services Decision included frequent [MEDICAL CONDITION] and attempts in the past, and the need for evaluation of psych meds and close monitoring of these meds. Individual counseling was recommended due to severe anxiety and depression. Because of the resident's emotional health, close observation was needed. The resident's clinical record contained a letter that noted that the PASRR Level II review for resident #21 found that he/she was eligible to receive additional specialized services and/or supports according to an individualized plan of care to treat their serious mental illness. A fax number was provided for the facility to arrange for these specialized services. Review of the facility-provided Entrance Conference Worksheet noted that resident #21 was not on the list of residents receiving PASRR Level II services. Review of Skilled Daily Nurses Notes from 03/25/11 to 05/18/11 noted the Mood section was marked as showing the following indicators: Depression: On 34 days Restless/Fidgety/Anxious: On 45 days Tired/Little Energy: On 16 days Poor Appetite: On 2 days Little Interest/Pleasure in Doing Things: On 47 days Abnormal Sleep Patterns: On 9 days Inability to Concentrate: On 1 day Nurse's Notes dated 05/05/11 noted the resident complained of increased [MEDICAL CONDITION] and anxiety at night, and was unable to lay down due to their nerves. On 05/07/11 it noted the resident had increased anxiety and couldn't sit still due to nervousness and anxiety On 05/17/11 it was noted the physician was notified of the resident's depression, anxiety, and always nervous. A Physician Visit note dated 05/17/11 noted that she was requested to see the resident by the nursing staff as the resident continued to complain of [MEDICAL CONDITION]; stated their meds weren't working; got extremely anxious at night and couldn't sleep; needed something for their nerves as they were shaking and not able to sleep. The physician assessed the resident as having increased anxiety and [MEDICAL CONDITION], and a referral was made to a Behavioral Health Center (BHC) for medication evaluation and adjustment. The BHC History and Physical on admitted d 05/18/11 noted this was the resident's second admission to that facility, and was transferred from the nursing home due to severe agitation, anxiety and depression over the past several weeks, expressing suicidal comments; feeling very nervous and depressed with severe [MEDICAL CONDITION]. It noted the resident had several admissions with attempted suicide. The physician diagnosed the resident with recurrent severe major [MEDICAL CONDITION]; dementia with behavioral disturbance, and chronic mental illness. The resident was readmitted to the nursing home on 06/10/11. Review of the 30-day Minimum Data Set (MDS) on 06/30/11 and Quarterly MDS on 09/20/11 and 12/20/11 revealed the resident was not receiving any psychiatric therapy. An Initial Social Service (SS) History form dated 03/23/11 noted the reason for admission was long term care. The Significant Life Experiences and Significant Medical and Psychiatric History sections were blank. The next SS Progress Note Form dated 05/11/11 noted the resident's mood was depressed, had a history of [REDACTED]. On 02/22/12 at 10:00 a.m., Licensed Practical Nurse (LPN)HH stated that resident #21 was seen by their attending physician, but the resident was not seen routinely by any psych services. At 10:45 a.m., the SS Director (SSD) verified that the resident had been approved for Level II specialized services on 03/22/11, but had not been seen by psych services since he/she had been there. At 11:00 a.m., the SSD stated that unless there was an order on admission for a resident to be seen by psych services, they were not seen on a routine basis.",2017-04-01
7440,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,441,E,0,1,D0IP11,"Based on observation and staff interview, the facility failed to wash their hands and/or wear gloves before handling food items on two (2) of three (3) halls, and failed to store an ice scoop in one (1) of one (1) ice machines in a sanitary manner. The facility census was ninety-eight (98). Findings include: 1. On 02/23/12 at 7:12 a.m., Certified Nursing Assistant (CNA) EE was noted was noted to pick up resident #55's toast with her bare hands when setting up the breakfast tray on the A-hall. 2. On 02/23/12 at 10:42 a.m., the ice scoop inside the ice machine was noted to be lying on top of the ice with the handle touching the ice. The Infection Control Registered Nurse (RN) stated there was only one ice machine in the building, and that the scoop should be stored outside the machine in a container. She verified the ice scoop was stored improperly on top of the ice. 3, Observations during the lunch meal on Hall B on 02/20/12 at 12:16 p.m. revealed staff to pass meal trays to residents in their rooms. One Certified Nursing Assistant (CNA) went into the residents room adjusted the window blind then without washing her hands picked up residents bread held it in her hands and spread mayonnaise on the bread. Another CNA adjusted a resident's wheelchair legs then without washing her hands or wearing gloves opened condiments, plastic off liquids, then took bread out of the wrapper and placed it on the resident tray. Observation on 02/23/12 at 7:32 a.m. revealed staff to pass meal trays. One (1) nurse and two (2) CNA's were seen to handle the resident's bread without washing their hands or wearing gloves. Another CNA adjusted the bed height using the cranks then without washing her hands, she put the resident's straw in res milk, touching the straw at the area that went into the resident's mouth. Interview with the Administrator on 02/23/12 at 8:05 a.m. revealed that staff should use gloves when handling resident's bread during meals and hands should be washed when assisting with meal tray set up.",2017-04-01
