rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
4194,PRUITTHEALTH - SWAINSBORO,115533,856 HIGHWAY 1 SOUTH,SWAINSBORO,GA,30401,2015-10-15,166,D,0,1,3IL511,"Base on record review and interview, the facility failed to resolved a grievance related to one (1) resident B on a sample of twenty-three (23) residents. Findings Include: During an interview on 10/14/15 at 3:02 p.m. the family member of resident B stated that resident B was admitted to the facility on the 200 hall, and that initially resident B was unable to shower due to a recent stroke. After receiving therapy services, resident B was beginning to go to the shower. Shortly afterwards, stated resident B did not want to go to the shower anymore. The family member of resident B continued to state that he/she came to the facility to speak with the Social Worker (SW) to find out why resident B was refusing showers and to request a room change. During an interview on 10/15/15 at 8:00 a.m. the Social Worker (SW), they acknowledged that the family member of resident B came to the facility with concerns about resident B not wanting to take showers and requesting a room change. SW stated that the family member of resident B informed him/her last week of these issues. When asked to explain the process for family/resident concerns or complaints, SW stated that a concern or complaint is written on a grievance form. The Social worker stated a grievance form was not completed for the family member of resident B because the SW had told another staff but could not recall whom. Review of the Grievance Log entries from 03/15 through 10/14/15 revealed there were no documented entries in the Grievance Log for resident B. Review of the facility policy entitled Grievances: Healthcare Center Section Procedure: (4.) The Social Services Partner will be responsible for following up with the patient/resident, authorized individual or other representative to make sure that the grievance has been resolved or that they understand what actions have been take. And number (5.) The Grievance/Complaint should be completed within three business days.",2020-02-01
4195,PRUITTHEALTH - SWAINSBORO,115533,856 HIGHWAY 1 SOUTH,SWAINSBORO,GA,30401,2015-10-15,309,D,0,1,3IL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to take measures to prevent a fecal impaction and follow physician standing order for one (1) resident (#115) from a sample of twenty-three (23) residents. Findings Include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] revealed Section G Functional Status for Toilet Uses that resident #115 was independently toileting and need set up only. Section C Cognitive Patterns Summary Score noted 03 indicating significant impairment. Section [NAME] Behavior revealed no resistance of care. Section I listed [DIAGNOSES REDACTED]. Review of Nurse's Note and the Nursing Home to Hospital Transfer Form dated 08/24/15 revealed resident #115 was found on the floor and was sent to[NAME]Regional Medical Center with an admitting [DIAGNOSES REDACTED].#115 returned to the facility on [DATE]. The Minimum Data Set (MDS) 5 day assessment dated [DATE] revealed Section I Active Diagnosis, of a [MEDICAL CONDITIONS], Hypertension and [MEDICAL CONDITION]. Section G Functional Status for Toilet Uses was extensive assistance. Section [NAME] Behavior revealed no resistance of care. Review of the Nurse's Note and a Nursing Home to Hospital Transfer Form dated 09/14/15 revealed that resident #115 was noted to have rectal bleeding was sent the Hospital Emergency Department for evaluation. admitting [DIAGNOSES REDACTED]. The Nurse's notes dated 08/30/15 through 09/14/15 revealed that the resident was assessed as incontinent of bowel and bladder and total dependent on staff for toileting. There were four (4) documented Nurse's Note entries that the resident were administered narcotics to ease the pain of his/her [MEDICAL CONDITION]. The Certified Nursing Assistant (CNA) Care Interventions Record Signature Sheet Form dated (MONTH) (YEAR) revealed during the month of (MONTH) 28-31, (YEAR) there was no documented bowel movement and was there was missing data. September 2-4, (YEAR) there were no document of a bowel movement and there was missing data. (MONTH) 5-13, (YEAR) noted small to no bowel movement and missing data. There were no documentation or indication that the Certified Nurse Assistant (CNA) had informed the Charge Nurse that resident #115 had two episodes of a three day period without having a bowel movement. Further record review revealed that resident #115's physician's orders [REDACTED]. Nurse's Notes and the Medication Administration Record [REDACTED]. An interview on 10/15/15 at 5:43 p.m. with the Director of Nursing (DON) revealed that Certified Nursing Assistants (CNA) are to report to their Charge Nurse any resident that had not had a bowel movement within three days, and that the Charge Nurses are expected to follow up with appropriate interventions.",2020-02-01
4196,PRUITTHEALTH - SWAINSBORO,115533,856 HIGHWAY 1 SOUTH,SWAINSBORO,GA,30401,2015-10-15,406,D,0,1,3IL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide continuing mental health services for one (1) (#97) of one (1) sampled residents for Pre-Admission Screening/Resident Review (PASRR) from a total sample of twenty-three (23) residents. Findings include: Review of the the medical record for resident #97 revealed the following [DIAGNOSES REDACTED]. Review of the 07/28/14 Level II Pre-Admission Screening/Resident Review (PASRR) revealed that the resident was eligible to receive additional specialized specialized services and/or supports according to an individualized plan of care to treat the resident's serious mental illness. Review of the 06/29/15 Quarterly Minimum Data Set (MDS), and the 08/07/15 Annual MDS revealed the resident had not displayed any behaviors and had not received Psychological therapy in the past seven days. During interviews with the Director of Nursing, the Administrator and the Nurse Consultant on 10/15/15 at 3:50 p.m., they stated there was not a staff person who was responsible for reviewing the Level II PASRR reviews, that it was a team approach. However, the facility could not provide any documentation of where the team had reviewed this resident's Level II PASRR or discussed his/her recommended ongoing psychiatric care. They further stated the resident had not had any behaviors until (MONTH) (YEAR) when the resident started throwing him/herself from bed or the chair. After the resident was found on the floor on 09/01/15, the resident's physician gave an order to send the resident to the emergency room for psychiatric evaluation. The resident was admitted for inpatient psychiatric treatment and returned to the facility on [DATE]. When they were asked who was responsible for determining if this resident would receive the recommended services they all stated the physician. They then confirmed that the resident's primary care physician was not a psychiatrist. They stated if any resident needed continued psychiatric care that the resident would be sent to the local hospital for psychiatric service to be conducted through Telemed services. During an interview with the staff at that time, they refused to answer the surveyor's question of whether this resident had received the Telemed psychiatric service. As of 10/15/15 at 6:30 P.M., the facility could not provide any documentation of where resident #97 had received the recommended diagnostic/ongoing psychiatric care as recommended by Georgia PASRR evaluation since his/her admission to the facility.",2020-02-01
4270,EASTMAN HEALTHCARE & REHAB,115622,556 CHESTER HIGHWAY,EASTMAN,GA,31023,2015-10-15,159,E,0,1,528G11,"Based on record review, staff and resident interview, the facility failed to have resident's personal funds available on the weekends and holidays for four (4) (#36, #51, #72), and #32 of six (6) residents from a sample of thirty two (32) residents. Findings included: During an interview on 10/13/15 at 3:24 p.m., resident #36 stated he/she was not able to get any of his/her personal funds on the weekends when the business office was closed. During an interview on 10/14/15 at 10:34 a.m., resident #51 stated that he/she was not able to get any of his/her personal funds on the weekends when the business office was closed. During an interview on 10/14/15 at 8:33 a.m., resident #72 stated they were not able to get any of their personal funds on the weekends when the business office was closed. In addition, the resident complained that they had not been able to receive any of their personal funds this month. Also stated that they had made several attempts to receive their money but was told to come back each time. They stated they would go back this date to attempt to receive their funds. During a review of resident #72's personal funds account on 10/16/15 at 2:41 p.m., the Administrator confirmed the resident's funds were deposited on 10/2/15, however they did not had those funds available to them until 10/14/15. During an interview on 10/13/15 at 2:21 p.m., resident #32 stated they were not able to get any of their personal funds on the weekends when the business office was closed. During an interview with the Administrator on 10/16/15 at 2:41 p.m., the Administrator confirmed the resident funds are not available to the residents on weekends.",2020-01-01
4271,EASTMAN HEALTHCARE & REHAB,115622,556 CHESTER HIGHWAY,EASTMAN,GA,31023,2015-10-15,160,D,0,1,528G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to ensure that resident personal funds were disbursed within thirty (30) days of death for one (1) out of three (3) resident accounts reviewed. Findings include: Review of deceased resident personal funds accounts for the past six (6) months revealed the following. 1. Resident #51 had a date of death of [DATE], with an outstanding balance of $2642.16 . This was not disbursed until [DATE], sixty one (61) days after death. An interview on [DATE] at 3:16 p.m., the Business Office Coordinator confirmed the funds were not conveyed within thirty days after death.",2020-01-01
4272,EASTMAN HEALTHCARE & REHAB,115622,556 CHESTER HIGHWAY,EASTMAN,GA,31023,2015-10-15,253,E,0,1,528G11,"Based on observation and staff interview, the facility failed to provide effective housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior as evidenced by floors with missing finish, doors and walls with missing paint and finish; paint missing from beds; holes in walls, bedside tables and chest with missing finishes; bathroom floors with brown/black discoloration; stained privacy curtains; shower rooms with worn/discolored flooring and missing tile on the walls; discolored grout in shower room floors; and missing baseboards. This failure affected five (5) of five (5) hallways, twenty-four (24) of forty-eight (48) resident rooms, two (2) of two (2) shower rooms, and eleven (11) of twenty-eight (28) resident bathrooms. Findings include: 100 Hall: During observation of the 100 hall on 10/13/15 at 10:30 a.m. scuffed walls and baseboards were present and cracked flooring was observed. During observation of room 101 on 10/13/15 at 10:30 a.m. the door frame had missing paint, the door had the finish missing in areas and the chest had areas where the finish was missing . During observation of room 105 on 10/14/15 at 10:47 a.m. the door frames had missing paint, the finish was missing on the doors and the bedside table next to A bed had the finish missing on the top edges. During observation of room 107 on 10/13/15 at 10:30 a.m. the finish was missing on the door on the outside, the walls had missing paint next to B bed and the door frames and chest had missing paint. During further observation of room 107 on 10/13/15 at 1:53 p.m. the over bed table had missing paint on the base and the wall behind A bed had missing paint . During observations of Room 109 on 10/13/15 at 10:30 a.m. the chest was missing the finish, three (3) nails were protruding from the wall over the B bed and the built in dresser was missing paint . Further observation of Room 109 on 10/13/15 at 5:02 p.m. doors with the finish missing. During observation of room 110 on 10/13/15 at 2:10 p.m. the A bed over bed table had missing paint on the base and legs, the wall had missing paint behind A and B beds, five (5) holes were present in the wall behind A bed and the walls had scuffed marks. During observation of room 112 on 10/31/15 at 10:30 a.m. the door was missing the finish on the inside and outside, the door frames had missing paint, the walls had missing paint and five(5) nails were observed protruding from the wall. During observation of room 114 on 10/13/15 at 10:30 a.m. missing paint was present on the walls, ten (10) nails were observed over the B bed and the doors had the finish missing. 100 Hall Bathrooms: During observation of the 105/107 bathroom on 10/14/15 at 10:47 a.m. black discoloration was present on the floor near the floor edges. During observation of the 108 and 110 bathroom on 10/13/15 at 2:11 p.m. the finish was observed missing on the bathroom door on the inside and on the bathroom door frames. During observation of the 109 and 111 bathroom on 10/13/15 at 10:30 a.m. the inside of the door had missing finish on the trim, a hole in the wall was observed behind the sink and sheet rock was missing in an area above the sink. Further observation of the 109 and 111 bathroom on 10/13/15 at 4:58 p.m. the door frames had missing paint. During observation of the 112 and 114 bathroom on 10/13/15 at 10:30 a.m. the door frames were observed to have missing paint and the floor had black discoloration present. Further observation of the 112 and 114 bathroom on 10/13/15 at 3:34 p.m. the doors were observed to be scuffed. 200 Hall During observation of the 200 hall on 10/16/15 at 2:45 p.m. missing paint was present on the walls and door frames and the finish was missing from doors . During observation of room 217 on 10/16/15 at 2:45 p.m. a missing baseboard near the sink was observed and a hole in the wall under the sink was present. 200 Hall Shower/Bath 2 During observation of the 200 hall of the shower/bath 2 on 10/16/15 at 3:55 p.m. broken tile was observed on the walls. 300 Hall During observation of the 300 hall on 10/13/15 at 10:30 a.m. the finish was worn off the floor in the hall, missing paint on the walls and baseboards and black discoloration was observed on the doors. During observation of room 302 on 10/13/15 at 10:30 a.m. black scuffed marks on the outside of the door were observed, the A bed, bed side table was missing the finish, the walls near the A bed had black scuffed marks, the wall behind B bed had missing paint and the walls had brown discoloration present. Further observation on 10/14/15 at 11:31 a.m. room 302 revealed the B bed over bed table had missing vinyl trim. During observation of room 304 at 10/15/15 at 9:56 a.m. a large brown stain was observed in the ceiling approximately three (3) feet long in which some of the area had been painted over. During observation of room 306 at 10/13/15 at 10:30 a.m. the white covering on the outside of the door had black discoloration present, a chair had the finish missing and the door frame had missing paint. 300 Hall Bathrooms: During observation of the 302 and 304 bathroom on 10/13/15 at 10:30 a.m. the door had black marks present on inside of the door, missing finish on the inside of the door and the baseboards and walls had missing paint. During observation of the 306 and 308 bathroom on 10/14/15 at 8:48 a.m. the toilet seat had missing paint/finish in several areas. 400 Hall During observation of room 402 on 10/13/15 at 2:25 p.m. the footboard and headboard on Bed B had missing wood pieces, the vent over bed B had black buildup present, and B bed had brown discoloration present on the pillow case. During observation of room 403 on 10/14/15 at 10:45 a.m black scuff marks were observed on the walls and doors throughout the room and missing paint was observed on the beds. During observation of room 404 on 10/13/15 at 2:58 p.m. black scuff marks were present on the walls throughout the room, chipped, missing paint on the walls, closet doors, and the railing. B bed privacy curtain was stained and ripped one inch, and brown spots were present on the ceiling near the window. During observation of room 405 on 10/13/15 at 10:31 a.m. a hole in the wall was observed near the floor at head of bed B and missing paint was present on the the wall. During further observation of Room 405 on 10/14/15 at 8:46 a.m. the bedside table next to the A bed had the finish missing, the baseboards had black discoloration present and paint missing and the door frames had paint missing. During observation of room 406 on 10/14/15 at 4:00 p.m. the door was observed to have a black discoloration present, the baseboards had a brown/black discoloration present. During observation of room 408 on 10/14/15 at 11:43 a.m. the door frame was observed to have missing paint and the finish on the doors was missing. During observation of room 409 on 10/14/15 at 8:32 a.m. the door to the room was observed to have the finish missing on the inside and outside and the door frames were observed to have black discoloration present on the door leading to the bathroom. 400 Hall Bathrooms During observations of the 403 and 405 bathroom on 10/14/15 at 10:45 a.m. black scuff marks on walls and doors was observed, the doors had the finish missing, door frames had missing paint, black and brown discoloration observed on the baseboards and the tile on the floor and black/green discoloration present on the sink. During observation of the 406 and 408 bathroom on 10/13/15 at 10:41 a.m. scuff marks on base boards were observed, black scratches present in toilet, black /dark brown discoloration on floors beneath the baseboards, baseboards observed with dark brown/black discoloration, door frames missing paint and black scuff marks on floor throughout the bathroom. During observation of the 407 and 409 bathroom on 10/14/15 at 8:32 a.m. brown/black discoloration on floor, under baseboards was observed and black discoloration was present on inside of doors. 500 Hall During observation of room 503 on 10/13/15 at 10:41 a.m. a brown substance was present on the wall near the closet, black marks present on the vent near bed B, brown substances observed on privacy curtain for bed A and missing paint was observed behind bed [NAME] During observation of room 504 on 10/13/15 at 10:41 a.m. one loose brick was observed in the window sill and missing paint and scuff marks present on wall in room and on the door. Further observation of Room 504 on 10/13/15 at 11:14 a.m. the tile by the closet was discolored, rust on bed legs and black scuff marks present on the doors. During observation of room 505 on 10/13/15 at 3:27 p. m. black scuff marks were present on the doors. During observation of room 506 on 10/13/15 at 10:41 a.m. missing paint and scuff marks observed on the walls, black scuff marks present on the doors and the B bed privacy curtain has brown areas present. During observation of room 507 on 10/14/15 at 11:22 a.m. black scuff marks were observed on the doors, baseboards and walls, black substance present on vent in ceiling and chipped wood on bed footboard. During observation of room 508 on 10/14/15 at 9:32 a.m. missing paint was observed on the baseboards. 500 Hall Bathrooms During observation of the 502 and 504 bathroom on 10/13/15 at 10:41 a.m. black scuff marks on the walls and doors in bathroom was observed and discolored flooring was observed under the sink. During observation of the 506 and 508 bathroom on 10/13/15 at 10:41 a.m. broken tile in bathroom was present, and the sink was discolored with black and greenish discoloration present. Further observation of 506 and 508 bathroom on 10/14/15 at 9:32 a.m. revealed rust on the edge of the sink, discolored tiles and cracked tiles. 500 Shower/Bath During observation of the 500 Hall shower/bath on 10/13/15 at 12:52 p.m. the shower had brown/black discoloration in the tile grout and missing tile on the walls. During interview and tour with the Maintenance Director on 10/16/15 from 4:45 p.m. until 5:15 p.m. he/she confirmed the above observations. During interview with Admnistrator on 10/16/15 at 5:00 p.m. He revealed that there was not a plan in place except for some painting to be done in the facility.",2020-01-01
5856,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,151,D,1,0,7J0Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor resident choices related to use of personal wheelchair and personal choice of diet for one (1) resident (#30) of the forty-seven (47) sampled. Findings include: Interview with resident #30 on 6/26/2015 at 2:30 p.m. revealed that her personal wheelchair had been removed from her use. Resident #30 stated the facility took it away and they brought in a different one, but it was too big for the transport van. The resident stated that the wheels on the facility's wheelchair were too wide for the ramp used for transport. The resident stated that she had not asked anyone about the old chair. Interview on 6/26/15 at 6:00 p.m. with the Administrator revealed the wheelchair had been placed in storage and another wheelchair was given to the resident for use. The administrator stated that the personal wheelchair of resident #30 was too small to fit her. Resident #30 also states that she has [MEDICAL CONDITION] and is supposed to be on a low salt diet but the diet she gets tastes like it has salt. Record review of the physician orders [REDACTED].",2018-05-01