7441,MOUNTAIN VIEW HEALTH CARE,115688,547 WARWOMAN ROAD,CLAYTON,GA,30525,2012-02-23,460,E,0,1,D0IP11,"Based on observation, resident and staff interview, the facility failed to provide curtains that ensured full visual privacy for twenty-six (26) of the twenty-eight (28) rooms with three (3) beds. Findings include: Interview with resident F on 02/20/12 at 9:40 a.m. revealed that there were times when she is was getting dressed and she does not have complete privacy. The curtains meant to provide privacy between multiple resident in the same room, only provide complete privacy for one resident at a time. Observation of all the rooms that contained three (3) resident beds revealed there were twenty-six (26) of twenty-eight (28) rooms that would not ensure visual privacy. Interview with CNA EE on 02/22/12 at 1:30 p.m., revealed that if care was (provided to more than one (1) resident in the room at a time, visual privacy for the other residents in the room could not be provided. Interview with Assistant Director of Nursing, Housekeeping Supervisor, and Administrator on 02/22/12 at 1:40 p.m., revealed the privacy curtains in the rooms with three (3) beds failed to ensure privacy.",2017-04-01
7713,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2012-02-23,243,B,0,1,2UV011,"Based on resident interview and staff interview the facility failed to provide a private place for the facility's resident council to meet without staff and/or visitors present. Finding includes: Interview with resident K conducted 2/21/2012 at 11:00a.m. revealed that the resident council meetings are held in an open dining area on the 2nd floor, in which facility staff are continuous walking in and out. This interrupts the meeting. On many occasions staff enter and ask what are we talking about or actually standing in the room listening to us. K also revealed that the residents attending the meeting do not feel comfortable discussing issues with staff present. He further revealed that the council haa been moved throughout the facility at the last minutes because the space that they were meeting in was needed to accomodate other activities. Interview with Social Services conducted on 2/22/2012 at 2:34p.m. revealed that resident council meeting are held in the 2nd floor Pharr Court Day room. There is not a door to prevent access to the meeting and therefore she stands outside the opened walk-way to prevent staff and visitors from entering the meeting. She did acknowledge that the council has been moved around due to the space was scheduled or needed for other occasions. She indicated that the area on the second floor was not very private and will attempt to move them to a more private area.",2016-12-01
7714,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2012-02-23,282,D,0,1,2UV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interview, the facility failed to follow the care plan for a bed alarm for one (1) resident (B) from a sample of thirty-four (34) residents. Findings include: Observation on 2/20/12 at 2:30 pm revealed resident B lying quietly in bed. The resident voiced no concerns or problems and there was no evidence of a bed alarm on the bed. Observation on 2/21/12 at 12:30 pm of the resident revealed no evidence of a bed alarm on the bed. Observation on 2/22/12 at 2:30 pm of resident B revealed the resident was lying in bed and no bed alarm was on the bed. The resident was alert and denied any problems. Interview on 2/23/12 at 8:13 am with staff AA revealed that one of the interventions for falls for resident B was a bed alarm on the bed. AA further revealed that a physician's orders [REDACTED]. She further revealed that the resident has not had a fall since 2/3/12. Observation with AA on 2/23/12 at 8:15 am revealed no evidence of a bed alarm on resident's bed. During this observation AA acknowledged there was not a bed alarm on the resident's bed. Review of the care plan dated 2/3/12 revealed one of the interventions for falls was the use of a bed alarm. Interview with resident B on 2/23/12 at 8:56 am revealed he has never has a bed alarm attached to his bed.",2016-12-01
7715,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2012-02-23,425,D,0,1,2UV011,"Based on observations, and review of facility policy, the facility failed to ensure all expired medications were disposed of timely for one (1) of eight (8) medication carts. Finding includes: During random inspection of fifth (5) floor South Hall medication cart, the following expired medications were in the cart: One (1) vial of Novolin Regular insulin with an open date of 1/2/2012. Mirtazapine 15mg tablets with an expiration date of 6/22/2011. Review of the facility policy for Medication Storage Parameters revealed that all vials of insulin products, except for Levemir, should be discarded twenty eight (28) days after opened/puncture.",2016-12-01
8302,LUMBER CITY NURSING & REHABILITATION CENTER,115404,93 HIGHWAY 19,LUMBER CITY,GA,31549,2012-02-23,252,D,0,1,T14011,"Based on observation and staff interview, it was determined that the facility failed to maintain an environment free of foul odors in the resident use bathroom between rooms #102 and #104 on one (A hall) of three halls. Findings include: Observation of the shared bathroom for room #102 and #104 on 2/20/12 and 2/23/12 at 11:45 a.m. revealed foul urine odor. During an interview on 2/23/12 at 11:45 a.m., a housekeeping staff said that urine was in the tile floor and grout. He/She said the room had always had that odor.",2016-03-01
8303,LUMBER CITY NURSING & REHABILITATION CENTER,115404,93 HIGHWAY 19,LUMBER CITY,GA,31549,2012-02-23,282,D,0,1,T14011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, it was determined that the facility failed to implement care plan interventions for one resident (#75) with a history of falls and skin tears in a total sample of 33 residents. Findings include: Resident #75 had a [DIAGNOSES REDACTED]. On the resident's 12/1/12 quarterly Minimum data set (MDS) assessment, nursing staff coded the resident as needing extensive assistance with transfers and dressing. The resident had history of falls. He/She had fallen twice in January 2012, February 2012 and December 2011; once in November 2011, and; eight times in October 2011. The resident had a history of [REDACTED]. The care plan initiated on 6/13/2011 had an intervention for staff to keep slip resistant footwear on the resident at all times when he/she was out of the bed. However, observations on 2/22/12 at 12:50 p.m. and 4:25 p.m. and on 2/23/12 at 11:30 a.m. revealed that the resident was not wearing slip resistant footwear. There was a handwritten intervention for staff to apply a bed/chair alarm on the resident. However, it was observed on 2/22/12 at 12:50 p.m. that staff had not attached the personal alarm to the resident. On 8/24/11, a handwritten intervention on the care plan noted that the resident's wheelchair was moved to his/her bedside. There was a 10/11/11 note that the resident's wheelchair brake had been repaired by maintenance. During observations on 2/22/12 at 4:25 p.m. and on 2/23/12 at 8:15 a.m., 10:45 a.m. and 11:30 a.m., the wheelchair was sitting next to the resident's bed but, staff had not locked the brake on the left side of the chair. The care plan since 6/13/11 addressed the resident's potential risk for getting skin tears and noted his/her history of having multiple skin tears to his/her upper extremities. There was an intervention since 10/17/11 for staff to monitor the resident and apply sleeves on both of his/her arms. However, the resident was observed on 2/20/12 at 1:55 p.m., and on 2/23/12 at 8:15 a.m. wearing short sleeve shirts. See F323 for additional information regarding resident #75.",2016-03-01
8304,LUMBER CITY NURSING & REHABILITATION CENTER,115404,93 HIGHWAY 19,LUMBER CITY,GA,31549,2012-02-23,312,D,0,1,T14011,"Based on observations and staff interviews, it was determined that the facility failed to provide nail care for two residents (#14 and #28) and hair care for one resident ( #14 ) from a total sample of 33 residents. Findings include: 1. Resident #14 was observed on 2/20/12 at 12:55 p.m. and on 2/21/12 at 9:00 a.m. to have dirty fingernails and greasy hair. A black substance was observed to have been beneath the resident's fingernails on 2/21/12 at 9:00 a.m. During an interview on 2/23/12 at 12:31 p.m., CNA AA stated that she bathed the resident every other day and washed his/her hair but, when she returned to work on the following days, the resident's hair was greasy. CNA AA stated that fingernail care was usually given every Sunday by the CNAs and any other day if it was needed. 2. Resident #28 was coded on the 1/26/12 MDS assessment as cognitively impaired and needing extensive assistance with activities of daily living. However, during an observation on 2/21/12 at 8:47 a.m., his/her fingernails were long and dirty. According to the facility's 4/15/11 In-service Report, dignity issues and nail care had been presented to all staff.",2016-03-01
8305,LUMBER CITY NURSING & REHABILITATION CENTER,115404,93 HIGHWAY 19,LUMBER CITY,GA,31549,2012-02-23,323,D,0,1,T14011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to consistently implement planned interventions for one resident (#75) with a history of falls and skin tears and to secure a disposable razor from one resident (#28) in a total sample of 33 residents. Findings include: 1. Resident #75 had a [DIAGNOSES REDACTED]. On the resident's 12/1/12 quarterly Minimum data set (MDS) assessment, he/she was coded as needing extensive assistance with transfers and dressing. The resident had history of falls. Licensed nursing staff documented that the resident had fallen twice in February 2012 January 2012 and December 2011, once in November 2011 and eight times in October 2011. Nursing notes documented that the resident had fallen on 2/01/12 and 2/08/12 when he/she transferred independently out of bed. The care plan initiated on 6/13/2011 had an intervention for staff to keep slip resistant footwear on the resident at all times when he/she was out of the bed. However, it was observed on 2/22/12 at 12:50 p.m. and 4:25 p.m. and on 2/23/12 at 11:30 a.m. that the resident was out of bed but was not wearing slip resistant footwear. During an interview on 2/23/12 at 11:30 a.m., the Director of Nursing stated that the use of non-skid socks on the resident when he/she was up should be changed to him/her needing to wear them at all times because of his/her attempts to transfer independently from the bed. There was a handwritten intervention on the care plan for staff to apply a bed/chair alarm on the resident. However, during an observation on 2/22/12 at 12:50 p.m., the personal alarm had not been attached to the resident. A handwritten intervention (dated 8/24/11) on the care plan noted that the resident's wheelchair was moved to his/her bedside. There was a 10/11/11 note that the resident's wheelchair brake had been repaired by maintenance. During observations on 2/22/12 at 4:25 p.m. and on 2/23/12 at 8:15 a.m., 10:45 a.m. and 11:30 a.m., the wheelchair was positioned next to the resident's bed but, staff had not locked the brake on the left side of the chair. Observations during those times revealed that the brake locks were functional on the wheelchair. The resident's care plan since 6/13/11 addressed his/her potential for having skin tears and noted his/her history of having had multiple skin tears on his/her upper extremities. There was an intervention since 10/17/11 for staff to monitor the resident and apply sleeves on both of his/her arms. There were handwritten entries on the care plan that the resident had sustained skin tears on his/her left upper extremity on 7/16/11, 8/05/11, 8/22/11, 9/23/11, 10/04/11, 10/06/11, 10/20/11, 11/14/11, 12/07/11, 01/13/12, 01/30/12, and 02/01/12. Staff documented that he/she had sustained skin tears on his/her right upper extremity on 8/15/11, 8/30/11, 9/23/11, 10/08/11, 01/16/12, and 02/08/12. However since the intervention was added on 10/17/11, there was not any evidence of whether or not the resident had been wearing sleeves when any of those the skin tears occurred. The resident was observed on 2/20/12 at 1:55 p.m., and on 2/23/12 at 8:15 a.m. wearing short sleeve shirts. He/She had multiple bruises on both of his/her lower arms and a skin tear on his/her left hand. During an interview on 2/23/12 at 11:30 a.m., the Director of Nursing stated that she was not aware of any preventative measures that had been put into place to protect the resident's arms. The care plan since 6/13/11 addressed the resident's cognitive loss and dementia with short term memory impairment. There was an intervention for staff to keep his/her call light within reach and to respond to it promptly. Staff documented on the care plan on 10/20/11 that the resident had been reminded to call for assistance as needed. However, that intervention was not appropriate because, it required a response of which the resident was not capable based on the facility's assessment of his/her cognitive status and short term memory problems. 