5857,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,225,J,1,0,7J0Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews, the facility failed to report misappropriation of property for three (3) residents (#32, #31, #33) (medications) and failed to report a fall with injury to the Department for one (1) resident (#35)with an injury affecting four (4) of the forty-seven (47) sampled residents. Finding include: 1. Interview on 8/26/15 at 2:26 p.m. with the Unit Manager - Faith 1 and Haven 1 revealed that there was an issue of narcotics missing. She revealed that there was an incident where a whole sheet of [MEDICATION NAME] which belonged to resident #32 was missing. As a result of the missing medication the nurses implemented a count of all narcotics. She revealed that the medications were for a resident that never asked for pain medication. Interview on 8/26/15 at 3:07 p.m. with the Unit Manager - Faith II and Haven II halls revealed that medication was missing around July 15, 2015, an audit was completed which revealed that [MEDICATION NAME] and the control count sheets was missing for resident #33 and resident #31. She revealed that the medication cart audits were completed on Sunday; and, by Wednesday the drugs sheets and medication were missing. She revealed that resident #33 did not use medications often. She revealed the Medical Director, Administrator, Director of Nursing and the Pharmacy were notified of missing medications. She revealed that a new count system was implemented to prevent further medication errors. The Unit Manager further revealed that an inservice was given to all nurses. She revealed that the residents never went without medication as the medication was refilled by the pharmacy. She revealed that the narcotics missing were for residents that were not alert and did not use, or ask for medication. Review of the Medication Error Report dated 7/13/15 for resident #33 revealed the following: Medication as ordered: [MEDICATION NAME] 5/325 milligram (mg) one (1) by mouth (po) every (q) six 6 hours (hrs). as needed (PRN); Description of error: Resident has PRN order for medication; but, the medication card and narcotic sheet are both missing from the medication cart, this was discovered on 7/12/15 during medication cart audit, and; Out come to resident: Resident denies pain and no signs or symptoms of pain or acute distress noted. Corrective action taken: Pharmacy notified and refill requested. Review of the Medication Error Report dated 7/13/15 for resident #31 revealed the following: Medication as ordered: [MEDICATION NAME] 7.5/325 mg one (1) tablet (tab) by mouth (po) every (q) six (6) hours (hrs.) as needed (PRN); Description of error: Resident #31 pain medication and narcotic count sheet was not on the medication cart. She revealed that the the medication had not been noted missing until 7-16-15, the medication was last noted on 7/12/15 during a cart audit; Outcome to resident: Resident has not voiced pain at this time and is not having any acute distress noted, and; Corrective action taken: Pharmacy notified and refill faxed. Per L, they will send a request for another prescription to physician and check to see if a request for another prescription to physician and check to see if resident has another refill under her current prescription. Review of a Medication Error Report dated 7/18/15 for resident #32 revealed the following: Medication as ordered: [MEDICATION NAME] 10 mg q PRN; Description of error: Medication not available for administration if needed; Out come to resident: no harm, resident #32 assessed and no signs or symptoms of pain voiced or noted, and; Corrective action taken: medication ordered/new drug count sheet implemented. Measures taken to prevent the recurrence of similar errors: new drug count sheets used every shift. Review of a memo dated 7/20/15 revealed effective immediately, Controlled Drug Record Sheet will be implemented immediately. Every nurse will count narcotics with the on-coming nurse and record the count on the Narcotic Sheet before surrendering the medication cart keys to the on-coming nurse. This process will be completed even at break and lunch time. Failure to comply with the process will result in disciplinary action and nurse will be held responsible if narcotics coming up missing. Review of the In-Service Log dated 7/20/15 indicated an inservice topic on the Narcotic Log Sheets. Review of statement written by LPN LL dated 7/20/15 indicated have been working on Faith One hall for the past three days from 7/16/15-7/18/15. On 7/18/2015 while checking the narcotics count against the narcotic sheet, she wrote in her tablet every narcotic sheet and the amount on the card. LPN LL counted on 7/18/15 at 7:00 a.m. with the on coming shift, count was correct. She revealed when she returned on 7/18/15 at 7:00 p.m. as she counted with 7:00 a.m. - 7:00 p.m. nurse the narcotic count was correct. I then pulled out my tablet and compared the narcotics card against the list of narcotics she had written down which revealed that an entire card of [MEDICATION NAME] 10 mg was missing from the cart along with the narcotics sheet from the narcotic book was missing. She revealed that she checked the pharmacy log book and that sheet was missing as well. She revealed that she then called the Director of Nursing (DON) and made her aware. Review of the Shipping Manifest (Schedules CII -CV) dated 7/6/15 indicated resident #32 was delivered [MEDICATION NAME] HCL 10 mg tablets -Qty-sixty (60). Review for resident #31 sheet dated 6/24/15 was delivered [MEDICATION NAME]-[MEDICATION NAME] 7.5-325-Qty- 60. Review of the Medication Reorder form dated 7/16/15 indicated an order for [REDACTED]. Review of the Medication Administration Controlled Substances policy indicated any discrepancy in a controlled substance medication count is reported to the DON immediately. It further indicates that if major discrepancies occurs or if there is apparent criminal activity, the DON notifies the Administrator, the consultant pharmacist and the pharmacy manager. A determination will be made by the administrator, the pharmacy manager, and the DON concerning other actions to be taken (e.g., notification of police or other enforcement agency).",2018-05-01
5858,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,226,K,1,0,7J0Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to thoroughly investigate and report resident to resident altercations for six (6) residents (R#3, R#23,R#40, R#42, R#44, and R#45) of seven (7) residents with resident to resident altercations, from a total sample of thirty-eight (38) residents. It was determined that the facilities non-compliance with one or more requirements of participation had caused or was likely to cause serious injury or harm to resident therefore on 12/10/15 at 3:20 p.m. the Corporate Director of Operations, Corporate Clinical Director of Clinical Services, and Administrator were notified that an Ongoing Immediate Jeopardy (IJ) caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents of the one-hundred twenty-three (123) residents that reside in the facility. The Ongoing IJ was determined to exist beginning on 9/05/2015 at 1:30 p.m. Findings include: 1) Review of the Admission Minimum Data Set (MDS) assessment for R #42 dated 9/24/15 revealed a Brief Interview for Mental Status (BIMS) summary score of thirteen (13) which indicated the resident was cognitively intact. Review of the resident's incident report dated 11/12/15 at 11:00 a.m. revealed the resident's roommate R #40 was yelling out repeatedly, when resident R #42 came near resident R #40's bed. R #40 kicked and struck R #42 in the left eye. An assessment of R #42 ' s left eye revealed slight redness. Review of R #42's Initial Social Service history 9/14/15 revealed the resident had a history of [REDACTED]. Review of the Quarterly MDS assessment for R #40 dated 7/31/15 revealed a BIMS summary score of eleven (11) indicating moderate impairment. Further review of the MDS revealed behaviors directed toward others as occurred one (1) to three (3) days out of seven (7) days assessed. Review of resident #40 ' s monthly nursing summaries dated 11/18/15 and 12/3/15 revealed the resident was easily upset and hostile frequently. Review of the facility incident report for residents R #40 and R #42 revealed the incident occurred on 11/12/15 at 11:00 a.m. and was faxed to the state according to facsimile on 11/13/15 at 4:47 p.m. Per the Abuse Prevention Policy and Procedure any allegation of abuse is reported immediately to the state agency as required per state and federal guidelines. Per the facility policy, immediately means as soon as possible, but should not exceed twenty four (24) hours after the discovery of the incident. Interview conducted on 12/10/15 at 4:30 p.m. with the Director of Nursing (DON) revealed he/she had never seen the facility Abuse Prevention Policy and Procedure. Further interview on 12/11/15 at 7:45 a.m. and review of the Abuse Prevention Policy and Procedure with the DON revealed the policy was not followed as below: Resident interviews were not completed on the date or on the shift the incident occurred, a signature was not entered by the nursing supervisor, employee witness statements were not completed on the shift the incident occurred, there was no evidence of employee/witness investigation forms , the DON was not notified of the incident on the date it occurred , R #40's physician was not notified of the incident that occurred on 11/12/15 and nursing did not document on R #40 and R #42's physical and emotional status every shift for seventy two (72) hours following the incident . During further interview the DON confirmed the facility failed to follow the facility policy for Abuse Prevention. Love, Angela Review of the facility's Abuse Prevention Policy and Procedures revealed the following: On Reporting: All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, so that the residents needs can be attended to immediately and investigation can be undertaken promptly. On Nursing Staff Duties: An incident of abuse must be reported to the charge nurse who will examine the resident document findings in the clinical records and immediately initiate the Investigation protocol. The administrative or nursing supervisor assumes responsibility for immediate notification of the Administrator and the Director of Nursing (DON), by phone if necessary, and also notifies the appropriate department head. Nursing is to document on the resident's physical and emotional status every shift for seventy-two (72) hours following the incident. Facility Social Worker duties: provide counseling and support to the resident and possibly the family involved. The counseling is to be provided as long as necessary. The psychosocial intervention is to be documented in the resident's clinical record. The policy further revealed that an immediate investigation into the alleged incidence, on the shift it occurred will be initiated. Investigation includes: Completion of the Resident Incident Report form at time of the incident/event. Follow-up and investigation results are completed per policy time zone and by appropriate personnel. Interview the resident or other resident witnesses (e.g. roommate, if appropriate). The interview is to be dated, documented and signed by the nursing supervisor. Interview all staff on that unit as well as other staff or other available witnesses. Witnesses are to document their knowledge of the incident in a written narrative, signed and dated, on the Employee/Witness Investigation Statement form. Facility Investigation included: The Executive Director, or his/her designee, will ensure that the investigation is completed within forty-eight (48) to Seventy-two (72) hours. If the facility is unable to adequately complete the investigation within seventy-two (72) hours, Incident/Event Committee Intervention must be contacted to approve a time extension for completing the investigation. Response included: The Executive Director, Director of nursing (DON) or their designee assumes responsibility for notification of the incident and investigation findings as well as follow-up. Immediate Response included: An incident report is to be completed, to include the written summary of the investigation and facility actions taken, for Quality Assurance (QA) review and litigation analysis. 2) Review of Resident to Resident altercation between R #3 and R #23, State Reported Incident #GA 789, with Resident Incident Reports dated on 09/05/2015 at 1:30 p.m. revealed that Certified nursing assistant (CNA) VV called for help after observing R#23 positioned on his hands and knees beside the doorway of room four (4). The investigation revealed the incident occurred when R#23 went into the room of R#3 (4A) and laid down on the bed of R#3. R#3 revealed he/she pushed R #23 off the bed and onto the floor. According to the report, R #23 landed on his/her knees in the entrance to room [ROOM NUMBER]A sustaining a skin tear to his right posterior forearm with bleeding noted, a skin tear to his left nostril and abrasions to his right posterior hand (no bleeding noted). R #23's statement revealed he was sorry. R #3 was advised by Licensed Practical Nurse (LPN), FF (who completed the report) to call for assistance when another resident was in his bed. Resident #3 indicated he would. Further review of the incident report revealed although the incident had occurred on 09/05/2015 it was not reported to the state until 09/07/2015, forty-eight (48) hours later and not within the twenty-four (24) hours required by the federal regulations. The final report was sent to the state on 09/11/2015, not within the five days specified by the Federal Regulations or within the forty-eight (48) to seventy-two (72) hours specified by the facility's policy. The completed investigation did not contain information on the Resident Incident Follow-up Report for R #23 or the Incident/Event Committee Intervention recommendations/corrective actions taken form completed in its entirety for either R #23 or R #3. 3) Review of Resident to Resident altercation between R #23 and R #45, State Reported Incident #GA 729, with Resident Incident Reports dated at 10:04/2015 at 10:00 a.m. revealed CNA YY was walking down the hallway and heard R#45 yelling at R#23 to get out of his room. R#23 was observed lying in bed A with R#45 (from bed B) striking R#23 above the left eyebrow with a closed fist. CNA YY intervened and called for a nurse. R #23 was noted with red and light purple discolorations above the left eyebrow. R #23 was assisted back to his bedroom. Further review of the incident report from on 10/04/2015 revealed the completed investigation did not contain information on the Resident Incident Follow-up Report for R #23 and R #45 and that the Incident/Event Committee Intervention recommendations/corrective actions taken was not completed in its entirety for either R #23 or R #45. 4) Review of Resident to Resident altercation between R #3 and R #23, State Reported Incident #GA 000, with resident incident reports dated 10/12/2015 at 6:00 p.m. revealed R#23 ambulated into the room of R#3 (room [ROOM NUMBER]) and the residents began yelling and arguing. Then R#3 began slapping and hitting R#23. R#23 sustained multiple skin tears to his left arm, left hand and to his neck. R#23 was confused and unable to give a description of the event. R#3 revealed he was upset because R#23 kept coming into his room and he did not want him coming into his room. The residents were separated. Further review of the completed investigation for the incident report from 10/12/2015 revealed the Employee Investigation Interview Form was only done by the nurse who completed the incident report. The report did not include witness interviews by the other staff on the unit (Faith II) where the incident occurred for either R #3 or R #23. The completed investigation also did not contain information on the Resident Incident Follow-up Report for R #3 or R# 23, and the Incident/Event Committee Intervention recommendations/corrective actions taken form was not completed in its entirety for either R #3 or R #23. 5) Review of Resident to Resident altercation between R # 23 and R # 44, State Reported on December 04, 2015 (with no Incident Number assigned at this time) with resident incident reports dated 11/30/2015 at 2:00 p.m. revealed resident #23 ambulated into the room of R#44 (room [ROOM NUMBER] B) who became agitated and punched R#23 in the chest. Then at 5:00 p.m. resident #23 went into the room of R#44 (room B) and the residents began fighting. Resident #23 sustained multiple skin tears and bruises to his bilateral, face neck and head. R#23 was confused and unable to give a description of the events. R#45 revealed he hit R#23 because he came into his room. The residents were separated and resident #23 was sent to the emergency room for evaluation. Further review of the completed investigation for the incident dated 11/30 15 at 2:00 p.m. revealed no completed Employee Investigation Interview Forms for either R #23 or R #44. The completed investigation report also did not contain information on the Resident Incident Follow-up Report for either R# 23 or R #44, and the Incident/Event Committee Intervention recommendations/corrective actions taken form was not completed in its entirety for either R #23 or R #44. 6) Review of Resident to Resident altercation between R #3 and R #23, State Reported Incident #GA 304, had a Facility Incident Report Form dated 11/30/2015 at 5:15 p.m.that revealed R#23 went into the room of R#3's (room [ROOM NUMBER]A) and got into the bed of R#3. R#3 became agitated and began hitting R#23. R#23 sustained multiple skin tears as well as a hematoma to the right forehead. R#23 was sent to the emergency room for evaluation. Further review of the investigation report for the incident dated 11/30/2015 at 5:15 p.m. revealed the initial report and the Summary for Completion of the incident report had been sent to the State Agency in a timely manner, however, no documentation regarding the investigation of the incident for either R#3 or R#23 was provided. Interview on 12/09/2015 at 6:50 p.m. with LPN FF (charge nurse) revealed that if a resident to resident altercation occurred it was the charge nurses responsibility to call the Administrator, Director of Nursing (DON), Unit manager and physician. The unit manager would also fill out an incident report and a Situation Background Assessment Report (SBAR). For the incident report, everyone present on the unit where the incident occurred had to fill out a witness investigation form. Copies of the witness investigation form were kept at the nurses' station. When the charge nurse's part was completed the incident report would go in the Unit Manager's box at the nurses' station and the SBAR would go in the chart. Interview 12/10/2015 at 12:40 p.m. with LPN ZZ revealed that if an incident occurred he/ she would fill out the incident report packet which included an incident report, skin assessment and neurological (neuro) checks if needed. The LPN would notify the DON as well as the physician and family for both residents. The investigation included statements of anyone who or had a part in the incident. Follow-up documentation included documentation in both resident's charts every shift for seventy-two (72) hours. Interview on 12/11/2015 at 7:45 a.m. with LPN GG revealed if an incident occurred he/ she would complete an incident report and an SBAR on all residents involved. The incident report included witness statements of everyone on the unit where the incident occurred whether they observed anything or not. LPN, GG further revealed he/she would complete neuro checks if needed. Interview on 12/11/2015 at 10:40 a.m. with LPN HH revealed if an incident occurred he/ she would complete an incident report including vital signs, neuro checks if needed, witness statements from all staff on the unit where the incident occurred, whether they saw anything or not and resident statements if they are able to tell what happened. LPN HH further revealed the staff are to put interventions in place to keep it from happening again. Follow-up included charting every shift for five (5) days. LPN HH revealed he/she would also put it on the twenty-four (24) hour report. Interview on 12/11/2015 at 10:55 a.m. with the DON, Assistant Director of Nursing (ADON)and both Minimum Data Set (MDS) Coordinators revealed they were not sure who was responsible for completing the follow-up portion of the investigation report but thought there had been an incident report committee that reviewed them. They further revealed incidents were reviewed weekly during the Patient at Risk (PAR) meetings at which time the chart would be brought to the meeting but the incident reports themselves were not always reviewed. The DON then added that approximately three (3) weeks ago it was implemented that the Unit Managers would do the follow-up on the incident reports.",2018-05-01