2. Resident #28 had been coded on his/her 1/26/12 MDS assessment as cognitively impaired and needing assistance for activities of daily living. However, during an observation on 02/22/12 at 8:49 a.m., the resident sat alone in a bedside chair in his/her room with a disposable razor on the floor behind his/her foot. That observation was confirmed by the A hall charge nurse. Review of a facility's inservice records dated 04/15/11 included a reminder that razors were supposed to be removed from rooms. The attendance record was signed by 29 certified nursing assistants (CNA).",2016-03-01
8306,LUMBER CITY NURSING & REHABILITATION CENTER,115404,93 HIGHWAY 19,LUMBER CITY,GA,31549,2012-02-23,328,E,0,1,T14011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation during the environmental tour and random observations, it was determined that the facility failed to properly store nebulizer masks, mouthpieces, nasal cannulas and tubing for four residents on A Hall, two residents on B hall and two residents on C hall from a census of 20 residents who were being provided respiratory care. Findings include: Observations were made on 2/20/12 between 11:10 a.m. and 11:40 a.m., during the environmental tour with the maintenance supervisor on 2/22/12 at 1:45 p.m., and/or on 2/23/12 between 10:30 a.m. and 11:00 a.m A Hall 1. The nebulizer mouthpiece was not covered and was on the floor in room [ROOM NUMBER]B. 2. The oxygen tubing was on the floor in room [ROOM NUMBER]B. 3. The nebulizer mouthpieces were not covered in room [ROOM NUMBER] at the A and B bed locations. B Hall 4. The oxygen tubing was on the floor in rooms 213B and 214B. C Hall 5. There was an uncovered nebulizer mouthpiece in room [ROOM NUMBER]A. The nebulizer mouthpiece was not covered and the tubing was on the floor during observations on 2/21/12 at 12:55 p.m., 2/22/12 at 8:55 a.m., and 2/23/12 at 9:30 a.m. 6. The nebulizer mouthpiece was not covered in room [ROOM NUMBER]B.",2016-03-01
8335,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2012-02-23,156,B,0,1,028H11,"Based on record review and staff interview, it was determined that the facility had failed to provide three (#33, #100, and #51) of three sampled residents, who were discharged from Medicare Part A services, with the CMS- form and the Skilled Nursing Advanced Beneficiary Notice (SNFABN) form (CMS - ) or a mandatory uniform Denial Letter to inform the resident of his/her right to an appeal and potential liability for the non-covered services and the estimated cost of those non-covered services. Findings include: On 2/23/12 at 1:12 p.m., the Minimum Data Set (MDS) coordinator stated that she had not provided the CMS- form and the SNFABN form or a mandatory uniform Denial Letter to residents who had been discontinued from Medicare Part A services for coverage reasons. She had incorrectly provided the CMS-R-131, a Medicare Part B form. Twenty-three residents had been discharged from Medicare Part A services for coverage reasons since 9/27/11. 1. Resident #33 was notified by the facility on 1/26/12 that Medicare Part A coverage for skilled services would end on 1/30/12. However, the facility failed to provide the resident with the required CMS form and the CMS- form or a uniform Denial Letter to inform the resident of his/her right to an appeal and potential liability for the non-covered services and the estimated cost of those non-covered services if the resident chose to continue to receive them. 2. Resident #100 was notified by the facility on 10/7/11 that Medicare Part A coverage for skilled services would end on 10/10/11. However, the facility failed to provide the resident with the required CMS form and the SNFABN form or uniform Denial Letter to inform the resident of his/her right to an appeal and potential liability for the non-covered services and the estimated cost of those non-covered services if the resident chose to continue to receive them. 3. Resident #51 was notified by the facility on 11/28/11 that Medicare Part A coverage for skilled services would end on 12/1/11. However, the facility failed to provide the resident with the required CMS form and the SNFABN form or uniform Denial Letter to inform the resident of his/her right to an appeal and potential liability for the non-covered services and the estimated cost of those non-covered services if the resident chose to continue to receive them.",2016-03-01
8336,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2012-02-23,241,E,0,1,028H11,"Based on observations, it was determined that the facility failed to provide a dignified dining experience during two of two meals observed in the South hall dining room. Findings include: Observations during the lunch meals on 2/20/12 and 2/22/12 in the South hall dining room revealed that residents sat and watched other residents eat before being served and/or assisted to eat their meals. 1. On 2/20/12, nursing staff were observed serving residents' lunch trays in the South Hall dining room from 11:30 a.m. to 11:50 a.m. At 11:50 a.m., there were 31 residents and 5 nursing staff members in the dining room. All five staff members were seated and assisting residents to eat but, not all of the residents had been served their meal. Seven residents had not been served. Those seven residents were not served and assisted to eat until 12:15 p.m. 2. One resident was observed with his/her lunch plate set up in front of him/her but, his/her silverware was not wrapped from 11:30 a.m. to 12:05 p.m. The resident began eating at 12:05 p.m after staff unwrapped the silverware. 3. One resident was observed playing with his/her food and untensils from 11:30 a.m. to 12:05 p.m. A staff member finished assisting another resident at 12:05 p.m. and then sat down to assist the resident. 4. On 2/22/12 at 11:20 p.m., staff failed to serve lunch at the same time to a table of five residents. During the observation, the first resident was served at 11:25 a.m. and the last resident at the table was not served until 12:02 p.m. 5. On 2/22/12 between 11:20 a.m. and 12:05 p.m., there were seven residents sitting at one table. The first resident at that table was served at 11:25 a.m. but, the last resident was not served his/her meal tray until 30 minutes later at 11:55 a.m Another table had five residents seated at it. The first resident was served at 11:30 a.m. but, the last resident was not served until 30 minutes later at 12:00 noon. Across the back of the dining room were five residents seated in a line. Staff served the first resident at 11:25 a.m. but, the fifth resident was not served until 40 minutes later at 12:05 p.m",2016-03-01
8337,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2012-02-23,253,E,0,1,028H11,"Based on observations, it was determined that the facility failed to maintain an environment that was free from dirty floors, rusty metal frames on raised toilet seats, a broken toilet paper holder, a rusty free standing toilet paper holder, a soiled commode chair seat, worn finishes on nightstands, a broken nightstand door, cracked and bubbled wallpaper, stored unused equipment in a common shower room, peeling trim on overbed tables, peeling wood and, soiled urinals on one (North hall) of four halls. Findings include: Observations were made during the initial tour on 2/20/12 between 11:10 a.m. and 11:40 a.m. and, during the environmental tour on 2/23/12 between 1:15 p.m. and 2:00 p.m 1. The bathroom floor around the door frame had a heavy build up of a black substance in room 344. The nightstand door was broken at the A bed location. 2. There was a rusty metal frame on the raised toilet seat in the bathroom of room 346. The toilet paper holder was broken. The seat of the commode chair was soiled. The floor had a heavy build up of dust and debris. 3. There was a rusty metal frame on the raised toilet seat in the bathroom of room 350. The wood was peeling off of the bathroom door. 4. The finish was worn off of the nightstands for A and B beds in room 354. There was a rusty free standing toilet paper holder in the bathroom. 5. The wallpaper was cracked and bubbled on the wall next to the window in room 341. 6. The edging was peeling off of the overbed table in room 345A. 7. There was a urinal on the siderail that had a dried white substance along the inside of it in room 352C. 8. There was a urinal on the overbed table that had a black substance along the lid in room 356C. 9. There were three mechanical lifts, two reclining chairs, two overbed tables, two geri chair table tops, a tube feeding pole, a tube feeding pump, two vital sign machines, a mattress overlay, a blood pressure machine, five straight chairs and one wheelchair stored in the common shower room.",2016-03-01
8338,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2012-02-23,282,D,0,1,028H11,"Based on observation, record review and staff interview, it was determined that the facility failed to provide nail care for one (#106) of 32 sampled residents. Findings include: Resident #106 was coded by licensed staff on the 1/14/12 quarterly Minimum Data Set (MDS) assessment as requiring limited assistance with personal hygiene. The resident had a plan of care since 10/12/11 to address his/her self care deficit. There was an intervention for staff to provide nail care weekly and as needed. However, the resident was observed to have brown matter underneath his/her fingernails on both hands on 2/21/12 at 10:15 a.m., on 2/22/12 at 11:00 a.m. after receiving a shower, and on 2/23/12 at 10:15 a.m See F312 for additional information regarding resident #106.",2016-03-01
8339,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2012-02-23,309,D,0,1,028H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to administer medications as ordered for two residents (#86 and #104) from a total sample of 32 residents. Findings include: 1. Resident #86 had a physician's orders [REDACTED]. However, a review of the October 2011 Medication Administration Record [REDACTED]. A review of the December 2011 MAR indicated [REDACTED]. Licensed nursing staff documented on that MAR indicated [REDACTED]. However, there was no evidence of when the medication was obtained or that the dose was administered. 2. Resident #104 had a physician's orders [REDACTED]. However, a review of nursing staff's documentation on the resident's MAR indicated [REDACTED]. During an interview on 2/22/12 at 4:30 p.m., the Director of Nursing (DON) stated that the restart and administration of the medication on 2/10/12 was an error on the nurses part. On 2/23/12 at 11:30 a.m., the resident's physician stated that the facility had called him after surveyor inquiry. He stated that he had written an order for [REDACTED].>",2016-03-01
8340,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2012-02-23,312,D,0,1,028H11,"Based on observation, record review and staff interview, it was determined that the facility failed to provide nail care for one (#106) of 32 sampled residents. Findings include: Resident #106 was coded by licensed staff on the 1/14/12 quarterly Minimum Data Set (MDS) assessment as requiring limited assistance with personal hygiene. The resident had a plan of care since 10/12/.11 to address his/her self care deficit related to his/her generalized weakness. There was an intervention for staff to provide nail care weekly and as needed. However, the resident was observed to have brown matter underneath his/her fingernails on both hands on 2/21/12 at 10:15 a.m., on 2/22/12 at 11:00 a.m. after being given a shower by nursing staff and, on 2/23/12 at 10:15 a.m During an interview on 2/23/12 at 10:50 a.m., certified nursing assistant (CNA) BB stated that staff would clean under a resident's fingernails if they noticed they were dirty.",2016-03-01