5859,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,242,J,1,0,7J0Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interviews, the facility failed to ensure that residents rights/choices of allowed visitors was honored for one (1) resident (#14) from a sample of thirty-eight (38)residents. This failure resulted in psychological harm when R #14 said I don't want the identified family member here. The identified family member had been abusing me and I'm scared of them. It was determined that the facilities non-compliance with one or more requirements of participation had caused or was likely to cause serious injury or harm to resident therefore on 12/10/15 at 3:20 p.m. the Corporate Director of Operations, Corporate Clinical Director of Clinical Services, and Administrator were notified that an Ongoing Immediate Jeopardy (IJ) caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents of the one-hundred twenty-three (123) residents that reside in the facility. The Ongoing IJ was determined to exist beginning on 9/05/2015 at 1:30 p.m. Findings include: Review of the following: Police Report dated 10/14/15 indicated Incident Type: Terroristic Threats. Incident date of 10/04/15 at 5:00 p.m. Incident Day: Sunday. Police report indicated: On Wednesday October 14, 2015 at 12:03 p.m., officer responded to facility in reference to terroristic threats. Upon arrival the officer met with the Director of Nursing (DON) who stated that R #14 told the Social worker that an identified family member threatened to get rid of him on Sunday, October 4, 2015. The DON stated that he/ she was told by the on duty nurse that worked on October 4, 2015 that the identified family member had not come to visit the on that day. The officer spoke to R#14 and he/she stated the the identified family member came to visit on October 4, 2015 and threatened to kill him/her. Resident #14 stated that the family member told him they were going to shoot him. Resident #14 stated that he/she had no witnesses to the threats that were made and stated that he/she does not want that family member around him/her and will try to obtain a restraining order. Review of the Face Sheet dated October 13, 2015 indicated R #14 was initially admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The face Sheet listed the identified family member as a contact person. Review of a Social Service Evaluation dated 07/15/15 indicated physical/functional status as Independent. The portion of the document for Family relationships/Support Systems was blank. Psychosocial Well-Being/Cognitive/Mental Status portion indicated R #14 as friendly towards others and able to make needs known. Review of the Care Plan for R #14 (having no date) indicated R #14 had episodes of making false accusations concerning the identified family member hitting him and wants no contact with the identified family member or the family to have any information. Staff Interventions listed: Educate resident on inappropriate behaviors and positive ways to express feelings and to communicate needs and re-direct resident as needed. Review of the Care Plan revealed there was no further documentation listed on the Care Plan regarding staff interventions, or how to protect R #14 if the family member came to the facility and did not address the resident's request to not have the family member visit. Review of Nurse's Notes dated 10/08/15 at 6:00 p.m. the following was documented. Writer talked with a friend of the resident on phone who preciously requested to visit resident and said she could visit. The resident's friend understood resident ' s family member was not to visit. Writer was walking into hall and noticed two (2) older white women exiting resident's room. Writer immediately checked on resident whom stated he/she was afraid and did not ever want to see the family member again. Writer tried to find visitors but they had already left the building. Review of the Nurse ' s Notes revealed no further evidence of documentation as to what occurred next. Interview on 12/07/15 at 2:25 p.m. with the Social Services Director (SSD) stated that R #14 did not want us (the facility) to have any contact with the identified family member. The SSD stated the family member was aware that R #14 made the allegations against them, police were called, and the last Administrator was aware of the situation. The SSD further stated that when this occurred, the family member was upset because they want to see R#14, but R#14 did not want them to visit. The SSD stated the system in place to protect R #14 is that everybody knows the identified family member is not supposed to have contact with the resident and the family member is not allowed in the facility because of the allegations of abuse; and if they were to show up, they would be asked to leave. The SSD further revealed that the resident could have supervised visits with the family member because he/she does not want them here. Interview on 12/07/15 at 2:50 p.m. Licensed Practical Nurse (LPN) PP stated that R #14 did not want the identified family member to visit him. LPN PP further revealed about a month and a half ago the identified family member of the resident showed up to the facility unannounced in the evening and the resident said that he/she did not want them here. LPN PP further explained that he/ she saw the family member of R #14 coming out of the room with another person. LPN PP stated R #14 was afraid and said he/she did not want to see them again. LPN PP stated she reported to the Director of Nursing (DON) who stated he/ she would take care of it. LPN PP stated this occurred on October 8, 2015 when the family member came to the facility unannounced. LPN PP stated if the identified family member came in, they would be asked to step out and he/she would have to ask R #14 if he/she wanted a supervised visit or not. LPN PP revealed no knowledge of a system in place by the facility to protect R #14 or prevent the identified family member from coming to the facility. Observation and interview on 12/08/15 at 8:45 a.m. with R #14, revealed he was ambulatory, alert and oriented. He was observed to be conversing with staff and other residents. R #14 stated they make their own decisions regarding their healthcare and everything. R #14 statedhe/she did not want the identified family member here. The identified family member had been abusing him/her, they continue doing that, and h/she was scared of them. He/she told the facility many times that he/she did not want them to come here and someone kept letting them in. He/she talked with the Social Worker and talked with the Police. He/She asked the Social Worker about a restraining order.He/sheI had no way to go to the courts to get a restraining order. He/she had asked the Social Worker, and no-one will help him/her so he/she did not know what to do. R #14 proceeded to say the last time his/her identified family member was in the facility was last Sunday. They came before supper and came alone. His understanding was that if they were to come here, someone had to come with them. He/she told everyone here and he/she wanted them out of here. He/she is their own guardian and makes his/her own medical and healthcare decisions. He/she stated they were scared. Interview on 12/08/15 at 1:30 p.m. the Administrator stated that she was not aware of a police report regarding R #14. The Administrator stated R#14 requested that the identified family member was not to see him and the fascility had honored his/her wishes. When the family member came they were told at the request of R #14 that they were not to come back to the facility to see him. The facility staff are all aware of that. The Administrator had no knowledge related to the restraining order he/she was requesting. Interview conducted on 12/08/15 at 2:05 p.m. with the Director of Nursing (DON) revealed the allegation that was made by R #14 in October stated the family member came to the facility and threatened to take him/her out. When the officer was called, R #14 reported the identified family member threatened him/her with a gun The DON further revealed that Social Services never mentioned anything about a gun. The DON further revealed the staff know the family member is not supposed to see the resident . He/she further revealed that last week the family member came to the facility to drop off paperwork and wanted to see him/her but it was the facility's understanding that he/she still had the right not to see them if the resident did not want to. The DON revealed this has been ongoing and further revealed that the Police gave him/her all the information and the resident was supposed to call. The DON further revealed he/she thinks the police gave R #14 information on how to file a restraining order but he/she did not. The DON further revealedhe/she does not have a documented action plan in place but the plan has been communicated by word of mouth. The DON further revealed the receptionist (s) and the staff were aware the identified family member is not permitted to come to the facility on the weekends . The DON further revealed he/she did not get the police report only a case number. Interview conducted on 12/09/15 at 7:15 a.m. with the Social Service Director (SSD) revealed he/she did not recall that obtaining a restraining order ever being brought to their attention. The SSD further revealed R #14 would have been assisted if he/she had asked or if it had been brought to his/her attention by any of the Department Heads or in the standup meetings. Interview conducted on 12/10/15 at 12:30 p.m. with the SSD revealed the staff know that the identified family member is not allowed to visit with R #14 . The SSD revealed everyone knows they cannot come into the facility or call him/her. The SSD further revealed there were no documented plans in place if the identified family member showed up in the evenings, off hours or on weekends. The SSD further revealed that the staff know that the identified family member is not to have any involvement with R #14 and to her knowledge, the family members came only to drop off paperwork. The SSD revealed he/she told the resident that he/she could come to her if he/she wanted a restraining order. R #14 said he thought he had to go through the court system.",2018-05-01
5860,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,248,E,1,0,7J0Y12,"Based on observation, interview and record review the facility failed to provide an ongoing meaningful program of meaningful activities to meet the interests, physical, mental and psychosocial well-being of the residents on the secure unit (Faith Two). This failure affected nineteen (19) residents (#1, # 4, #5,#23, #24, #44, #47, #48, #49, #50, #51, #52,#53, #54, #55, #56, #57, #58, #59) that remain in the secured unit to attend activities of the twenty-nine (29) residents who reside on the secured unit. Findings include: Review of the daily census provided on 12/07/2015 revealed twenty-nine (29) residents reside on the secured unit (Faith II). Observation on 12/07/2015 at 9:55 a.m. of activity calendar revealed exercise activity being offered. Observation on the secured unit revealed eleven (11) random residents in the day room/dining room with the television (TV) on. Staff members present were sitting with the residents. Other residents were moving about in the hallway and in their rooms. Observation revealed no other activity being offered on the secured unit at that time. Observation on 12/07/2015 at 11:00 a.m. of the activity calendar revealed crossword puzzles activity. Revealed random residents in dining room with TV on and two staff members present sitting with the residents. Observation revealed no other activity being offered on the secured unit at that time. Observation on 12/07/2015 at 11:45 a.m. of a random female resident attempting to push another random sampled female resident, in the wheelchair, who was objecting loudly. Staff intervened to disengage resident from pushing the wheelchair and the resident continued walking in the hallway but did not re-approach the wheelchair. No other activity was offered to the either resident. Observation on 12/07/2015 at 12:00 p.m. of a random sampled resident in the hallway who had a firm grip on the doors at the entrance to the unit. Staff attempting to disengage resident from the doors but the resident was not easily redirected. Two other staff members were able to get resident to let go of the door. One of those staff members walked up the hall with the resident. Observation on 12/08/2015 at 8:55 a.m. of random sampled residents who were up in the dining room for an activity of watching a movie. Staff were present sitting with the residents. One resident was agitated and yelling out occasionally with staff redirecting the resident. Interview on 12/08/2015 at 10:40 a.m. with Certified Nursing Assistant (CNA) EE revealed the staff tried to keep the residents occupied with activities such as movies, singing, playing games and throwing balls on the unit. The CNA revealed that the residents that were not wanderers would go off the unit for activities. The residents that could not go off the unit to attend activities stayed on the unit. The CNA went on to reveal there were two activity directors. The activity directors brought snacks to the unit. The staff on the unit tried to keep the wanderers occupied and monitor their movement on the unit to keep them out of other resident's rooms and belongings. Residents were removed from other rooms as needed. Observation 12/08/2015 at 11:30 a.m. revealed residents in the day room/dining room on the unit with music on and staff present. Observation on 12/08/2015 at 1:30 p.m. revealed random sampled residents in the day room/dining room with TV on and staff present sitting with the residents. One random observed CNA was ambulating in hallway with two residents. Observation on 12/08/2015 at 1:30 p.m. of the Activity Calendar on the unit revealed (on large board on wall across from the nurses station): On December at 7th at 9:30 a.m. GW News, 10:00 a.m. exercise, 11:00 a.m. Crossword Puzzles, 2:00 p.m. One to One activity room visits, 2:45 p.m. snack cart, 4:00 p.m. playing cards, On December 8th at 9:30 a.m. GW news, 10:00 a.m. Exercise, 11:00 a.m. Arts and Crafts, 2:00 p.m. Shopping List,6:00 p.m. Gentlemen's Hour Interview on 12/08/2015 at 1:35 p.m. with the Care Now Licensed Clinical Social Worker (LCSW) revealed she made recommendations to the staff regarding activities residents might benefit doing, including R #3, from sensory stimulation such as movies to sing-a-longs. Interview on 12/08/2015 at 1:55 p.m. with CNA VV regarding activities on the unit revealed the residents who were able to went off the unit for activities in the main part of the facility. The other residents on the unit would watch TV or listen to music. The CNA further revealed she was not aware of any staff coming onto the unit to do activities with the residents. The CNA also denied having supplies for activities on the unit such as balls, balloons or coloring pages. Observation on 12/08/2015 at 2:15 p.m. of an activity in main dining room off the unit revealed a group singing (activity not listed on activity calendar). Residents from the secured unit were being asked regarding attending the activity and being escorted to the activity. Random sampled residents were observed to remain on the secured unit in the day/dining room with the TV on. Residents were also observed in their rooms and ambulating in the halls. Observation revealed no other activities being offered on the secured unit at that time. Interview on 12/08/2015 at 2:15 p.m. with the Activity Director (AD) revealed she had been employed as the AD for approximately eight (8) to nine (9) weeks. Her background included nine (9) years in memory care as an AD but this was her first experience in long term care (LTC). She was aware of the need for an activity program on the unit and was working on a memory care calendar, however right now she was still trying to learn the paper work and processes associated with LTC. She continued to state regarding activities on the locked unit (Faith Two) unit were conducted by the staff on the unit. If a special group came in to the facility she let them go to the secured unit if they would - such as those groups that would walk through the facility interacting with the residents. She stated that about eleven residents come off the unit for activities. The activity department also provided one on one (1:1) activities three (3) times a week and a snack cart three times a week. Music was provided randomly - not on a schedule. The staff could be providing sensory activities such as massaging hands and nail care. There is a part time activity director who helps with activities on the unit who will sing to them and read Bible stories to them. The AD stated she would need supplies - baskets and laundry items - to train staff on providing the low level activities such as sorting and folding but right now there is no budget for them. She had made a request of supplies to the last administrator who said he would get them but never did. She had not asked the current administrator because the current administrator was so new to the facility. Interview on 12/08/2015 at 5:45 p.m. the Administrator revealed there was no policy and procedure for an activity program but she did provide an NBC Requirements paper stating All regulatory requirements, federal and state specific, are followed by NBC activity directors and 7 day a week activity program in place that meets the needs of residents. Weekend activities required. Interview on 12/09/2015 at 8:10 a.m. with CNA XX revealed that one of the activity leaders did the activities on the unit but the staff would occasionally do activities with the residents when the activity staff were unable to. The unit staff could provide activities including ball toss and crossword puzzles that could be obtained from the AD. CNA XX had not had any training in providing activities to the special population on the unit other than what they got from observing the AD, however, they did receive training on care of residents with dementia. Interview on 12/09/2015 at 8:30 a.m. with LPN EE regarding activities on the unit revealed the AD had been coming back and playing movies and passing snacks. Residents who could, went out to activities off the unit. LPN EE also revealed the staff were not responsible for providing activities on the unit. If a resident needed a diversional activity LPN EE would offer a snack. Observation on 12/09/2015 at 7:00 p.m. revealed activity in the main facility dining room, Baptist Ministries, as scheduled on the activity calendar. While this activity was going on in the main facility dining room, residents on the secured unit (Faith Two), were observed in the day/dining room with TV on - eleven (11) residents - and other residents observed walking in halls. Observation revealed no other activity being offered on the secured unit at that time. Interview on 12/09/2015 at 2:15 p.m. with the Director of Clinical Services, Admin, DON, Director of Operations revealed they were not aware of a prior request being made regarding activity supplies for the unit and they would approve any requests made for resident activities; however, The Director of Clinical Services added that she had been made aware of the need for an activity program on the unit and knew what the building needed (did not specify what that was). The directors further revealed that they were hiring for another full time activities person to help on the closed unit. Interview on 12/10/2015 at 8:45 a.m. with the Medical Director (MD) revealed he did not observe meaningful activities on the unit. He recalled that at one time there was an activity person on the unit. He recalled that activities for the unit had been discussed in a Quality Assurance (QA) meeting but he could not recall when. He did remember it was discussed to offer more activities in the evenings when residents could experience increased agitation. He is in the facility on Tuesday mornings so he does not know what happens on the unit when he is not there. Further Review of activity calendar for December revealed: On December 09 at 9:30 a.m. GW News, 10:00 a.m. Exercise, 11:00 a.m. Manicure, 2:00 p.m. One to One room visits, 4:00 p.m. Crosswords, 7:00 p.m. Baptist Ministries On December 10 at 9:30 a.m. GW News, 10:00 a.m. Exercise 11:00 a.m. Baking Class, 12:30 p.m. Christmas Carols by guest 2:00 p.m. Ladies Hour, 3:00 p.m. Devotion Hour, 4:00 p.m. Afternoon Room Visits On December 11 at 9:30 a.m. GW News, 10:00 a.m. Exercise, 2:00 p.m. One to One room visits, 2:45 p.m. Snack Cart 4:00 p.m. Bingo. Interview on 12/10/2015 at 12:20 p.m. the AD clarified the activity calendar and part time activity director revealed GW NEWS was the morning announcements made over the facility public address (PA) system. Shopping list was when the residents met in the main dining room to give her their shopping lists and money, she would then go get items for them. She further revealed she makes her supply requests by writing them down on a piece of paper, no specific form and would turn in to the administrator - she does not make requests to corporate. She has also bought some supplies with her own money and received reimbursement. Regarding the manicure activity on the schedule for yesterday she revealed that the residents who desired had been brought out from the unit to participate; and she had asked for the names of any residents on unit that would like manicures but was not provided with any names. Observation on 12/10/2015 at 12:30 p.m. revealed Christmas Carols by (guest) activity occurring in the main facility dining room. Observations on the secured unit revealed random residents on the day/dining room being assisted with meals by staff, TV on. Other random residents were observed in the independent dining room in the secured unit with staff assisting as needed. Observation revealed no other activities being offered on the secure unit at that time. Interview with on 12/10/2015 at 12:50 p.m. with CNA VV regarding any changes to the activities on the unit. The CNA revealed that there was an activity person who worked with the residents on the unit but she left around the first of the year and things were not the same after that. Then there was another activity assistant who would try to do extra activities with the residents but she went part time a couple of weeks ago. The CNA also revealed she had not received training in providing activities to cognitively impaired residents. Interview on 12/11/2015 at 7:45 a.m. with LPN GG regarding activities. The LPN revealed the residents on the unit did not have an activity schedule. The residents had the TV room, some residents that were more alert would talk with each other, some residents had TVs in their rooms, and some residents who smoked had smoke breaks. The residents who can will go off the unit for activities. Activities that have been offered on the unit have included movies, snacks and popcorn, music, painting and painting nails. Also sometimes churches would come back and sing songs and music. She revealed she had received training in activities appropriate for special populations but could not recall when. Observation on 12/11/2015 at 10:35 a.m. revealed conclusion of the exercise activity in main dining room and one resident sitting at a table with blocks. Observations on the secured unit revealed five (5) random residents in the day/dining room, music playing and one resident engaged in manipulating stems of artificial flowers, no staff observed in the day room. Observation on 12/10/15 at 1:10 p. m. of the Common Day room in the secured unit revealed six (6) random sampled residents sitting in chairs with a staff member supervision. Continued observation revealed that the television was on for the residents to watch no other activity was provided.",2018-05-01