8341,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2012-02-23,314,D,0,1,028H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record review, it was determined that the facility failed to ensure interventions were in place to prevent pressure ulcer development for one resident (#72 ) who had a history of [REDACTED]. Findings include: Resident #72 had an annual Minimum Data Set (MDS) assessment completed on 12/2/11. Licensed staff coded him/her as requiring extensive assistance with bed mobility, personal hygiene, bathing, and dressing and total assistance with transfers and toilet use. The resident was coded as being at risk for pressure ulcer development. In section M1200 of the MDS assessment, licensed staff had checked that a pressure reducing device for the bed was in use. Nursing staff developed a care plan dated 2/25/11 to address the resident's risk for skin integrity impaired because of having had a pressure ulcer on admission, impaired mobility, bowel and bladder incontinence and decreased nutritional status. During observation on 2/20/12 at 3:15 p.m., the resident was in bed sleeping. The alternating pressure pump attached to the foot board of the bed was in the 'off' position so that the overlay pressure pad was not inflated. It was observed on 2/21/12 at 8:10 a.m., 9:00 a.m., 1:30 p.m., 3:00 p.m., 4:10 p.m. and 5:10 p.m. and on 2/22/12 at 7:05 a.m., 8:20 a.m. and 8:55 a.m., that the resident was in the bed with the alternating pressure pump in the 'off' position and the overlay pressure pad not inflated.",2016-03-01
8342,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2012-02-23,328,E,0,1,028H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews with a resident and staff, it was determined that the facility failed to properly store respiratory therapy equipment for four sampled residents (#32, #73, #90 and A) and for two unsampled residents from a total sample of 32 residents. Findings include: Review of the facility's Policy and Procedure for Respiratory Therapy Equipment revealed that oxygen cannulas and tubing were to be stored in a plastic bag when not in use. Nebulizers were to be stored in a plastic bag. Staff were to change the prefilled humidifier bottles when the water level was low. However, staff failed to implement those procedures for residents #32, #73, #90, A and two unsampled residents. 1. Resident #32's nebulizer mouthpiece and tubing were uncovered and laying on the floor on 2/20/12 at 3:05 p.m. and on 2/21/12 at 8:30 a.m. 2. The oxygen mask and tubing for resident #73 was uncovered and draped over the oxygen meter on the wall on 2/20/12 at 3:00 p.m. On 2/21/12 at 8:35 a.m., the mask and tubing was in a plastic bag dated 6/12/11. 3. The nebulizer mouthpiece and tubing for resident #90 was uncovered, draped over the oxygen meter and was not dated on 2/20/12 at 2:30 p.m. and on 2/21/12 at 8:35 a.m. 4. Resident A had a 9/29/11 physician's orders [REDACTED]. However, the resident's oxygen was set at 3Liters/minute and the humidifier bottle was empty on 2/20/12 at 2:30 p.m., 2/21/12 at 9:00 a.m., and 4:00 p.m., 2/22/12 at 8:35 a.m. and 4:45 p.m. and on 2/23/12 at 10:00 a.m. There was also an uncovered oxygen mask draped over the oxygen meter on those dates and times. During an interview on 2/23/12 at 10:00 a.m., resident A stated that the inside of his/her nose would get dry, sore and would bleed at times. The following observations were made during the initial tour on 2/20/12 between 11:10 a.m. and 11:40 a.m 5. The oxygen tubing was draped over the oxygen meter and was not dated in room [ROOM NUMBER]A. 6. The oxygen mask and tubing was draped over the oxygen meter in room [ROOM NUMBER]B. The oxygen mask was uncovered and there was not a date on the humidifier bottle, tubing or mask .",2016-03-01
8343,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2012-02-23,371,F,0,1,028H11,"Based on observations and staff interview, it was determined that the facility failed to maintain the floor pantry ice machine on the North Hall in a clean and sanitary condition. Findings include: During the environmental tour on 2/23/12 at 1:13 p.m., the ice machine in the floor pantry on the North hall had a heavy build up of a brown substance in the back of the machine where the ice was made. During an interview on 2/23/12 at 3:05 p.m., the administrator stated that the floor tech was supposed to be cleaning the machine. After surveyor inquiry, he/she provided a cleaning schedule to be instituted 2/24/12.",2016-03-01
8344,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2012-02-23,428,D,0,1,028H11,"Based on record review and staff interview, it was determined that the facility failed to act upon a pharmacy recommendation for one resident (#86) from a total sample of 32 residents. Findings include: Resident #86 had a recommendation from the pharmacist on 9/30/11 for the physician to review the continued need for the medication Procrit due to the medication being held several times for hemaglobin levels greater than 12. The resident's attending physician's documented response on the recommendation form was that another physician had ordered the medication. There was no further evidence in the clinical record that the pharmacist's recommedation was addressed. The Director of Nursing confirmed on 2/23/12 at 4:40 p.m. that the recommendation was not addressed.",2016-03-01
8345,COOK SENIOR LIVING CENTER,115655,706 NORTH PARRISH AVE .,ADEL,GA,31620,2012-02-23,431,D,0,1,028H11,"Based on observation, record review and staff interview, it was determined that the facility failed to properly store controlled medications in a separately locked compartment on one (North) of two halls. Findings include: Review of the facility's Policy and Procedure for Controlled Medications revealed that controlled drugs were to be placed in the locked controlled drug cabinet in the medication rooms. However, nursing staff failed to secure a controlled drug in the North Hall medication room. During an observation of the North Hall medication storage room on 2/23/12 at 12:00 p.m., there was a bubble pack of 30 tablets of Vicodin 5/500 milligrams in an unlocked cabinet. There was a sheet of paper wrapped around the pack with the resident's name, a date of 2/22/12 and a note on it that 30 tablets remained. Licensed nurse AA stated at that time that the medication should not have been stored in an unlocked cabinet. The nurse immediately placed the medication in a separate locked box that was affixed to the wall. AA stated that when a controlled substance had been discontinued, the medication and the count sheet was supposed to be taken to the nursing supervisor.",2016-03-01