5861,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,250,J,1,0,7J0Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview the facility failed to ensure that the Social Service Department responded to needs of the one (1) resident (R #14) that requested help obtaining a protective order after an alleged threat of death was made by a family member. This failure resulted in psychological harm when the resident said the alleged family member threatened to get rid of them. It was determined that the facilities non-compliance with one or more requirements of participation had caused or was likely to cause serious injury or harm to resident therefore on 12/10/15 at 3:20 p.m. the Corporate Director of Operations, Corporate Clinical Director of Clinical Services, and Administrator were notified that an Ongoing Immediate Jeopardy (IJ) caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents of the one-hundred twenty-three (123) residents that reside in the facility. The Ongoing IJ was determined to exist beginning on 9/05/2015 at 1:30 p.m. Findings include: Review of a Police Report dated 10/14/15 indicated Incident Type: Terroristic Threats. Incident date 10/04/15 at 1700 (5:00 p.m.) to 10/14/15. Incident Day: Sunday. Police report states: On Wednesday October 14, 2015 at 1203 hours, officer responded to facility in reference to terroristic threats. Upon arrival officer met with (name of nursing director) who stated that (name of R #14) told his social worker that his mother threaten to get rid of him on Sunday October 4, 2015. (Name of Nursing Director) stated that she was told by the on duty nurse that worked on October 4, 2015 that his mother didn ' t come to visit him on that day. Officer spoke to resident and he advised that his mother came to visit him on October 4, 2015 and threaten to kill him. Resident stated that his mother told him she was going to shoot him. Resident stated that he had no witnesses to the threats that were made and stated that he doesn ' t want his mother around him and will try to obtain a restraining order. Review of the Face Sheet for R #14 dated Oct. (October) 13, 2015 indicated R #14 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The face Sheet also indicated that mother of R #14 is listed was a contact person. Review of a Social Service Evaluation dated 07/15/15 indicated physical/functional status is Independent. The portion of the document for Family relationships/Support Systems was left blank. Psychosocial Well-Being indicated R #14 is friendly towards others and Cognitive/Mental Status portion indicated R #14 is able to make needs known. Review of the Care Plan for R #14 (not dated) indicated I (R #14) have episodes of making false accusations concerning my mother hitting me and he doesn ' t want her to contact him, not give her any information. Staff Interventions are: Educate resident on inappropriate behaviors and positive ways to express feelings and to communicate needs and re-direct resident as needed. There was no further documentation listed on the Care Plan regarding staff interventions, or how to protect R #14 if the mother came to the facility or his need for a restraining order against his mother. Review of Nurse ' s Notes dated 10/08/15 at 6:00 p.m. indicated Writer talk (sic) with (name of resident friend) on phone previously whom requested to visit resident said she could visit. (Name of resident friend) understood resident ' s mom wasn ' t to visit. Writer was walking into hall & notice (sic) 2 older white women exiting resident room. Writer immediately checked on resident whom stated he was afraid and didn ' t ever want to see his mom again. Writer tried to find visitors but they had already left the building. Review of the Nurses ' Notes revealed no further documentation as to what occurred next. On 12/07/15 at 2:25 p.m. during interview when the Social Services Director (SSD) was questioned about the allegation made in October 2015, she stated that he (R #14) does not want us (the facility) to have any contact with his mother. The SSD stated she was aware R #14 made the allegations against his mother, police were called, and the last Administrator was aware of the situation. The SSD further stated that when this occurred, The mom was upset because she wants to see him, but he doesn ' t want her to see him. When the SSD was asked if there was a system in place to protect R #14 from his mother, the SSD stated Everybody knows she (the mother) is not supposed to have contact with him. She is not allowed in the facility because of his allegations of abuse towards her, and if she were to show up, she would be asked to leave. We can ' t have supervised visits for her because he does not want her here. On 12/07/15 at 2:50 p.m. during interview Licensed Practical Nurse (LPN #1) stated that he (R #14) does not want her (his mother) to visit him. When asked why. LPN #1 stated, about a month and a half ago the mother of R #14 Showed up unannounced in the evening time at the facility and he was saying that did not want her here. LPN #1 stated that she saw the mother of R #14 coming out of R #14 ' s room with another person. LPN #1 stated He was afraid and was saying he did not want to see her again. LPN #1 stated that she told the Director of Nursing (DON) that R #14 didn ' t like her (his mother) and never wanted to see her and the response from the DON was that she would take care of it. The LPN stated this occurred on October 8, 2015 when the mother of R #14 came to the facility unannounced. When LPN #1 was asked what system is in place if the mother of R #14 showed up at the facility again? LPN #1 stated, If she came, I would ask her to step out. I would have to ask him if he wanted a supervised visit from her or not. When LPN #1 was asked, if this was something that was implemented and put into place she stated, No not at this time. On 12/08/15 at 8:45 a.m. during observation and interview with R #14, he was observed to be ambulatory, alert and oriented. He was observed to be conversing with staff and other residents. During interview, R #14 stated I make my own decisions regarding my healthcare and everything. When R #14 was asked if he had any visitors that come to see him, he stated No and I don ' t want my Mom here. R #14 stated My mom had been abusing me. She keeps doing that, and I ' m scared of her. I told them (referring to the facility) many times that I don ' t want her to come here and someone keeps letting her in. I talked with the Social Worker and I talked with the Police. I asked the Social Worker about a restraining order. I have no way to go to the courts to get a restraining order. I have asked the Social Worker, and no-one will help me so I don ' t know what to do. R #14 then proceeded to say the last time his mother was at the facility was Last Sunday my mom was here. She comes before supper and comes by herself. My understanding was that if she were to come here, someone had to come with her. I told everyone here and I want out of here. I don ' t have my own guardian. I make my own medical and healthcare decisions and I ' m scared. On 12/08/15 at 1:30 p.m. during interview the Administrator stated that she was not aware of a police report regarding R #14. The Administrator stated In speaking with him (R#14) he requests for her (the mother) not to see him, so we have honored his wishes. When the Administrator was asked how have you honored his wishes she stated, Well, she (the mother) came here and we have told her his request is not for her to come back to the facility to see him. We are all aware of that. I also didn ' t know about the restraining order he was requesting. Again, everybody is aware that he does not want to see her and she is not allowed to go back on the hall to see him. On 12/08/15 at 2:05 p.m. during interview the Director of Nursing stated that the allegation that was made by R #14 in October was that He (R #14) stated his mother came up here and threatened to take him out. When the deputy was called, he (R #14) said his mother threatened him with a gun. Social Services never mentioned anything about a gun to me. Staff just know she (the mother) is not supposed to see him. Last week she (the mother) came to the facility to drop off paperwork and was wanting to see him but it was our understanding that he still had the right not to see her if he did not want to. This has been ongoing and the staff just know. When the DON was asked if she assisted R #14 in obtaining a restraining order she stated, The Police gave him all the information and he was supposed to call. The DON then stated everybody just knows he does not want to see her. I don ' t have an action plan in place that I can show you. It has all just been word of mouth. The receptionists know she is not supposed to come here on the weekends and the staff know as well. On 12/09/15 at 7:15 a.m. during interview regarding R #14 needing assistance in filing a restraining order, the Social Services Director stated, I don ' t recall it ever being brought to my attention. I would have assisted him if he asked but it was not brought to my attention by any of our Department Heads or in our stand up meetings. On 12/10/15 at 12:30 p.m. during interview the SSD stated If the mother were to visit him staff just know that she is not allowed to see him. Everyone know she cannot come into the facility or call him. When the SSD was asked what plans are in place if the mother were to show up in the evenings, off hours or on weekends. The SSD stated, They know. They just know she is not to have any involvement with him and to my knowledge all she did was just come and drop off paperwork. The SSD then stated When I talked to him this week, I told him all he had to do was ask about a restraining order. He told me that he thought he had to go to a courthouse to file a restraining order but I told him he can just go online on the computer. His response was that he didn ' t know he could do that. The SSD was asked if anything had been set up previously to assist R #14 obtaining a restraining order. The SSD stated, No, not to my knowledge.",2018-05-01
5862,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,252,F,1,0,7J0Y12,"Based on observation and staff interview the facility failed to provide a homelike environment for four (4) of four (4) resident halls, the main dining area, and resident smoking area. This deficient practice had the potential to affect all one hundred twenty three (123) residents residing in the facility. It was determined that the facilities non-compliance with one or more requirements of participation had caused or was likely to cause serious injury or harm to resident therefore on 12/10/15 at 3:20 p.m. the Corporate Director of Operations, Corporate Clinical Director of Clinical Services, and Administrator were notified that an Ongoing Immediate Jeopardy (IJ) caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents of the one-hundred twenty-three (123) residents that reside in the facility. The Ongoing IJ was determined to exist beginning on 9/05/2015 at 1:30 p.m. Findings include: Review of the Guardian Angel Program policy revealed that the Guardian Angel Room Rounds form will be completed to ensure a comfortable, home like setting present and satisfactory to resident/family. The Guardian Angel Program policy continues to state that resident room issues identified will be addressed immediately when possible or brought to attention to the executive director for resolution. However, per observations the Guardian Angel Program Policy failed to assure a comfortable environment for residents who reside in the facility. Common Areas: On 12/07/15 at 11:30 a.m., 2:30 p.m., and 6:00 p.m. observation revealed that two (2) of the two (2) resident smoking areas that were located off of the main dining room alcove and on the secured unit Faith Two (2) were not located twenty five (25) feet from the entrance doors, as revealed in the facility's smoking policy. Observations revealed the odor of smoke was coming into the facility when the exit doors, located at desinated smoking areas, were opened during the resident smoking times. On 12/07/15 at 10:00 a.m. observations revealed cigarette butts located on the ground, on top of trash disposal cans, window ledges and wooden ledges of screened wall of the main smoking area off of the main dining room alcove. Observations further revealed a broken basketball hoop and weathered picnic tables located in the outdoor common area, off of the main smoking area. On 12/07/15 at 10:00 a.m. observations revealed cob webs that stretched along the ceiling to the wall that was located next to the exit door of the main dining room alcove. Observation on 12/07/15 at 10:10 a.m. of the main smoking area revealed that there were sixteen (16) cigarette butts scattered throughout the area on the concrete floor. Interview on 12/07/15 at 11:30 a.m. resident #13 revealed that someone needs to check on the smoking area with the trash and bugs on the ground. Interview on 12/07/15 at 10: 18 a.m. with the Housekeeping/Laundry Supervisor confirmed that there were several cigarette butts on the ground in the main resident smoking area. Interview further revealed that housekeeping staff are to sweep the area after each resident smoke break and confirmed that housekeeping staff did not sweep after the 8:30 a. m. smoke break time. On 12/07/15 at 2:15 p.m. observations revealed broken and discolored rocking chairs located on the front porch of the facility. Resident Rooms Observation on 12/07/15 at 1:20 p.m. of room # 20 on Faith One Hall revealed the bathroom exhaust fan had a layer of dust and lint. Observation on 12/07/15 at 2:20 p.m. of room # 27 on Faith One Hall revealed the three-in-one commode over the toilet had rust on the metal frame under the front seat and rust on the frame of the back right leg. Continued observation revealed dirt in the floor corners to the entrance of the bathroom. Observation on 12/07/15 from 2:26 p.m. until 3:20 p.m. of room #57 revealed brown/black discoloration on the floor and brown discoloration above the baseboards. Observation on 12/07/15 from 2:26 p.m. until 3:20 p.m. of room # 59 revealed black discoloration on the floor tiles near B bed. Observation on 12/07/15 at 10:15 a.m. Of the shared bathroom for room # 60 and # 62 revealed black discoloration in the floor grout. Observation on 12/07/15 at 10:15 a.m. of room # 61 revealed black discoloration on the floor tiles in the corner. Observation on 12/07/15 at 10:15 a.m. of room # 62 revealed black discoloration on the floor. Observation on 12/07/15 at 10:15 a.m. of room #65 revealed black discoloration on the floor and in the corners of the room. Observation on 12/07/15 from 2:26 p.m. until 3:20 p.m. of the shared bathroom for room # 64 and # 66 revealed black discoloration around the base of the toilet. Observation on 12/07/15 from 2:26 p.m. until 3:20 p.m. of room # 66 revealed black discoloration on the floor. Observation on 12/7/15 from 2:26 p.m. until 3:20 p.m. of the shared bathroom for room # 67 and # 69 revealed brown discoloration on the top of the tile baseboards. Observation on 12/07/15 at 10:15 a.m. Of the shared bathroom for room # 68 and # 70 revealed black discoloration on the bathroom floor tiles. Observation on 12/7/15 from 2:26 p.m. until 3:20 p.m. of room # 69 revealed brown/black discoloration on the floor. Observation on 12/07/15 at 10:15 a.m. of room #70 revealed black discoloration on the floor tiles in the corner of the room near the A bed. Observations on 12/07/15 at 10:00 a.m. of room #74 revealed that there was a buildup of dirt and small particles of trash in the corner next to bed B and the window. Observations on 12/07/15 at 10:00 a.m. of room #76 revealed floor tiles were discolored and stained with scuffs and dirt toward the entrance and center of the of the room. Observations on 12/07/15 at 10:00 a.m. of room #77 revealed discolored and stained floor tiles. Interview on 12/8/15 from 2:45 p.m. until 3:32 p.m. the above observations were confirmed by the Plant and Facility Maintenance Supervisor, the Regional Plant and Facility Maintenance Supervisor and the Interim Housekeeping Supervisor confirmed the above findings. Interview on 12/08/15 at 2:30 p.m. with the Regional Plant and Facility Supervisor revealed that he confirmed that rooms stated above for Faith One Hall had dust, dirt, and resident equipment ha rust. He revealed that department managers complete the Guardian Angel forms on their assigned resident rooms daily which is to identify such concerns. He revealed that he completed a verbal in-service to department managers regarding how to complete the Guardian Angel from as well as what to observe in the resident rooms.",2018-05-01
5863,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,253,E,1,0,7J0Y11,"AMENDED: Based on observation and interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior in resident's rooms and bathrooms and maintain bathroom fixtures in good working order for nineteen (19) rooms effecting four (4) of seven (7) halls and in common areas used by all residents that reside in the facility. Findings include: August 2015 1. Observation on 8/25/2015 at 1:30 p.m. of room number 52, bathroom revealed the sink faucet was leaking, hair, dirt and debris in corners, in the doorway and behind the toilet. 2. Observation on 8/25/2015 at 1:35 p.m. of room number 56, revealed that the vinyl cover on the entry door is falling off (held in place by a tack), and there are cobwebs and dead bugs in corners of windowsill. Interview with the resident revealed the vinyl cover has been like that a long time. 3. Observation on 8/25/2015 at 1:40 p.m. of room number 74, revealed that the bathroom floor is dirty, entry to bathroom and behind the toilet is caked with dust, dirt and debris. 4. Observation on 8/25/2015 at 2:00 p.m. of room number 44, revealed in the bathroom the hand sanitizer dispenser is off the wall, sitting on the toilet, rust stains on the sink, the plumbing under the sink is dripping, stains on the wall, the bathroom corners, entry, and behind the toilet are caked with hair, dirt and debris. 5. Observation on 8/25/2015 at 2:10 p.m. of room number 49, bathroom revealed that the toilet was leaking, hair, dirt and debris were observed in the corners, in the doorway and behind the toilet. 6. Observation on 8/25/2015 at 1:30 p.m. of room number 52, bathroom revealed the sink faucet was leaking, hair, dirt and debris in corners, in the doorway and behind the toilet. 7. Observation on 8/25/2015 at 1:35 p.m. of room number 56, revealed that the vinyl cover on the entry door is falling off (held in place by a tack), and there are cobwebs and dead bugs in corners of windowsill. Interview with the resident revealed the vinyl cover has been like that a long time. 8. Observation on 8/25/2015 at 1:40 p.m. of room number 74, revealed that the bathroom floor is dirty, entry to bathroom and behind the toilet is caked with dust, dirt and debris. 9. Observation on 8/25/2015 at 2:00 p.m. of room number 44, revealed in the bathroom the hand sanitizer dispenser was off the wall, sitting on the toilet, rust stains on the sink, the plumbing under the sink was dripping, stains on the wall, the bathroom corners, entry, and behind the toilet were caked with hair, dirt and debris. 10. Observation on 8/25/2015 at 2:10 p.m. of room number 49, bathroom revealed that the toilet was leaking, hair, dirt and debris were observed in the corners, in the doorway and behind the toilet. The above observations were confirmed with the Maintenance Supervisor on 8/25/2015 at 3:20 p.m. October 2015 1. Observation on 10/14/2015 at 12:00 p.m. in shared bathroom for room numbers 15 and 16 revealed a brown discoloration to the tile behind the toilet, build-up of dirt in corners at both doorways and dark brown build-up along the entrance to the bathroom. 2. Observation on 10/14/2015 at 12:02 p.m. in room number 18 revealed a brown build-up on the floor along the right wall that the door opened on to, across door threshold, and to the left of the doorway. Special painted finish on floor chipped in several places along the floor and baseboards. Windowsill with peeling paint on left side. Floor mat at bedside with build-up of dirt and debris and sections chipped and missing from the edges and top. Bed wheel assembly for right, head of bed post broken. bent and lying beneath the head of the bed. In the bathroom, the paint/finish was peeling from the vanity. Brown matter on top grab bar where attached to the wall. 3. Observation on 10/14/2015 at 12:10 p.m. in room number 14 revealed rusty bed frame on bed A. Floor mats for beds A and B with build-up of dirt and debris. Bed A mat with cracked and chipped edges. Inside bottom of bathroom door cracked. Brown discoloration on grout behind the sink, grout cracked and separated from the wall. 4. Observation on 10/14/2015 at 12:23 p.m. in room number 10 revealed dim pink ceiling lighting over bed A, ceiling light over bed B and night light not working properly. Paint peeling and wood split on bottom left of windowsill. 5. Observation on 10/14/2015 at 12:30 p.m. in room number 6 of night light not working. Call light working but box in room did not light up and re-set button was missing. Build up of brown material at both bathroom doorways of shared bathroom with room number 7. 6. Observation on 10/14/2015 at 12:35 p.m. in room number 2 of the left blind broken at the bottom. Door frame on both sides of the bathroom door rusted with large gaps filled with dirt and debris. Brown discoloration around base of toilet. Brown material on top of handrail beside toilet. Air conditioner unit with build up of dirt and debris in vents and vents rusty. Bedside table for bed B with top two drawers broken and unable to close properly. 7. Observations on 10/14/15 at 10:45 a.m., 12:45 p.m., and again on 10/15/15 at 9:35 a.m., in the shared bathroom between room numbers 23 and 25 the ceiling light in the tub area was not working. 8. Observations on 10/14/15 at 10:45 a.m., 12:45 p.m., and again on 10/15/15 at 9:35 a.m., in the shared bathroom between room numbers 24 and 26 the finish on the tub was worn off in several places. 9. Observations on 10/14/15 at 10:45 a.m., 12:45 p.m., and again on 10/15/15 at 9:35 a.m., in room number 37, large black scuff marks on the wall behind the head of the second bed were observed. 10. Observations on 10/14/15 at 10:45 a.m., 12:45 p.m., and again on 10/15/15 at 9:35 a.m., in room number 46, the elevated toilet seat in the bathroom had peeling and flaking paint and rust on the frame. 11. Observation on 8/25/2015 at 2:10 p.m. of room number 49, bathroom revealed that the toilet was leaking, hair, dirt and debris were observed in the corners, in the doorway and behind the toilet. 13. Observations on 10/14/15 at 10:45 a.m. and 12:45 p.m., and; on 10/15/15 at 9:35 a.m. of room number 49, revealed large sections of missing paint and scuffs to the bottom portion of the door leading to the bathroom. 14. Observations on 10/14/15 at 10:45 a.m. and 12:45 p.m., and; on 10/15/15 at 9:35 a.m., in room number 60, the bottom portion of the walls in the bathroom had been repainted white in an uneven pattern, while leaving the top portion of the walls yellow. 15. Observations on 10/14/15 at 10:45 a.m., 12:45 p.m., and again on 10/15/15 at 9:35 a.m., in room number 69, there was missing paint and large scuff marks to the lower portion of the bathroom door. In the common areas used by all residents, the following was observed: 19. Observation on 10/14/2015 at 11:55 a.m. in the assisted dining room at the entrance to the unit revealed paint peeling on the right side of the windowsill, paint peeling on the right wall that the door opened on to and paint peeling on the outside of the door. 20. Observation on 10/14/2015 at 12:26 p.m. of the smoking area the planter was observed with eight (8) cigarette butts on it and another eight (8) cigarette butts on the ground to the left of the sidewalk. 21. Observation on 10/14/2015 at 12:45 p.m. in the independent dining room on the unit revealed missing paint to the bottom of the two windowsills. 22. Observations on 10/14/15 at 10:45 a.m., 12:45 p.m., and on 10/15/15 at 9:35 a.m., in the independent dining room the floor in the large dining room had multiple stains, food debris, a build up of debris along the edges of the baseboards, floor; The piano bench was broken in two pieces, laying on top of the piano; A popcorn machine next to the piano had a coating of oil and popcorn bits to the interior of the machine; Large sections of the lower portions of the walls leading to the smoking porch had multiple dark scuff marks. The large fish tank had a build up of a reddish-brown substance to the interior of the tank and the water was amber in color. Interviews on 10/14/2015 at 2:50 p.m. and 10/15/2015 at 8:40 a.m. with the Executive Director and the Maintenance Director revealed there were maintenance logs at each nurse's station for reporting of maintenance and/or environmental concerns and the staff was aware of how and when to use them. They were checked every weekday morning by the maintenance department. Concerns were addressed the same day if possible. The staff should have been reporting the environmental concerns on the unit. Angel rounds were conducted daily by management on every resident's room to observe for environmental and/or maintenance concerns. These were discussed in the morning meeting and again at the step down meeting at the end of the day. The TELS program was used to prompt the Maintenance Director on Federally Required training and maintenance items and the Administrator received a weekly report of any overdue items. The administrator had been employed at the facility approximately five (5) weeks and was aware of the needs of the building and had spent a large sum of his personal money to get needed paint and supplies to begin some of the needed repairs. Observations on 10/15/2015 at 9:50 a.m. with the Maintenance and Housekeeping Supervisors confirmed the above findings. Interview on 10/15/2015 at 10:10 a.m. with the Housekeeping Supervisor, revealed he had been employed at the facility approximately one and one-half (1.5) months. He had been aware of build-up on the floors and had the residents rooms, especially the doorways, cleaned; however, he was not aware of the heavy build-up in the bathrooms. Rooms and bathrooms were cleaned daily and re-visited as needed. The rooms were deep cleaned on a repeating schedule. Any housekeeping concerns could be reported to him. Housekeepers would also be responsible for cleaning the floor mats.",2018-05-01
5864,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,279,E,1,0,7J0Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the development of a comprehensive care plan, regarding one (1) resident (#41) receiving [MEDICATION NAME] therapy from a sample of seven (7) residents reviewed; and failed to develop a comprehensive plan of care to address preferences and risk factors related to mental and psychosocial needs for two (2) residents with behaviors (#3 and #42) out of ten (10) residents reviewed. Findings include: Review of the medical record revealed that R #41 had the following Diagnoses: [REDACTED]. Review of the 12/01/15 physician's medication orders revealed that the resident was ordered the following medications: [REDACTED]. Continued review of the 12/01/15 physician's orders [REDACTED]. Review of the Laboratory results revealed that the resident had an INR completed on 12/01/15 with the results of 1.58 (low). Review of the plan of care revealed a Focus area for pacemaker and to the related history of automatic implantable cardiac defibrillator. Further review revealed that the plan of care included risk for bleeding and bruising due to use of [MEDICATION NAME] and Eliquis. Intervention included to monitor vital signs weekly (Sundays) and notify the physician of significant abnormalities; and observe/document/ report as needed (PRN) any signs or symptoms of altered cardiac output or pacemaker malfunction: dizziness, [MEDICAL CONDITION], difficulty breathing (dyspnea), pulse rate lower than programmed or lower than baseline blood pressure (BP). Further review of the Care Plan revealed no Focus or interventions addressing the use of [MEDICATION NAME]. During an interview on 12/10/15 at 1:45 p. m. the Minimum Data Set (MDS) Coordinator Licensed Practical Nurse (LPN) DD confirmed that a care plan for [MEDICATION NAME] use and interventions was not present . During an interview on 12/10/15 at 1:48 p.m. the Unit Manager Registered Nurse (RN) BB confirmed that the resident did not have a care plan to address the use of [MEDICATION NAME] and no interventions related to monitoring the resident or to monitoring of laboratory results. During an interview on 12/10/15 at 1:56 p. m. the Director of Nursing (DON) revealed he/she expected the care plan to be correct . Love, Angela Review of R#3's Minimum Data Set (MDS) Annual assessment dated [DATE] revealed the following: Section B : Hearing, Speech and vision - resident sometimes understood when expressing ideas and wants, ability is limited to making concrete requests; resident sometimes understands verbal content, responds adequately to simple, direct communication only Section C: Cognitive Patterns - Brief Interview for Mental Status (BIMS) Summary score 06 - severely impaired cognition; Section E: No behavior symptoms; Section F: Interview for daily preferences -it was very important for the resident to take care of his personal belongings or things, and he considers it very important to be able to go outside and somewhat important to be around animals, music, groups of people and religious services. Section I - Active [DIAGNOSES REDACTED]. Review of the Behavior/Intervention Monthly Flow Records, for R #3 dated November 2015 revealed evidence of behaviors including yelling out, refusal of care and danger to others with one episode of yelling out on 7 a.m. to 7 p.m. shift on 11/14/2015. Review of the Care Now Comprehensive Psychiatric Diagnostic Evaluation dated 07/06/2015 revealed a [DIAGNOSES REDACTED]. Review of the Behavioral Health Evaluation dated 08/04/2015 revealed the R#3 had a history of [REDACTED]. No current [MEDICAL CONDITION] noted. Review of the Care Now Services Behavioral Health Services Progress Note dated 09/21/2015, revealed R#3 had an altercation on 09/05/2015 with another resident. Review of the Situation Background Assessment Report (SBAR) revealed this to have been with R#23). R#3 could be agitated at times but denied problems with another resident. (resident not specified in the progress note). R#3 is estranged from family and has no visitors. R#3 appeared displeased and hopeless with a flat affect. Record review revealed that on 09/05/2015, R#23 entered the room of R#3 and laid down on the bed. R#3 pushed R#23 off the bed. According to the SBAR communication form for R#23, R#23 sustained a skin tear to his right posterior forearm and underneath the left side of his nose and an abrasion to his right posterior hand. Then on 10/12/2015 R#3 became upset due to R#23 continuing to enter his room. R#3 was yelling at and slapping R#23. According to the SBAR communication form for resident R#23, R#23 sustained multiple skin tears to his left arm, left hand and to the neck. Review of the SBAR Communication Form and Progress Note dated 11/30/2015 revealed that R#23 got into the bed of R#3. R#3 became agitated and started to fight R#23. R#23 and R#3 were separated and a police report filed. Interview on 12/08/2015 at 1:35 p.m. with the Licensed Clinical Social Worker (LCSW) for Care Now Services revealed R#3 had depression regarding his placement in a facility and regarding his lack of family support, therefore his room was his whole word and he became agitated if other residents got in his personal space. Regarding activities for R#3 the LCSW recommended sensory stimulation such as movies and sing-a-longs. The LCSW also revealed she worked with R#3 on self-calming practices such as walking away. A review of the Plan of Care included the following Focus areas, goals and interventions: Focus: The resident has a behavior problem talking to himself and at television. Using inappropriate language towards staff and peers, writing inappropriate things on drinking cups, speech is garbled/mumbled at times, physically abusive towards peers and staff at times. Goal: The resident's behavior would not affect the rights of others by a review date of 03/08/2016. Interventions included anticipating and meeting the resident's needs, intervening as necessary to protect the rights and safety of others: approach/speak in a calm manner, divert attention. Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention and psychiatric consult as needed. Review of the plan of care revealed no focus to address the importance that R#3 placed on his personal space and belongings that could result in physical aggression and actual harm to other residents or staff if he felt his rights were violated. Further review of the plan of care revealed no consideration of interventions aimed specifically at protecting the rights and safety of R#3 and other residents. Review of the plan of care also revealed no consideration of the residents preferences for diversional activities. Although the plan of care addressed psychiatric consults as needed, it revealed no evidence that the resident actually received scheduled psychiatric care and services. Interview on 12/11/2015 at 10:55 a.m. with the Director of Nursing (DON), Assistant Director of Nursing (ADON) and both MDS Coordinators regarding R#3's behavioral plan of care revealed they considered the plan of care to be appropriate for the resident and any information not available on the plan of care regarding resident behaviors and interventions could be found in the nurse's notes. Olson, Elizabeth Review of the physician's orders [REDACTED].#42 had [DIAGNOSES REDACTED]. Review of the admission Social Service Assessment completed on 09/14/15 revealed the resident was transferred from another facility due to behaviors on 09/11/15. Further review of the Social Service Assessment revealed the resident had a history of [REDACTED]. Review of the Care Plan for R #42 revealed that the Care Plan failed to address the resident's history of being short tempered, argumentative, violent and combative at times. Further review of the Care Plan revealed that it did not include the 11/12/15 resident to resident altercation. Further review of the resident's Care Plan revealed on 12/9/15 it was identified that the resident had a history of [REDACTED]. During an interview on 12/10/15 at 11:15 a.m. the Social Service Director (SSD) revealed the admission Social Service Assessment that he/ she completed on 9/14/15 included the resident's history of aggressive behaviors toward other residents and violent at times. Further interview with the SSD revealed that the resident's history should have been addressed in the Care plan. The SSD revealed he/she was responsible for addressing the behaviors on the resident's care plan as well as altercations and failed to do so. The SSD confirmed the history of aggressive behaviors was added to the Care Plan on 12/09/15.",2018-05-01
5865,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,309,G,1,0,7J0Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow physicians' orders related to sliding scale insulin coverage for ten (10) residents (#1, #3, #5, #6, #8, #11, #12, #13, #14, #20) of forty-seven (47) sampled residents; failed to follow finger stick blood sugar (FSBS) assessments causing actual harm to one (1) resident (#1), when the resident was found unresponsive and sent to an acute care facility with a greater than (>) 2000 blood sugar after the facility failed to have blood sample testing supplies available for the residents and increasing the likelihood of hyper/hypo glycemia to all diabetics in the facility. Findings include: 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the residents' physician orders [REDACTED]. for FSBS of 150-199 = 2 units; for FSBS of 200-249 = 4 units; for FSBS of 250-299 = 6 units; for FSBS of 300-349 = 8 units; for FSBS of 350--400 = 10 units; for FSBS of greater than 400 = 12 units, notify MD; FSBS before meals with sliding scale coverage; FSBS at bedtime without sliding scale coverage and notify MD if greater than 400 at 9:00 p.m. Record review of the Medication Administration Record [REDACTED]. Continued review revealed a SBAR communication form and Progress Note dated 8/4/15, revealed that the resident was clammy and lethargic. The physician and family were notified and at 6:05 a.m. and Emergency Management Services (EMS) was notified for transport to the emergency room . Review of the emergency room History and Physical dated 8/4/15 at 9:16 a.m., revealed that the chief complaint was [MEDICAL CONDITION], unresponsive with a blood sugar of >2000. Before admission to the nursing home, the resident had been seen in the emergency room numerous times for Diabetic Ketoacidosis and was known to be noncompliant with diabetes control. After a discussion with the emergency room doctor, the poor quality of life for the resident, the family asked for comfort measures only and the resident was transferred from the emergency room to Hospice Care. 2. Record review of the physician orders [REDACTED]. [MEDICATION NAME] Regular (R) 100 Units/Milliliters(ML) sliding scale; 150-199 = 2 units; 200-249 = 4 units; 250-299 = 6 units; 300-349 = 8 units; 350-399 = 10 units; 400 or greater = 12 units and notify Medical Doctor (MD) #FSBS at 4:30 p.m. with sliding scale coverage. Also, FSBS at bedtime with no sliding scale coverage; notify MD if blood sugar is greater than 400. Record review of the Medication Administration Record [REDACTED]. 3. Review of the physician orders [REDACTED]. [MEDICATION NAME] R 100 Units/ML sliding scale; [MEDICATION NAME] 100 unit/ml Insulin sliding scale 200-250 = 2 units; 251-300 = 4 units; 301-350 = 6 units; 351-400 = 8 units and; > than 400 or less than 60 - notify MD. Review of the MAR indicated [REDACTED]. 4. Review of the physician orders [REDACTED]. sliding scale [MEDICATION NAME] 100 unit/ml Insulin sliding scale 150-199 =2 units; 200-249 = 4 units; 250-299 = 6 units, 300-349 = 8 units; 350-400 = 10 units; > 400 = 12 units and call MD; FSBS every morning at 11:30 a.m. and every night at 9:00 p.m. without sliding scale Insulin coverage, and; [MEDICATION NAME] 100 U/ML Insulin ([MEDICATION NAME], HUM, Rec. anlog) inject 24 units SQ every morning at 8:00 a.m. Review of the MAR indicated [REDACTED]. On 8/5/15, 8/7/15 at 9:00 p.m. and on 8/15/15 there was no evidence of FSBS monitoring and/or Insulin administration. 5. Review of the physician orders [REDACTED]. [MEDICATION NAME] 100 unit/ml sliding scale Insulin as follows: 150-199 = 2 units; 200-249 = 4 units; 250-299 = 6 units; 300-349 = 8 units; 350-400 = 10 units; > than 400 = 12 units and notify MD, and; FSBS before meals with sliding scale coverage. Review of the MAR indicated [REDACTED]. 6. Record review of resident #12 revealed a physician order [REDACTED]. Review of the MAR indicated [REDACTED]. 7. Review of the physician orders [REDACTED]. FSBS monitoring at 4:30 p.m. and bedtime 9:00 p.m. with sliding scale coverage only at 4:30 p.m. and notify the MD if > than 400 for the FSBS at both times. Sliding scale coverage was for [MEDICATION NAME] 100 unit. ML 150-199 = 2 units; 200-249 = 4 units; 250-299 = 6 units; 300-349 = 8 units; 350-400 = 10 units; greater than 400 = 12 units and notify the MD. FSBS at bedtime are ordered without sliding scale coverage but notify MD if > 400. Review of the MAR for 8/3/15 and 8/5/15 at 9:00 p.m. revealed no evidence of FSBS monitoring. 8. Review of the physician orders [REDACTED]. Humalog 100 Units/ML sliding scale Insulin for 150-199 = 2 units; 200 - 249 = 4 units; 250-299 = 6 units; 300-349 = 8 units, 350-400 - 10 units; than 400 = 12 units; >400 and notify the MD; FSBS before meals with sliding scale coverage. Review of the MAR indicated [REDACTED]. 9. Review of physician orders [REDACTED]. 150-199 = 2 units; 200 - 249 = 4 units; 250 -299 = 6 units; 300 - 349 = 8 units; 350-400 = 10 units; > than 400 = 12 units and notify the MD and FSBS before meals with sliding scale coverage. Review of the MAR indicated [REDACTED]. 10. Record review of the MAR for resident #3 revealed FSBS monitoring at bedtime with no sliding scale coverage. A review of the MAR indicated [REDACTED]. Interview on 8/18/15 at 12:00 noon with Licensed Practical Nurse (LPN) AA, revealed that on 8/3/15 at 9:00 p.m. and 8/4/15 at 6:30 a.m., there were not enough diabetic test strips in the building to perform FSBS monitoring. AA further stated that she informed the Director of Nursing on 8/4/15 in the morning. LPN AA stated that she did not call the physicians to report their orders were not followed. Interviews on 8/18/15, at 5:45 p.m. with the Interim Administrator, Interim Director of Nursing and both Unit Unit Managers, confirmed all the above findings. Interview on 8/26/15 at 10:00 a.m. after observation of medication administration with LPN HH revealed that the narcotic count was correct. LPN HH stated having plenty of supplies available for resident care on my shifts. Observation of medication administration on 8/26/15 at 10:20 a.m. with LPN II revealed the narcotic count was correct and that lancets and blood monitoring strips were present. Interview on 8/26/15 at 10:31 a.m. with LPN II revealed that there had been no recent problems with narcotic county recently, however there was one day when there was not enough supplies for FSBS because the order did not come in, and we got some from another facility. Interview on 8/26/15 at 10:50 a.m. with LPN JJ revealed that there had been no problems with narcotic counts, or lancets or blood monitoring strips. Observation of the medication cart used by LPN JJ revealed there was supplies and the narcotic count was correct. Interview on 8/26/15 at 1:54 p.m. with Account Payable revealed that on a weekend the facility ran out of blood monitoring strips, the supply clerk had ordered the strips, however they did not come in from the supply company. The DON sent staff to a sister facility and picked up some strips, then the ordered strips came in. Interview on 8/26/15 at 2:58 p.m. with the Unit Manager of Faith-1 and Haven-1 revealed that when the last survey was conducted twenty-one (21) residents were identified as diabetics, eight (8) of the 21 did not receive FSBS monitoring due to the lack of monitoring strips. Interview on 8/26/15 at 4:30 p.m. and observation of the supply room with the Supply Clerk revealed that supplies are ordered once a week on Tuesdays, the PAR level (Par levels are boundary markers in inventory levels that signal [MEDICATION NAME] is necessary) has been increased to assure supplies related to blood sugar monitoring.",2018-05-01
5866,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,319,K,1,0,7J0Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review revealed R#45 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] for R#45 revealed the following: Section B: Hearing, Speech and vision - resident understood when expressing ideas and wants, resident usually understands - misses some part/intent of message but comprehends most conversation; Section C: Cognitive Patterns - short term and long term memory problems, able to recall current season, location of room, staff names and faces, and that he/she is in a nursing home. Moderately impaired Cognitive skills for making decisions regarding tasks of daily life, decisions poor, and cues/supervision required; Section E: no behavior symptoms or wandering. Section F: Interview for daily preferences not completed - resident rarely/never understood and, Section I - Active [DIAGNOSES REDACTED]. Review of PASRR Level II dated 07/25/2013 revealed the resident required Service Planning for Diagnostic/ongoing paychiatric care. Review of the Physician's progress notes revealed a psychiatric consult completed 07/16/2015 with follow-up in two (2) to three (3) months. Record review and requests for psychiatric records from the facility failed to reveal R#45 received ongoing psychiatric care. Review of the Physician's telephone orders revealed an order dated 06/22/2015 for Care Now Services to Evaluate and treat for [MEDICAL CONDITION], anxiety, [MEDICAL CONDITIONS] and dementia. Record review and requests for psychiatric records from the facility failed to reveal R#45 received a Care Now Evaluation after it was ordered. Based on observation, record review and staff interview, the facility failed to provide services to evaluate, diagnose, and/or treat two (2) resident's (#42 and #40) with a history of behaviors and failed to provide psychiatric services as ordered/recommended for one (1) resident (#45) for a total of three (3) residents with behaviors from ten (10) residents reviewed with behaviors, from a total of thirty-eight (38) sampled residents. It was determined that the facilities non-compliance with one or more requirements of participation had caused or was likely to cause serious injury or harm to resident therefore on 12/10/15 at 3:20 p.m. the Corporate Director of Operations, Corporate Clinical Director of Clinical Services, and Administrator were notified that an Ongoing Immediate Jeopardy (IJ) caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents of the one-hundred twenty-three (123) residents that reside in the facility. The Ongoing IJ was determined to exist beginning on 9/05/2015 at 1:30 p.m. Findings include: 1. Record review of the 12/1/15 physician's orders [REDACTED]. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], section C Brief Interview for Mental Status (BIMS) revealed a score of thirteen ( 13) indicating the resident to be cognitively intact. Further review of the MDS section D revealed the absence of mood symptoms and section D revealed the absence of [MEDICAL CONDITION] and no behavioral symptoms. Review of the admission Social Service Assessment completed 9/14/15 revealed that the resident was transferred from another facility due to behaviors on 9/11/15. Further review of the Social Service Assessment revealed that the resident had a history of [REDACTED]. Review of the information provided by the previous facility revealed that the resident was receiving Care Now Behavioral Health services at their facility. Further review of the records from the previous facility revealed a 8/20/15 Care Now note with documentation that R #42 received therapeutic interventions including symptom management and reflective listening and reassurance. Review of R #42's physician orders [REDACTED]. [MEDICATION NAME] 20 mg by mouth was indicated on the physician's orders [REDACTED]. During an interview on 12/9/15 at 1:15 p.m. with Licensed Practical Nurse (LPN) LL he/she revealed the resident had been verbally abusive, cursing and became very angry in the past about a change in the shower schedule. Review of the nurses notes for R #42 revealed an altercation on 11/12/15 with a roommate that resulted in this resident being kicked and a room change was done. Further review of the resident's nursing notes from 11/12/15 after the resident to resident altercation until 12/7/15 revealed no further documented altercations or behaviors. During an interview on 12/11/15 at 8:00 a.m. the resident's physician revealed that there was a shortage of psychiatric providers in the area and it was difficult to get anyone to come to the facility and provide services . The physician further revealed it would have been appropriate to try to find someone to provide services for this resident. The physician revealed the resident could have benefited from psychiatric evaluation and possibly services with the resident's history. During an interview on 12/11/15 at 8:15 a.m. the Social Service Director(SSD) revealed that the resident should have been referred for a psychiatric evaluation and it was not done. The SSD revealed that R #42 was referred to the facilities psychiatrist on 12/10/15. 2. Review of R# 40's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) cognitive status of eleven (11) which indicated cognitive impairment . Further review of the 7/31/15 MDS section I revealed the absence of a Psychiatric /Mood Disorder. Record review of the annual Care Plan for Resident #40 dated 11/12/15 revealed a Focus of episodes of verbally aggressive behaviors, physically aggressive behaviors, socially inappropriate behaviors and kicking another resident in the face was identified with an intervention of Psychiatric consult as needed. Further review of the Care Plan included a Focus with a revision date of 11/30/15 that the resident is resistive to care, refuses showers and medications and at times refuses to get out of bed and refuses activities. Further review of the resident's monthly summary for 11/18/15 and 12/3/15 revealed documentation that the resident's emotional status was easily upset, expresses according to situation and is hostile frequently. Record review of the resident's nurses notes from 10/26/15 to 12/10/15 revealed documentation of the resident refusing medications, refused to get out of bed and yelling profanity. Also, the documentation revealed the resident had an altercation with another resident on 11/12/15 and kicked another resident. During an interview on 12/11/15 at 8:15 a.m. the resident's physician revealed that the resident would probably benefit from psychiatric evaluation and services. During an interview on 12/11/15 at 8:30 a.m. the Social Service Director revealed the resident should have had a psychiatric evaluation. The Social Service Director further revealed it was her responsibility to arrange it and failed to do so. The Social Service Director revealed that nursing and social services identify residents who need psychiatric services and they notify the physician for an order . The Social Service Director revealed that she had attempted to educate the resident on anger management but was not successful.",2018-05-01