9631,PRUITTHEALTH - AUGUSTA HILLS,115672,2122 CUMMING ROAD,AUGUSTA,GA,30904,2012-02-23,282,D,0,1,QKQT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow the comprehensive care plan for one (1) resident (#29) with a Port-A-Cath on a sample of forty-one (41) residents. Findings include: Review of the Comprehensive Care Plan for resident #29 revealed a care plan had been developed on 8/11/2011 to address the resident's Port-A-Cath. An intervention on the care plan indicated the resident would have the Port-A-Cath flushed as ordered. Review of the physician's orders [REDACTED]. Further review of the Medication Administration Record [REDACTED]. 1/2012 and 2/2012 revealed no evidence the catheter had been flushed as ordered. During an interview on 2/23/12 at 1:30 p.m., Registered Nurse (RN) ""BB"" stated she could find no evidence the port had been flushed as ordered. She stated the facility requested the port be flushed when the resident went out of the facility to the hospital, however no evidence could be found to indicate the Port-A-Cath had been flushed since the resident's admission to the facility on [DATE]. She further stated there was no one in the facility that was competent to flush the Port-A-Cath. She stated if there was a need to flush the port, they would bring in a staff member employed by the corporation to flush the port. However, there was no evidence this had been done.",2015-06-01
9632,PRUITTHEALTH - AUGUSTA HILLS,115672,2122 CUMMING ROAD,AUGUSTA,GA,30904,2012-02-23,309,D,0,1,QKQT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that physician orders [REDACTED].# 162) and to maintain patency of a Port-A-Cath for one (1) resident (#29) on a sample of forty-one (41) residents. Findings include: 1. Review of the medical record for resident # 162 revealed that the resident was admitted on [DATE] from the hospital with [DIAGNOSES REDACTED]. He received on [MEDICAL TREATMENT] three (3) times a week. Review of the Physician order [REDACTED]. The parameters were to check the blood pressure and to give: -[MEDICATION NAME] 0.3 milligrams by gastrostomy tube at 6:00 a.m., 2:00 p.m. and 10:00 p.m. if the blood pressure was above 110/60 -The [MEDICATION NAME] 10 milligrams was to be given at 6:00 a.m. -The [MEDICATION NAME] 20 milligrams at 9:00 a.m. and 9:00 p.m. if the blood pressure was above 110 over 60. Review of the MAR indicated [REDACTED]. Interview with Licensed Practical Nurse (LPN)""DD"" on 2/22/12 at 2:55 p.m. they were not taking the resident's blood pressure prior to administering the blood pressure medications. 2. Review of the physician orders [REDACTED]. During an interview on 2/23/12 at 1:30 p.m., Registered Nurse (RN) ""BB"" stated she could find no evidence the port had been flushed as ordered. She stated the facility staff had requested the port be flushed whenever the resident went out of the facility to the hospital, however no evidence could be found to indicate the Port-A-Cath had been flushed since the resident's admission to the facility on [DATE]. She further stated there was no one in the facility that was competent to flush the Port-A-Cath. She stated if there was a need to flush the port, they would bring in a staff member employed by the corporation to flush the port. However, there was no evidence this had been done.",2015-06-01
9633,PRUITTHEALTH - AUGUSTA HILLS,115672,2122 CUMMING ROAD,AUGUSTA,GA,30904,2012-02-23,371,F,0,1,QKQT11,"Based on observation and staff interview the facility failed to ensure that the temperature of foods served to residents was held at or above the level necessary to prevent potential foodborne illnesses. This affected all residents on oral alimentation (census = 105). Findings include: During a measurement of temperatures of food items held on the steamtable which were being served to residents at the lunch meal on 2/20/12 at 12:15 p.m., the following items were found to be below the minimum safe temperature level of one hundred and thirty-five degrees Fahrenheit (135 F): Pureed Country Fried Beef Steak at 133 degrees F Chopped Country Fried Beef Steak at 125 degrees F Baked Tilapia at 109 degrees F The above observation was made using the food service department's digital thermometer and was confirmed by the facility's Food Service Director.",2015-06-01
9634,PRUITTHEALTH - AUGUSTA HILLS,115672,2122 CUMMING ROAD,AUGUSTA,GA,30904,2012-02-23,441,E,0,1,QKQT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review and staff interview the facility failed to follow appropriate hand washing technique for four (4) residents (#4, #154, #161 and #166), appropriate cleaning of a Glucometer for two (2) residents (#162 and #163) and appropriate technique during a dressing change procedure for one (1) resident (#154) on a sample of forty-one (41) residents. Findings include: 1. During observation of the dining experience on the B hall on 2/20/12 at 12:15 p.m. Certified Nursing Assistant (CNA) ""AA"" was observed passing trays to the resident's in their rooms. CNA ""AA"" was observed entering the room of resident #4. The CNA set up the resident's tray on his over-bed table. He did not wash his hands before or after setting up the resident's tray. In addition the resident was on contact isolation and the CNA did not wear a gloves while in the resident's room. The CNA then entered the room of resident #166. He proceeded to adjust the resident's oxygen canula in her nose and pulled the resident up in the bed. He then set-up the resident's lunch tray. He did not wash his hands before or after assisting the resident or before he set up the resident's tray. The CNA then entered the room of resident #154. This resident was also on contact