5867,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,323,K,1,0,7J0Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, interview, record review, facility policy review and review of the facility's State reported investigations, the facility failed to assure that one (1) resident (#23), who wandered into other resident's rooms, was free from physical abuse and three (3) resident (#3, #44, #45), into whose rooms resident #23 wandered, was free from mental abuse of the ten (10) sampled. The facility failed to ensure disposable razors were properly stored for one (1) resident #40; failed to ensure two (2) sharp objects were removed from the residents smoking area and the cabinet containing resident smoking paraphernalia was locked; failed to ensure a power strip was mounted properly to provide a safe environment for one (1) resident #29, from a sample of forty (40) residents reviewed and twenty (20) smoking residents. The facility's failure to assure that resident #23 did not wander into other residents rooms, caused resident #23 actual harm increasing the likelihood of/or was likely to cause serious harm, impairment or death to resident(s). Resident #23, has suffered actual harm with skin tears, abrasions, and bruises/discolorations, because the facility failed to protect the resident from wandering behaviors. As a result of the wandering behavior of R#23, R #3, R#44 and R#45 have suffered mental abuse including the daily fear of lack of a secure environment and R#23 has suffered mental abuse by the physical, threatening behavior of the other residents. It was determined that the facilities non-compliance with one or more requirements of participation had caused or was likely to cause serious injury or harm to resident therefore on 12/10/15 at 3:20 p.m. the Corporate Director of Operations, Corporate Clinical Director of Clinical Services, and Administrator were notified that an Ongoing Immediate Jeopardy (IJ) caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents of the one-hundred twenty-three (123) residents that reside in the facility. The Ongoing IJ was determined to exist beginning on 9/05/2015 at 1:30 p.m. Findings include: 1. Record review of the Minimum Data Set (MDS) annual assessment dated [DATE] for R#23, revealed the following: Section B : Hearing, Speech and vision - resident usually understood when expressing ideas and wants, difficulty communicating some words or finishing thoughts but able if prompted or given time; resident sometimes understood verbal content, responded adequately to simple, direct communication only; Section C : Cognitive Patterns: Staff Assessment for Mental Status (Brief Interview for Mental Status not completed) - short term and long term memory problems, able to recall staff names and faces only with severely impaired decision making: never/rarely made decisions regarding tasks of daily life Section E: Wandering - behavior occurred daily but did not significantly intrude on the privacy or activities of others; Section I - Active [DIAGNOSES REDACTED]. Cognitive Communication deficit and delusional disorder. Record review of the Behavior/Intervention Monthly Flow Records, for resident #23 for September through November revealed documentation for behaviors regarding: Danger to others, Afraid/Panic. December Behavior/Intervention Monthly Flow Records revealed documentation for behaviors regarding: Danger to others, Afraid/Panic and striking out. Further of the Behavior/Intervention Monthly Flow Records revealed documentation of Danger to others for biting on 10/12/2015, compulsive and danger to self on 10/14/2015. Review of the Nurse's Notes revealed a Situation Background Assessment Report (SBAR) Communication Form and Progress note dated 07/18/2015 regarding a resident to resident incident between R#23 and R#45. R#45 pushed R#23 to the floor R#23's sustained a skin tear to the left forearm. No further information was provided. Review of the SBAR Communication Form and Progress note dated 08/08/2015, revealed a CNA observed R#23 to enter the room of R#45 (no time given) R#45 pushed R#23 to the floor. R#23 sustained skin tears to the right hand index finger and thumb. Review of the SBAR Communication Form and Progress note dated 09/05/2015, (no time given) revealed the R#23 had entered room of 4-A (R#3). R#23 laid down on the bed then R#3 pushed R#23 off the bed. R#23 sustained a skin tear to the right posterior forearm, an abrasion to the right posterior hand and a skin tear underneath the left side of the nose. (Review of resident incident report noted time of 1:30 p.m.) Review of Resident to Resident altercation between R #3 and R #23, State Reported Incident #GA 789, with Resident Incident Reports dated on 09/05/2015 at 1:30 p.m. revealed that Certified nursing assistant (CNA) VV called for help after observing R#23 positioned on his hands and knees beside the doorway of room four (4). The investigation revealed the incident occurred when R#23 went into the room of R#3 (4A) and laid down on the bed of R#3. R#3 revealed he pushed R #23 off the bed and onto the floor. According to the report, R #23 landed on his knees in the entrance to room 4A sustaining a skin tear to his right posterior forearm with bleeding noted, a skin tear to his left nostril and abrasions to his right posterior hand (no bleeding noted). R #23's statement revealed he was sorry. R #3 was advised by Licensed Practical Nurse (LPN), FF (who completed the report) to call for assistance when another resident was in his bed. Resident #3 indicated he would. Review of the SBAR Communication Form and Progress note dated 10/04/2015, (no time given) revealed R#23 was observed by a CNA to be in the bed of room 2- A ( R#45 resided in room 2-B). Resident #45 asked R#23 to get out of the bed/room then began striking R#23 with closed fist. R#23 sustained a light purplish discoloration above the left eyebrow. Review of resident incident report noted time of 10:00 a.m. Review of Resident to Resident altercation between R #23 and R #45, State Reported Incident #GA 729, with Resident Incident Reports dated at 10/04/2015 at 10:00 a.m. revealed CNA YY was walking down the hallway and heard R#45 yelling at R#23 to get out of his room. R#23 was observed lying in bed A with R#45 (from bed B) striking R#23 above the left eyebrow with a closed fist. CNA YY intervened and called for a nurse. R #23 was noted with red and light purple discolorations above the left eyebrow. R #23 was assisted back to his bedroom. Review of the SBAR Communication Form and Progress note dated 10/12/2015, revealed R#23 ambulated into the room of R#3, who resides in room 4-A. Resident #3 began yelling, slapping and hitting R#23. Resident #23 sustained multiple skin tears to the left arm, hand and neck. Review of resident incident report noted time of 6:00 p.m. Review of Resident to Resident altercation between R #3 and R #23, State Reported Incident #GA 000, with resident incident reports dated 10/12/2015 at 6:00 p.m. revealed R#23 ambulated into the room of R#3 (room 4) and the residents began yelling and arguing. Then R#3 began slapping and hitting R#23. R#23 sustained multiple skin tears to his left arm, left hand and to his neck. R#23 was confused and unable to give a description of the event. R#3 revealed he was upset because R#23 kept coming into his room and he did not want him coming into his room. The residents were separated. Review of the SBAR Communication Form and Progress note dated 11/30/2015, 2:15 p.m. revealed R#23 noted as constantly wandering into other resident's rooms was witnessed by a Certified Nursing Assistant (CNA) to walk into the room of the resident in room 2-B bed (R#44). R#44 became agitated and began punching R#23 in the chest, no injuries were noted. Review of Resident to Resident altercation between R # 23 and R # 44, State Reported on December 04, 2015 (with no Incident Number assigned at this time) with resident incident reports dated 11/30/2015 at 2:00 p.m. revealed resident #23 ambulated into the room of R#44 (room 2 B) who became agitated and punched R#23 in the chest. Then at 5:00 p.m. resident #23 went into the room of R#44 (room B) and the residents began fighting. Resident #23 sustained multiple skin tears and bruises to his bilateral, face neck and head. R#23 was confused and unable to give a description of the events. R#45 revealed he hit R#23 because he came into his room. The residents were separated and resident #23 was sent to the emergency room for evaluation. Review of the SBAR Communication Form and Progress note dated 11/30/2015 at 5:00 p.m. revealed that R#23 ambulated into the room 4-A, R#3 and got into the bed. R#3 became agitated and struck R#23. Resident #23 sustained multiple skin tears and bruises to the face and neck and an abrasion to the head. Resident #23 was sent to the emergency room for further evaluation. When the family member was notified she stated the resident would not be returning to the facility, however, the resident did return to the facility after the emergency room visit. Review of Resident to Resident altercation between R #3 and R #23, State Reported Incident #GA 304, had a Facility Incident Report Form dated 11/30/2015 at 5:15 p.m.that revealed R#23 went into the room of R#3's (room 4A) and got into the bed of R#3. R#3 became agitated and began hitting R#23. R#23 sustained multiple skin tears as well as a hematoma to the right forehead. R#23 was sent to the emergency room for evaluation. Observation on 12/07/2015 at 12:15 p.m. revealed Resident #23 up ambulating in the hallway, several scabbed areas observed on bilateral arms. Observation on 12/08/2015 at 7:50 a.m. on Faith Two (the secured unit). Yelling heard from room four (4). Observed resident #23 in the bed of resident in room 2 B, R#60. R#60 yelling loudly at resident R #23 for resident to get out of his room (resident in bed 2 A, R #3, not present). Resident #23 got up off the bed but continued wandering around the bed with resident R#60 yelling at him the entire time. After five (5) minutes (7:55 a.m.), resident #23 left the room and began walking up the hallway. The stop sign was not up on the doorway of room 4. Administrator appeared and put the stop sign up on the doorway and apologized to the R#60. Staff assisted resident #23 up the hallway. Interview on 12/08/2015 at 8:00 a.m. with resident #60 revealed there were two (2) wanderers on the unit including Resident #23 (he did not name the other resident) who went in and out of resident's rooms. It only bothered the R#60 if he was trying to watch TV (this TV was presently on). R#60 added that the facility had put a stop sign up which was working to keep residents from wandering into his room. Interview on 12/09/2015 at 8:45 a.m. with the Director of Nursing and the Assistant Director of Nursing regarding resident #23. Resident #23 required redirecting. A new psychiatrist started and reviewed the resident's medications and made changes, a stop sign was put up on the door to one room to deter him and staff attempted to keep an eye on him and to keep him entertained. Interview on 12/09/2015 at 9:20 a.m. with the Social Service Director (SSD) regarding resident #23, he required constant redirection. A room change on the unit was discussed, however the resident was in and out of every room on the unit regardless. Interview on 12/10/2015 at 8:45 a.m. with the Medical Director (MD) regarding altercations with physical injury involving resident #23, the MD would expect the resident to be watched to make sure that did not happen. He thought the SSD had been trying to place the resident in another facility but was having difficulty due to his behaviors. Resident #23 had medications available but the MD was opposed to chemical restraints. There was also a new psychiatrist available and Salus Behavior Management was available. Interview on 12/10/2015 at 10:30 a.m. with the DON, ADON and LPN AA in the nursing office revealed that, LPN AA was responsible for staffing on Faith Two. When asked if they had ever considered increasing the staff on Faith Two due to occurrences with resident #23 the staff replied that they had to go with what they had due to people resigning/quitting and the paycheck problems they had. Also, not everyone desires to work with the special populations such as the residents on Faith Two. The physician had suggested medication changes but the family did not want resident #45 on certain medications. He had altercations with a prior roommate (#45) so that resident was moved to another room on Faith II, but resident #23 continued to identify with the old roommate and go into the new room with ongoing altercations with resident #45 resulting in resident #45 being transferred to a different facility with a behavior unit 2. Review of the MDS Annual assessment dated [DATE] for R#3 revealed the following: Section B : Hearing, Speech and vision - resident sometimes understood when expressing ideas and wants, ability is limited to making concrete requests; resident sometimes understands verbal content, responds adequately to simple, direct communication only; Section C: Cognitive Patterns - Brief Interview for Mental Status (BIMS) Summary score 06 - severely impaired cognition; Section E: No behavior symptoms; Section F: Interview for daily preferences -it was very important for the resident to take care of his personal belongings or things, and; Section I - Active [DIAGNOSES REDACTED]. Review of the Behavior/Intervention Monthly Flow Records, for resident #3 dated November 2015 revealed evidence of behaviors including yelling out, refusal of care and danger to others with one episode of yelling out on 7 a.m. to 7 p.m. shift on 11/14/2015. Review of the Care Now Comprehensive Psychiatric Diagnostic Evaluation dated 07/06/2015 revealed a [DIAGNOSES REDACTED]. Review of the Behavioral Health Evaluation dated 08/04/2015 revealed the R#3 had a history of [REDACTED]. No current psychosis noted. Review of the Care Now Services Behavioral Health Services Progress Note dated 09/21/2015, revealed R#3 had an altercation on 09/05/2015 with another resident (SBAR revealed this to have been with R#23). R#3 could be agitated at times but denied problems with another resident. (resident not specified in the progress note). R#3 is estranged from family and has no visitors. R#3 appeared displeased and hopeless with a flat affect. 09/05/2015 Resident #23 entered the room of resident #3 and laid down on the bed. Resident #3 pushed R#23 off the bed. (according to the SBAR communication for res R#23, R#23 sustained a skin tear to his right posterior forearm and underneath the left side of his nose and an abrasion to his right posterior hand) 10/12/2015 R#3 became upset due to R#23 continuing to enter his room. R#3 was yelling at and slapping R#23. (according to SBAR for resident R#23, R#23 sustained multiple skin tears to his left arm, left hand and to the neck). Review of the SBAR Communication Form and Progress Note dated 11/30/2015, R#23 got in to the bed of R#3. R#3 became agitated and started to fight the R#23. R#23 and R#3 were separated, and a police report filed. Interview on 12/08/2015 at 1:35 p.m. with the Licensed Clinical Social Worker (LCSW) for Care Now Services revealed R#3 had depression regarding his placement in a facility and regarding his lack of family support, therefore his room was his whole word and he became agitated if other residents got in his personal space. 3. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] for R#45 revealed the following: Section B: Hearing, Speech and vision - resident understood when expressing ideas and wants, resident usually understands - misses some part/intent of message but comprehends most conversation; Section C: Cognitive Patterns: Staff Assessment for Mental Status (Brief Interview for Mental Status not conducted) - short term and long term memory problems, able to recall current season, location of room, staff names and faces, and that he/she is in a nursing home. Moderately impaired Cognitive skills for making decisions regarding tasks of daily life: decisions poor, and cues/supervision required; Section E: no behavior symptoms or wandering. Section F: Interview for daily preferences not completed - resident rarely/never understood and, Section I - Active [DIAGNOSES REDACTED]. Review of the Nurse's Notes and SBAR Communication Form and Progress note revealed, the following: On 07/06/2015 (time not given, MD notified at 6:57 p.m.), R#45 pushed another resident (not identified) into the dining room table. The other resident sustained [REDACTED]. On 07/16/2015 (time not given, family notified at 11 a.m.) R#23 and R#45 (room 1 A&B) were upset with each other and resident #23 rushed out of the room, tripped, fell and stated resident #45 was crazy. Resident #45 responded that resident #23 had stood over his bed and scared him. No physical altercation. Resident #45 was transferred to another room. On 07/18/2015 (time not given but family notified at 2:15 p.m.) Residents #45 and R#23 were observed arguing and yelling at each other (location not given) when resident R#45 pushed R#23 to the floor. R#23 sustained at skin tear to the left forearm. On 08/08/2015 (time not given, but family notified at 8:45 p.m.) R#23 wandered into the room of R#45 (2B)where R#45 grabbed R#23 by the hand causing injury to R#23 ' s hand (not specified) and causing R#23 to fall. On 09/07/2015 (time not given but family notified 5:40 p.m.), R#23 went into room 2B of R#45 who pushed R#23 to the floor. Resident #23 sustained a laceration to the right eye. On 09/07/2015 (times not noted) R#45 struck R#5 in the abdomen, because R#5 sat beside R#45 (location not given). On 09/21/2015 (time not noted but family notified at 4 p.m.) R#45 became agitated in the dining room and threw a chair at the staff. On 10/04/2015 (time not noted but family notified at 4:40 p.m.)Resident #45 entered his room - 2 bed B and found R#23 was lying in bed 2 bed A. R#45 began striking R#23 with his fist above the left eyebrow causing injury. (Injury not specified). R#45 discharged to another facility on 10/07/2015. Observation on 12/07/2015 at 9:55 a.m. revealed eleven (11) residents sitting up in the day room/dining room with the television (TV) on, no staff members observed in the room. Interview on 12/07/2015 at 10:00 a.m. with LPN AA on the Faith Two (the locked unit) revealed there was usually one (1) nurse and three (3) CNA's on the unit. Observation on 12/07/2015 at 10:15 a.m. revealed rooms 1 and 2 to be across the hall from each other and rooms 2 and 4 to be diagonally across the hall from each other. Soft Velcro stop sign across doorway of room 4. Interview on 12/08/2015 at 10:40 a.m. with CNA EE revealed that to help control behaviors the staff attempted to keep the residents occupied with activities such as movies, singing, playing games and throwing balls. Regarding wanderers the staff monitored the residents walking in the halls to keep them from going into other resident's rooms and getting into other resident's belongings. Residents were re-directed from other resident's rooms as needed and attempted to keep occupied. Attempts were made to have a staff member in the dining room at all times and to have someone monitoring the other residents at all times. A stop was sign was put up to keep R#23 from going into one of the rooms. Interview on 12/09/2015 at 8:30 AM with LPN FF revealed if a resident becomes agitated she does 1:1 by having the resident stay with her while she is passing medications. The residents responded to the attention and would settle down. Interview on 12/09/2015 at 9:20 a.m. with the Social Service Director (SSD) revealed she completed the MDS for sections C (Cognition), D (mood), E (behaviors) and Q (participation and goal setting). She also completed the care plan for these sections with appropriate interventions including those for redirection. Examples of caring for dementia residents would include understanding their face and body language since they cannot communicate like non- dementia residents, look at past work history for topics of conversation or related activities and talking with them, getting into their word is very important. Interview on 12/09/2015 at 2:15 p.m. with the Administrator, Regional Plant and Facility Supervisor, Corporate Clinical Director of Clinical Services and Corporate Director of Operations revealed that the intervention to assure the safety of residents on the unit was to separate them. The interview further revealed that there were nursing staff that rotated being on call and could come in to the facility if needed to help cover staff shortages, however, they were unaware of any current staff shortages. Interview on 12/10/2015 at 8:45 a.m. with the Medical Director (MD) regarding residents with behaviors. He stated the facility should have enough staff and manage the residents. Stated the facility needed more staff for resident safety and he had addressed this in the Quality Assurance Committee (QUA) meetings, the meeting prior to the last one. The MD revealed that in some cases the need for additional staffing could place residents at risk for harm due to aggressive behaviors putting residents and staff at risk, however, there were so many residents with psychiatric issues, staffing might not effect that regardless. Regarding management of behaviors, the MD revealed that he completed medication reviews but was against oversedating residents to manage behaviors. The MD went on to reveal he thought the facility was not equipped to take residents with behavior issues. Interview on 12/10/2015 at 10:30 a.m. with the DON, ADON and LPN AA in the nursing office revealed that, LPN AA was responsible for staffing on Faith Two. LPN AA revealed that she attempted to have three (3) CNA's for the 7-3 and 3-11 shifts and two (2) for the 11-7 shift. If there was a call out she, or designated staff, attempted to find a replacement. During the day, up until 5 p.m. to 6 p.m., there were staff available in the building to help as needed including a Unit Manager that worked between Faith Two and Haven Two, an activity person, a central supply person who was also a CNA and restorative nursing were on the unit at times. After 5 p.m. there would be a shift supervisor present over the entire building until 7 p.m. (hours 1 p.m. - 7 p.m.) and then on the 11 p.m. -7 a.m. shift. For weekends, there was a weekend supervisor and a department manager available. Any extra resident care staff in the building would get pulled to Faith II. Also, there were residents that went off the hall for activities, which meant fewer residents to care for during those times. Staffing was based on the acuity of care and the census. Acuity of care could mean such things as: more or an increase in the prevalence of behaviors, new residents getting acclimated, transfers from other halls and prevalence of roommate compatibility issues. LPN AA revealed she considered input from the staff who worked with the residents when completing the schedule. When asked if there had ever been consideration of increasing the staff on Faith Two due to occurrences with resident #23, the staff replied that they had to go with what they had due to people resigning/quitting and the paycheck problems they recently had. Also, not everyone desires to work with the special populations such as the residents on Faith Two. Staffing concerns had been brought up to corporate who had determined that two CNA's were adequate as long as the charge nurse could be available to assist, so changes to how medications were scheduled and administrated were implemented to allow the charge nurse more time off the cart to assist with resident care ( This was earlier in the year sometime). Nothing else they could recall had been brought up to corporate, however it was mentioned that they could not recall ever having such a high census on Faith Two. Regarding R#23, the interview revealed the physician had reviewed the medications and suggested some changes to the family who refused certain medications including Depakote in particular citing they felt the resident had been overly sedated at the last facility he was at. Interview on 12/10/2015 at 12:20 p. m. with the administrator revealed there were ten (10) wanderers on Faith Two. Interview on 12/11/2015 at 7:45 a. m. (works the night shift) with LPN GG revealed there were five (5) wanderers on the unit (resident #23 discharged to another facility). If a resident becomes agitated they might have a prn order available and staff can redirect as much as they can, supervise, and attempt to take to their own room. Were she to need additional staff on her hall she could check with another hall for staff to pull and call her supervisor. She had been on staff her for four years and could not recall a problem with needing help at night. Regarding the safety of resident #23, he was redirected back to his room and discouraged form contact with other residents and has prn available. It can be challenging when more than one resident at time requires redirection. Interview on 12/11/2015 at 10:40 a.m. with LPN HH revealed resident #23 had dementia and was in and out of resident's rooms. He required constant redirection and checking on where he was. He would get out of his bed and go to other rooms without staff seeing. He would swing out at other residents. It was especially difficult with two CNAs on 7 a.m. - 7 p.m. She stated the residents were possessive and wanted their privacy. Every time resident #23 got into an altercation with another resident it was because he went into their room. He would take their clothing and have their shoes on. The staff cannot provide 1:1 and the hall is L shaped so one staff member has to be able to see down the other hallway which was extremely difficult, especially if working with short staff; was manageable with three but when there were two CNAs, the incidents would increase. But, it was not like that every day. There were days on which nothing would occur. Also there were a lot of residents with behaviors. The physician tried to adjust resident #23s medications but the family refused certain medications due to feeling the resident was over sedated at his last facility. A review of staffing on days of incident occurrence revealed two CNA's on Faith II when the following occurred: 11/30/2015 5:15 p.m. Resident #23 and resident #3 - 2 CNA's 3-11 Census 30 10/12/2015 6:00 p.m. Resident #23 and resident #3 - 2 CNA's 3-11 Census 28 Review of the Facility Policy regarding Resident Rights revealed the residents had the right to be free from mental and physical abuse, had the right to self-determination and to security of possessions. Abuse prohibition review completed and revealed no concerns. Observations made on 12/07/15 at 11:15 a. m. revealed that the facility had two (2) resident smoking areas, main smoking area, located out the alcove off the main dining room, and the secured smoking area, located off of Faith 2 (secured unit). Continued observations of the main smoking area revealed a broken wooden broom handle with a Sharpe and jagged end. Further observations of the main smoking area revealed that there was an unlocked metal cabinet that contained unlocked block boxes. The black boxes were tabled with with resident names. It was revealed that the containers contained cigarette lighters and cigarettes. Further observations revealed metal rod with a hinge in the middle. Each portion of the rods measured approximately 3 (three) feet in length when folded, and approximately 6 (six) feet in length when unfolded. Each end of the medal rod had a Sharpe and pointed end. The metal rod was located on the window ledge on the right side of the metal cabinet. Further observations revealed that a door that was leading to the laundry department, from the resident smoking area, was propped open with a wooden handle and floor dryer. Observations on 12/07/15 at 11:30 a. m. revealed that fifteen (15) resident went on the scheduled smoke break. One (1) staff member was observed passing out cigarettes, Observations revealed that some residents received 2 (two) cigarettes at a time, when others were given just one. Residents were observed placing cigarette butts on the ground, on window ledges, and on the lids of the disposal trash cans. Interview on 12/08/15 at 8:30 a. pm. with Certified Nursing Assistant (CNA) RR revealed that the resident smoking supplies were stored and locked in the metal cabinet. RR revealed that each resident had a separate black box with cigarettes and lighters. The storage cabinet is to be kept locked and secured. It was further revealed that different floor staff are assigned to different smoke breaks. Interview further revealed that the residents get two cigarettes during the break, and that some get one at a time with others getting both. When asked about the cigarette butts that were not placed in the proper disposal containers, the interview revealed that the residents should place the discarded butts in the provided containers. CNA RR that should not be any cigarette butts on the ground or window ledges. Interview revealed that they were there when the day shift came to work. CNA RR revealed that each unit and environmental services monitor different smoke braes, and that all staff do not monitor the residents like they should. Interview revealed that the environmental services was to keep area clean and that the area should be clean. Observation on 12/07/15 at 1:30 p.m., 12/08/15 at 10:15 a.m., and 10/09/15 at 12:05 p.m. of resident #29 room revealed a power strip on the floor towards the right side of the bed side night stand. Continued observation revealed that the power strip was 2 feet from the resident's reclining chair and the resident's oxygen concentrator was plugged into the strip. Interview on 12/09/15 at 12:25 p.m. with the Regional Plant and Facility Engineer Supervisor they acknowledged that the power strip was located on the floor with resident medical care equipment plugged in. Continued interview revealed that he expects staff to notify him if a resident requires additional outlets for equipment. He revealed that he was told from someone who's name he cannot recall that the facility is not to use any power strips in the resident's sleeping areas. Surveyor: Olson, Elizabeth Review of R#40's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) cognitive status of eleven (11) which indicated cognitive impairment . Further review of the 7/31/15 MDS section G revealed R#40 required extensive assistance with personal hygiene and section I revealed [DIAGNOSES REDACTED].Altered Mental Status and Genarized Muscle Weakness. Observation on 12/7/15 at 4:17 p.m. of room # 60 revealed R #40 was in bed, alert and revealed he/she was not able to get out of bed because he/she would fall.Observation revealed the presence of three blue(3) disposable razors in the window sill next to the resident's bed. Licensed Practical Nurse (LPN) LL was informed of the presence of the razors at 4:17 p.m. on 12/7/15 and he/she confirmed the presence of the razors in the window sill next to the resident's bed and removed them. The resident stated he threw the razors on the window sill because he shaves himself. Resident #40 stated he shaves every other day and uses one razor each time he shaves. During interview the resident was observed to not have a roommate and revealed no residents come into his room . R#40 further revealed that if anyone came into his room he/she would call the nurse. During an interview on 12/7/15 at 4:20",2018-05-01
5868,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,354,D,1,0,7J0Y11,"Based on interview, and record review the facility failed to have a Registered Nurse for at least eight (8) consecutive hours a day to assess the residents residing in the facility and a Director of Nursing on a full time basis. Findings include: Interview on August 18, 2015, with the Human Resources staff revealed that the facility did not have a Registered Nurse on duty for eight (8) consecutive hours on August 14 and 15, 2015. The interview also revealed that the Director of Nursing (DON) did not return from a leave of vacation on August 12, 2015, therefore, the facility was without a Director of Nursing from August 12, 2015 until the morning of August 16, 2015. Interview on 8/26/15 at 3:07 p.m. with the Unit Manager of the Faith II revealed that there has been no shortage of staff on Haven II. She revealed that there is shortage of staff if the Census is decreased and that the Certified Nursing Assistant (CNA) is pulled from the unit to help cover the facility. Review of the two week staffing sheet for the pay period 8/9/15 confirmed there was no Registered Nurse coverage for 8/10/15, 8/14/15, and 8/15/15.",2018-05-01
5869,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,372,F,1,0,7J0Y12,"Based on observation and staff interviews the facility failed to ensure the area surrounding the dumpster was free from garbage items and cigarette butts as recommended by the contracted pest control company for prevention of pest/insects in order to provide the residents with a pest/insect free environment. Findings include: Observation on 12/07/15 at 10:15 a. m. of the facility's large compacting dumpster revealed that it was located towards the back left side of the building off o the laundry department and sat on an asphalt pad. Continued observation revealed garbage scattered around on the ground of the compacting dumpster and consisted of empty food containers such as ice cream cups, juice cups, Gatorade bottles, and plastic water bottles. Additional garbage items included eight (8) clear plastic disposable gloves, plastic drinking cup lids, and plastic drinking straws. The ground surrounding the dumpster was also covered with cigarette butts. Interview on 12/07/15 at 10:15 a. m. with the Registered Dietitian (RD) revealed that she confirmed that there was garbage and cigarette butts scattered on the ground around the dumpster. The RD also confirmed that several pieces of garbage were empty food containers from the kitchen. The RD stated that housekeeping was responsible for the area surrounding the dumpster but did expect dietary staff to make sure kitchen garbage went into the dumpster and not on the ground. Interview on 12/07/15 at 10:15 a. m. with the Interim Dietary Manager confirmed that there was garbage and cigarette butts on the ground surrounding the dumpster area. She confirmed that they were empty food containers from the kitchen on the ground and expects dietary staff to pick up the trash and dispose of it properly. The Interim Dietary Manager revealed that she monitors the dumpster area once a day for garbage, debris, and spillage usually in the afternoon. She revealed that housekeeping is responsible for the dumpster area but dietary does assist if kitchen trash has spilled. Interview on 12/07/15 at 10:18 a. m. with the Interim Housekeeping Supervisor confirmed that there was garbage and cigarette butts scattered on the ground surrounding the dumpster area. She stated she did not realize the amount of garbage surrounding the dumpsters and had expected someone on staff to assist with keeping the area clean. She revealed that housekeeping is the responsible department for monitoring the condition of the dumpster and the dumpster area.",2018-05-01
5870,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,428,D,1,0,7J0Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the consultant pharmacist failed to identify and report medication irregularities, related to Insulin orders and administration, for one (1) resident (#18) of sixteen sampled residents. Findings include: Review of the physicians order for resident #18 dated 12/1/15 revealed a [DIAGNOSES REDACTED]. Review of the physician's telephone order dated 11/18/15 revealed an order for [REDACTED]. Further review of the November 2015 Medication Administration Record [REDACTED]. Review of the December 2015 physician's orders [REDACTED]. Further review of the December MAR indicated [REDACTED]. Review of the physician orders [REDACTED]. Start Lantus 40 units sq. Review of the Medication Regimen Reviews revealed a medication review was done by the Consultant Pharmacist on 12/1 /15 with no new suggestions documented on the regimen review sheet. During an interview on 12/7/15 at 4:33 p.m. the Consultant Pharmacist stated the December physician's orders [REDACTED]. The Consultant Pharmacist revealed that he/she does a monthly drug regimen review and reviews the physician's orders [REDACTED]. Further interview on 12/9/15 at 11:45 a.m. the Consultant Pharmacist confirmed that when he/she came to the facility on [DATE] he/she would not have identified the Insulin dosage issue because he/she did not have the December physician order [REDACTED]. [REDACTED]. During interview on 12/10/15 at 4:30 p.m. the Associate Director of Nursing (ADON) and Director of Nursing (DON) stated they were not aware the Consulting Pharmacist was not able to review the December physician's orders [REDACTED]. The ADON and DON further revealed that they are the ones who are responsible for the pharmacy recommendations and reports and so they would have been the ones to be notified that the physician's orders [REDACTED]. During further interview on 12/11/15 at 9:30 a.m. the Consultant Pharmacist revealed the DON should have known he/she was not able to review the December physician order [REDACTED].",2018-05-01
5871,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,441,F,1,0,7J0Y12,"Based on observations, staff interviews, and policy review the facility failed to follow infection control policy and handling of soiled laundry for all one hundred twenty three (123) residents. Findings include: On 12/07/15 at 11:00 a. m. observation of the laundry department revealed that it was located in an alcove section of the building and excess by going through the resident smoking area. Continued observation revealed that the facility had three (3) washing machines and 3 dryers. Further observation of all 3 dryers revealed a build-up of lint in the filter and lint on the back and sides of the dryer machines. On top of the center washing machine was a box with discarded used plastic gloves. Continued observation of the center washing machine revealed four (4) yellow personal protection gowns. A black plastic garbage bag was tied and hung to the door of the center washing machine. This black plastic garbage bag contained lint and other black garbage bags filled with trash. Continued observation revealed a gray bin located in the corner across from the washing machines that was full and overflowing with soiled resident clothing. There were three (3) piles of soiled resident clothing laying on black plastic garbage bags across from the washing machines. Further observation revealed a yellow plastic bin across from the washing machines that contained several used gloves and a wheelchair leg rest. Observation of the washing machine on the right revealed a large white soiled blanket on the floor in front of the washing machine. Observation revealed that the laundry department floors were soiled and had a build-up of dirt and lint around the equipment and in the corners. Observation also revealed a signage document scotched taped to the wall which indicated Attention all Laundry Aides; 1) make sure all shelves are clean and neat, 2) make sure floors are swept and mopped, 3) empty all trash. Observation of an additional room leading from the three large dryers revealed additional piles of resident clothing piled on top of each other alongside the wall. On 12/07/15 at 11:05 a. m. observation of the laundry department revealed that laundry staff member JJ was handling dirty and soiled resident clothing without gloves or personal protection equipment. Observations revealed that laundry staff member JJ had obtained dirty and soiled resident clothing from the clothing bin and placed them in one (1) of the washing machines. Protective gowns and gloves were observed located on top of the center washing machine. On 12/08/15 at 8:45 a. m. a second observation of the laundry room was made in which at this time, the same pile of urine/feces soiled resident clothing that was observed the day before was still piled up in the corner in the grey bin. On 12/09/15 at 7:45 a. m. a third observation was made of the laundry room which revealed the same pile of resident soiled clothing to be piled on top of each other. At this time there were two to three yellow isolation gown observed hanging over the clothes hanger racks across from the washing machines. On 12/07/15 at 10:10 a. m. during interview when laundry staff member NN was asked what do staff do if a resident is in isolation and how do they handle residents clothing, he stated, What's that. On 12/07/15 at 10:15 a. m. during interview when laundry staff member NN was asked why there was a soiled blanket on the floor in front of washing machine on the right. Interview revealed the washing machine sometimes leaks but it hadn't in a while. It was further revealed that the blanket was there in case the washing machine on the right leaked. On 12/07/15 at 11:20 a. m. interview with laundry staff member JJ revealed that staff are to wear gloves when touching soiled clothing. Continued interview revealed that laundry staff JJ was in a rush and did not put gloves on. When asked, laundry staff member JJ was not sure about the policy and procedure for handling of the isolation laundry. JJ stated that there were yellow gowns that they can wear, but they only had a few. The interview further revealed that JJ was unaware of the location of any heavy duty utility gloves or any written infection control policy. On 12/08/15 at 9:00 a. m. interview with the Housekeeping/Laundry Supervisor revealed that she was not aware of a written policy for handling soiled isolation linen and clothing. Interview further revealed that the staff were told to wear the yellow isolation gowns and gloves with handling of all dirty or soiled linen. It was further revealed that they reuse the same gowns due to the short supply of them. The interview further revealed that request for supplies are given to the Administrator, but supplies of gowns had not been received as of 12/08/15. On 12/08/15 at 2:25 p.m. during interview with the Regional Plant and Facility Supervisor when asked if there is a Preventative Maintenance Program in place for the environment he stated, The nurses and Certified Nursing Assistant (CNA)s point out issues and we do not have a program . When he was asked if there was a long term plan to get the washers/dryers operational he stated They are for spare parts only. On 12/09/15 at 8:00 a. m. during interview the Housekeeping Supervisor confirmed that the pile of soiled clothing was in fact resident soiled linen that had not been washed yet. During interview when asked about the yellow isolation gowns, the Housekeeping Supervisor stated I have told my staff to use the isolation gowns and I have been on them about using the gowns. I even told them about a week or so ago that they are supposed to be wearing the gowns. When working with the soiled linens and loading clothes into the washing machines, they are not to touch anything without having an isolation gown on because of contamination. After that, I have told them to throw away their gowns and get a clean one when they get ready to load the machines the next time. When the Housekeeping Supervisor was asked if staff have been utilizing the Isolation Gowns when handling soiled linens, she stated, No that has not been happening. I was trying to get the previous housekeeping supervisor to let him know my staff were needing to have gowns on all the time and the response was that He would get them ordered for us. Just yesterday, I told my staff again they are needing to be wearing the gowns . On 12/09/15 at 8:05 a. m. during interview with laundry/housekeeping staff member OO regarding the yellow isolation gowns, she stated We put them on when we load the machines to keep our clothes from getting dirty I guess. So when the dirty clothes come from the halls we are supposed to put these gowns on. We have been using these (referring to the yellow isolation gowns) the last couple of days. When we get ready to load the washing machines with the soiled clothes, we are supposed to put the gowns on then take them off after loading the machines with the soiled clothes . When she was asked if staff dispose of the yellow gowns after each use with soiled linens she stated, No, we keep re-using them . On 12/09/15 at 8:07 a.m. during interview regarding the yellow Isolation Gowns, laundry staff member NN stated, We are supposed to be wearing them when we handle the soiled clothes and put them in the washers . When he was asked if they are disposed of afterwards, he stated, No we keep wearing and re-using them because we don ' t have very many . On 12/09/15 at 2:30 p.m. during interview regarding Infection Control, the Administrator stated It was just brought to my attention today that there were issues with the proper us of handling linens, so we in-serviced staff on the proper disposal of linens. It was just reported to me today. The Corporate Director of Operations stated The Housekeeping Supervisor has access to supplies, and we get supplies as necessary. On 12/10/15 at 10:15 a. m. interview with the Housekeeping Supervisor regarding the piles of soiled resident clothing, she stated that the large pile of soiled clothing had been piled up for at least three days. She stated I told the previous Housekeeping Supervisor that they can't just depend on me to do it all by myself and someone needs to pick up where I left off. The Housekeeping Supervisor indicated she was off work for two days, then came back to work and noticed the pile of soiled clothing was there. When I told the previous Housekeeping Supervisor, the response was that he would get with the laundry people and let them know to get the clothes out . On 12/10/15 at 5:10 p. m. interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that they were not aware of any concerns related to infection control problems with the handling of laundry. Further interview revealed that the DON and the ADON had only been with the facility for a few months and had never been to the laundry department and did not know what it looked like. The facility policy for laundry guidelines was requested from the Housekeeping/ Laundry Supervisor, Administrator, and the Director of Nursing (DON) on 12/08/15 and they failed to provide the requested policy until 12/11/15 at11:45 a.m. Review of the facility policy revealed the laundry staff did not follow the guidelines for handling of the laundry.",2018-05-01