isolation for a Entailing Resistant Staphylococcus Aureus (MRSA) infection. The CNA did not wash his hands before he set up the resident's tray or before leaving the room. In addition he did not wear gloves while in the room. The CNA then proceeded to enter the room of resident #161. He set up the tray for the resident and proceeded to feed the resident. He did not wash his hands before setting up the tray and before or after feeding the resident. During and interview on 2/23/11 at 11:30 a.m. Registered Nurse ""BB"" stated the expectation would be that the CNA should wash his/her hands before and after resident contact. She further states if the resident was in isolation, the CNA should have applied gloves before entering the residents room and washed his hands after removing the gloves. Review of the facility's Handwashing Policy revealed that hands should be washed before and after each resident contact and after touching a resident or handling his/her belongings. Review of the facility policy for Contact Precautions indicate gloves should be worn when entering the room and while providing care for a resident. Further review indicated the gloves should be removed before leaving the resident's room and hands should be washed immediately. 2. During medication pass on 2/21/12 at 4:30 p.m. Licensed Practical Nurse (LPN) ""FF"" was observed to carry a plastic box containing the glucometer, lancets and alcohol wipes into a resident's room and set it on bedside table next to an empty urinal. She laid the glucometer on the bed of resident #163 while she was preparing to check his blood glucose. After she completed the fingerstick blood glucose she cleaned the glucometer with an alcohol wipe, placed the glucometer back in the plastic box and carried it out to the medication cart. The nurse was observed to clean the glucometer with an alcohol wipe, place into the plastic box and take it into a second resident's room and place it on the bedside table. She completed the fingerstick blood glucose test for resident # 162, cleaned the glucometer with an alcohol wipe and returned the meter to the medication cart. LPN ""FF"" was observed to carry the plastic box into two rooms, check two fingerstick blood glucose levels, return the plastic box to her medication cart and never placed the items on a clean field or sanitized the glucometer between residents. Interview with LPN ""FF"" at that time revealed she always cleaned the meter with an alcohol wipe. She stated that they have bleach wipes but were out of them on her cart. On 2/22/12 at 11:30 a.m. LPN ""DD"" was observed to clean the glucometer with alcohol and a bleach wipe before taking the glucometer into a resident's room. She placed the meter on the resident's bed while she checked the blood glucose level. Interview with LPN ""DD"" at that time revealed that she was instructed on proper cleaning of the glucometer by the Director of Nurses (DON) but it had been awhile. She stated she had placed paper work regarding cleaning the glucometer in front of the Medication Administration Record (MAR) book for Unit III but someone had removed it. Review of the facility policy for cleaning and disinfecting glucometers revealed that staff are to wash hands, put on clean gloves and clean the outside of the glucometer with [MEDICATION NAME] alcohol wipe and then sanitize the meter with a bleach solution wipe and allow to dry. 3. Record review of the MDS PPS 14 day assessment documented that resident #154 was admitted to the facility with multiple pressure sores (stageable and unstagable) as well as surgical wounds. In addition the resident was identified to have MARSA (infection) in the wounds and was on contact isolation. Observation on 2/23/12 at 10:18 am of wound/ulcer care provided by Licensed Practical Nurse (LPN) ""CC"" revealed a work area was established, hand washing, gloves and isolation gown were applied appropriately. LPN ""CC"" removed a pillow from the seat of a chair in resident's room. She used the pillow to elevate the resident's left leg, the dressing was removed from the lateral side of the leg and a green-gray, slight to moderate drainage was observed with 99% slough present across the surface of the wound. This wound/ulcer area measured approximated 5X7 cm in size. Due to the location of this uncovered wound it was observed to rest directly onto the pillow and the weight of the leg depressed the pillow until the wound was no longer visible. LPN ""CC"" proceeded to clean the multiple open wounds/ulcers on the knee and leg until at 11:00 a.m. when the resident complained of discomfort. Wound care was stopped, the leg was loosely wrapped with gauze and medication for pain was administered. After 40 minutes, wound care was resumed and LPN ""CC"" was observed to remove the gauze dressings from the left leg and the open uncovered wound on the lateral side of the leg was rested onto the same pillow. Again, the open area was observed to no longer be visible as the sides of the pillow covered the open wound/ulcer. Interview with LPN ""CC"" at that time, revealed this was her normal practice to use a pillow to elevate the leg and it had not occurred to her to use a clean barrier between the surface of the pillow and the open wound. She agreed the open wound rested directly onto the pillow and there was no way to know if the pillow was clean or what it had been used for prior to the wound care.",2015-06-01
9635,PRUITTHEALTH - AUGUSTA HILLS,115672,2122 CUMMING ROAD,AUGUSTA,GA,30904,2012-02-23,456,C,0,1,QKQT11,Based on observation and staff interview the facility failed to maintain the environment of the food preparation area in a safe and orderly condition. Findings include: During the initial tour of the facility's kitchen on 2/20/12 at 12:10 p.m. an observation revealed that a section of the baseboard by the exit to the main dining room had missing tiles which exposed the inner structure of the wall. It was also noted that the bottom part of the outer wall in the dishwashing area was severely deteriorated and was crumbling. This observation was confirmed at that time by the facility's Food Service Director.,2015-06-01