5872,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,456,D,1,0,7J0Y11,"Based on observation, and interview, the facility failed to maintain a comfortable environment for one (1) resident (#30) related to air conditioning; failed to ensure that two (2) of three (3) washing machine and one (1) of three (3) dryers in the laundry room was operational. Findings include: 1. Interview with resident #30 on 6/26/2015 at 2:30 p.m. who states she is much cooler now. The resident stated a family member brought in a fan for use. Resident #30 further states that no one at the facility offered a fan, but someone brought in the smaller one after the resident complained. 2. Observation and interview on 6/26/15 at 3:45 p.m. with the Maintenance Director revealed the following temperature monitoring using the facility's infra-red temperature gauge in the Dining room - 77 ; in the Hallway - 72 (AC Vent directly overhead); in room # 14 the temperature was - 78 ; in the Locked unit - 76 and on the Back hallway - 77 . There were no temperatures of 80 degrees observed. The Maintenance Director revealed he was called into the residents room two weeks or so ago because the resident was complaining that it was too hot. The temperature in the room measured 76 at that time. He worked on the thermostat the next day to make sure it was working correctly. He further states that the facility is doing all that it can to ensure residents are comfortable. He has performed maintenance on the units and they are working at maximum capacity. Interview on 6/26/2015 at 5:50 p.m. with Assistant Director of Nursing (ADON) and Administrator revealed that he went to resident MM room to investigate the room temperature and called Maintenance to service the thermostat and a fan for resident MM. The Administrator revealed that on 6/16/2015 an air condenser fan motor went out on one of the Air Conditioning (AC) units on Haven 2 hall. It was replaced on 6/18/2015 and residents were offered extra hydration. The same issue occurred on 6/24/2015 on Haven 1 hall and was repaired. Residents again were offered additional ice and water and fans were placed in the hallway to keep air moving. 3. Observation on 8/26/15 at 11:30 a.m. of the Laundry Room revealed one (1) large bin of dirty clothes that was delivered that morning. Further observations revealed only one (1) large washer working of the three (3) washers in the room. There was only two (2) of three (3) dryers working. Interview on 8/26/15 at 11:30 a.m. with the Laundry Room/Housekeeping Manager revealed that there had been no complaints about the laundry not being returned on time. She revealed that the facility had personal clothes days on Mondays and Fridays for the residents that want their clothes washed on those days. She revealed that they go to those residents room every Monday and Friday. She also revealed that there was only one (1) washer working; and, that the parts to another washer should be in on 8/26/15. Continued interview revealed that only two (2) of the dyers were working and she did not know when the third (3rd) dryer would be repaired. She revealed that she has been able to keep up with clean laundry getting out to the staff and residents because she usually comes in to work at 6:00 a.m. She revealed that this is her way of making sure that the clothes are clean and the staff have enough linens. Interview on 8/29/15 by telephone with floor tech SS revealed that the washers and dryers have been breaking down at different intervals over a period of time. He revealed that when the Maintenance worker is not there; repairs are reported to the Director of Nursing (DON). He revealed that the DON would call the Maintenance Director because he is on call 24/7. He revealed that parts have to be ordered for the washers and dryers and it takes a while. He revealed that the only time he has seen clothes piled in the laundry room is when clothes are donated by families. He revealed that it was not because the laundry staff was unable to wash the clothes.",2018-05-01
5873,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,463,E,1,0,7J0Y11,"Based on observation, and interview, the facility failed to ensure that all call lights were functioning to alert staff of residents (#28, #29, and #34) needing assistance of the forty-nine sampled residents. Findings include: 1. Interview on 8/25/2015 at 3:05 p.m. with resident # 28, revealed that the call light has not been working for as long as the resident can remember. Observation and a test of the call light for resident # 28 was performed by depressing the button on top of the call light cord which should have caused the light outside of room 30 to turn on, thereby signaling the nurse that the resident requires assistance. The light outside the room did not turn on despite multiple attempts including unplugging and replugging the cord and resetting the call light switch. Interview with the Charge Nurse for Faith One hallway on 8/25/2015 at 3:10 p.m. revealed no knowledge that the call light in room 30 was not operational. Interview on 8/25/2015 at 3:15 p.m. with the Maintenance Supervisor reveals no one has told him the call light was not working, but parts for call lights have been ordered and should be delivered with-in the next 7 -10 days. Observation on 8/25/2015 at 4:05 p.m. revealed the call light was repaired and functioning properly. 2. Observation and interview on 8/25/2015 at 1:40 p.m. with resident #29, revealed that the call light has not worked since admission. The resident is in a single room and is bed bound. Inspection of the call light panel reveals that the call system is non-functional. Interview on 8/25/2015 at 3:20 p.m. with Maintenance Supervisor reveals that he was unaware of the call light not working but recalls that there have been problems with it in the past. Interview on 8/25/2016 at 4:05 p.m. with the Charge Nurse for Haven Two hall revealed no knowledge of the call light not working. Interviews on 8/25/2015 at 4:00 p.m. with the Maintenance Director and Maintenance Supervisor reveals that there is no work order system in place for reporting maintenance issues. Neither employee was aware of any call light issues. An Annual Work Order History Report was produced that reveals that the Nurse Call System is tested every three months and the next test is due in September. Interview on 8/25/2015 at 5:00 p.m. with Maintenance Director and Maintenance Supervisor reveals all call lights will be monitored for working order beginning 8/25/2015 and work orders will be entered for repairs. 3. Observation on 10/14/2015 at 12:30 p.m. resident #34 resides revealed the call light working but box in room did not light up and re-set button was missing. Interview on 10/15/2015 at 10:10 a.m. with the Maintenance Director and the Housekeeping Supervisor revealed the call light observations were on the Angel Rounds as well as a weekly maintenance rounds and the routine three month rotating schedule. He was not sure how there currently could be any call lights in need of repair in the building.",2018-05-01
5874,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,465,F,1,0,7J0Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain functioning laundry equipment for one (1) of three (3) washing machines and one (1) of three (3) clothes dryers for the facility. Findings include: On 12/07/15 at 11:00 a. m. observation revealed that the facility had two (2) of three (3) washing machines that were in working condition, and two (2) of three (3) dryers in working condition. Observations further revealed piles of resident clothing located in the laundry department. Observations revealed that the equipment was not in operation for five (5) of the five day survey. On 12/07/15 at 11:10 a.m. an interview with the Housekeeping/Laundry Supervisor revealed that the facility had only two working washing machines, and two working dryers for over 10 (ten) years. Interview further revealed that the washer to the right had a history of [REDACTED]. On 12/07/15 at 4:45 p.m. an interview with the Regional Plant and Facility Supervisor revealed that the dryer and washer had not been working for about twelve (12) years. Further interview revealed that the equipment had not been removed because the facility staff uses the equipment for spare parts. Continued interview revealed that there was no place to repair or replace the washer or dryer. It was further revealed that it was not cost effective to repair the dryer or washer. On 12/11/15 at 9:00 a.m. interview with Administrator revealed that there were plans to get estimates for repairing or replacing the broken dryer and washing machine. The Administrator further revealed that the plans had not been completed. On 12/07/15 at 10:15 a.m. during an interview with laundry staff member NN , he stated that the blanket on the floor next to the washing machine on the right was because Sometimes it leaks but it hasn ' t in a while. We just have it there in case it does.",2018-05-01
5875,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,469,E,1,0,7J0Y11,"Based on observation and interview the facility failed to provide an effective pest control program for six (6) resident rooms (# 52, 56, 77, 49, 44, and 42) of the twelve (12) sampled rooms. Findings include: 1. Interview and observation on 8/25/2015 at 1:30 p.m. with the resident who resides in room 52 revealed, one (1) dead bug laying on floor. The resident stated he had killed the bug earlier in the morning. 2. Interview and observation on 8/25/2015 at 1:35 p.m. of room 56, the resident who resides in the room , revealed dead bugs in corners of windowsill. 3. Observation on 8/25/2015 at 1:50 p.m. of room 77, revealed flies were flying in the room. 4. Interview on 8/25/2015 at 2:10 p.m. with the resident who resides in room 49, revealed that bugs have been a problem and reported them to the previous Administrator. 5. Interview on 8/25/2015 at 2:00 p.m. the resident who resides in room 44, stated there used to be a problem with bugs which was reported to the Administrator, but has not had any problems recently. 6. Interview on 8/25/2015 at 1:40 p.m. the resident who resides in room 42, revealed that bugs have been a problem, but not recently. Interview with the Maintenance Director and Maintenance Supervisor on 8/25/15 at 5:00 p.m. revealed that a new pest control contract had been signed on 7/20/2015 for monthly service. The new service includes monthly service inside and outside of the building. The contract also includes insect light traps were installed and bait stations inside and outside of the facility. The contract also includes rodent, flies, and drainage management. The last pest service was on 8/19/15. Interview with the Administrator and the Director of Nursing on 8/25/15 at 5:10 p.m. revealed that the pest control company would be called the next day for additional services. Interview on 10/15/15 at 9:15 a.m. with Certified Nursing Assistant (CNA) ZZ revealed that she was walking through the main dining room at 7:00 a.m. and saw three (3) roaches. The CNA stated that they see bugs everyday, but there has been some improvement now that the bug company comes every week. The CNA stated she did not report seeing bugs to anyone and did not know who to report seeing bugs to.",2018-05-01
5876,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,490,K,1,0,7J0Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review the facility administrator failed to assure that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents of the one-hundred twenty-three (123) residents that reside in the facility. On [DATE] at 3:05 p.m. Goodwill Health and Rehab, Corporate Director of Operation, Corporate Clinical Director of Clinical Services, and the Administrator were notified that an Ongoing Immediate Jeopardy (IJ) had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents of the one-hundred twenty-three (123) residents that reside in the facility. The Ongoing IJ was determined to exist beginning on [DATE] at 1:30 p.m. when the Administrator failed to assure that: The Code of Federal Regulations (CFR) 483.13(c) (F226 K) when R #3 and R #23 sustained a Resident to Resident altercation (State Reported Incident #GA 789), dated on [DATE] at 1:30 p.m. when R#23 went into the room of R#3 (4A) and laid down on the bed of R#3 pushed R #23 off the bed and onto the floor. R #23 landed on their knees in the entrance to room [ROOM NUMBER]A sustaining a skin tear to his right posterior forearm that was bleeding, a skin tear to the left nostril and abrasions to the right posterior hand. Continue review revealed that resident to resident altercations for four (4) other residents (R#40, R#42, R#44, and R#45) sustained resident to resident altercations. The CFR 483.13(c)(1)(ii)-(iii)(c)(2)-(4) (F225 K) when R#14 reported to the facility that they had been threatened bodily harm including death by an identified family member reported on [DATE] (the alleged threat occurred on [DATE]), and the Administrator failed to assure interventions were in place to protect the resident even though the facility reported to the State Agency a self report incident (GA 6054). The CFR 483.15 (h)(1) (F242 J) when R#14 reported the desire to have a retraining order after an identified family member threatened bodily harm even death on [DATE]. The resident suffered actual psychological harm expressed as fear. However, the Administrator continued to allow the identified family enter the facility the first week of [DATE]. The CFR 483.14 (h)(1) (F252 F) and CFR 483.15(h)(2) (F253 F) the Administrator failed to assure that the resident rooms, common areas used by residents were maintained in a clean, orderly, and homelike environment which increased the likelihood to affect all of the one-hundred-twenty three (1230 residents residing in the facility on four (4) of (4) halls including resident rooms, bathrooms, dining room, smoking areas, and hallways. The CFR 483.25(F)(1) (F319 K) the Administrator failed to assure services to evaluate, diagnose, treat and implement psychiatric recommendations for three (3) residents (R#45, R#42 and R#40) with a history of behaviors that affected the residents and others. The CFR 483.25(h) (F323 K) the Administrator failed to assure that one-hundred-twenty-three- residents who reside in the facility had a safe environment including accident/hazards, abuse free related to resident to resident altercations ((R#3, R#23, R#40, R#42, R#44, and R#45) with resident to resident altercations, psychological harm related to behaviors of non-cognitive residents wandering into other residents rooms, and allegations of threatened bodily harm/death for R#14. Findings include: On [DATE] at 2:15 p.m. the Administrator makes random rounds in that area and we have a guardian angel program that staff monitor as well. The Administrator stated, I monitor the common areas myself (Administrator), Housekeeping and maintenance are doing routine rounds. My housekeeping Supervisor just started Monday. According to the Plan of Correction the Administrator stated We make rounds together 5x/week and have been doing so weekly. When the Administrator was asked do you go into the rooms together? She responded We do. We take care of things as they arise. It would also be housekeeping that would oversee the common areas. The Administrator stated the Pest Control did provide services. The Administrator stated, We were focusing on the 2567 only and all the rooms on the 2567. We paid close attention to those, then we would move on as time allows. The Administrator stated the Guardian Angel Program-we enter a room I make rounds with housekeeping as well and give the staff timeframe as to when things should be completed. When the Administrator was asked why the issues the team has identified have not been addressed, the Administrator stated, We only focused on the 2567. Per the Administrator the Guardian Angel Program only focused on rooms and not really on common areas. When asked what was the Administrator thoughts about the medication concerns, the Administrator stated, We took full accountability. We notified the Dr. of the transcription error. The Administrator stated, I go to the medication carts daily and I communicate with central supply coordinator. Staff will be held accountable. The DON is supposed to check every day and I do random audits 5x week. The Administrator stated we did a facility wide sweep and made sure supplies were in house that was checked by the DON. The Administrator stated we will bring charts to pre-clinical meets to make sure charts are audited every morning Monday through Friday. The Administrator stated related to [MEDICATION NAME] we will start a cart to Medication Administration Audit (MAR) audit and if there are any changes we will put that on the cart to refer to the MAR indicated [REDACTED]. The Administrator stated related to the [MEDICATION NAME] medication order, It should be the nurse or unit manager that was supposed to fax the order over. The administrator stated ' We are now implementing that cart audits to make sure orders are being carried over. When asked about the [MEDICATION NAME] what system was in place the Administrator stated We were doing weekly chart audits to ensure medications were in the building. Regarding residents on the locked secure unit with behaviors, and resident to resident altercations the Administrator stated You separate them. Give us the opportunity to fix the problem. I understand where you are coming from. As far as activities there is no program in place. Regarding Infection control- Per the Administrator she stated Infection control was brought to my attention today that there were issues today so we in-serviced the staff today on the disposal of linens and it was just reported to me today.",2018-05-01
5877,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,493,K,1,0,7J0Y11,"Based on record review and interview the Governing Body failed to assure that employees were paid, the Quality Assurance Committee was effective, investigations were conducted and reported, equipment was maintained and the facility had 8 hours of Registered Nurse coverage. Cross reference: 1. F225-the governing body failed to assure that investigative reports were completed to the Department within 5 business days after an incident of injury and that narcotics were safe guarded against non-resident use; 2. F309-the governing body failed to assure that the facility had supplies to monitor blood sugar of insulin dependent diabetics causing actual harm to one resident; 3. F354-the governing body failed to assure that a Registered Nurse was on duty at least eight (8) hours a day, and failed to assure a Director of Nursing was in charge of nursing services; 4. F493-the governing body failed to assure that adequate financial support was available to cover expenses for the care and services of all the residents including paying employees, per interview with the Administrator via telephone, payroll checks did not clear the bank, and the payroll has been changed from every other Friday to every other Tuesday. Per interview with twenty-one (21) employees, six (6) employees had payroll funds be insufficient, and; 5. F520-the Qaa Committee failed to monitor the Plan of Correction for the Standard survey with F309 re-cited on the revisit. Findings include: Interview on 8/26/15 at 1:54 p.m. with Accounts Payable revealed that the first time payroll checks bounced was on the 7/31/2015. The corporate office was notified and reported to the employees that any service charges would be paid by the company. Then corporate changed payroll dates would be to every other Tuesday but did not notify the employees of the change. Interview on 8/26/15 at 10:00 a.m. through 12:18 p.m. with twenty-two (22) employees revealed that six (6) staff had payroll checks bounce, including one (1) Licensed Practical Nurse, 1 floor technician, 1 laundry worker, 1 Medical Record staff, the Director of Admission and 1 Unit Manager.",2018-05-01
5878,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,514,D,1,0,7J0Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate clinical records regarding transcription of physician orders [REDACTED].#18)of sixteen insulin dependent residents. Findings include: Review of the clinical record for resident #18 revealed an 11/18/15 physicians's order for [MEDICATION NAME] 40 units subcutaneous (sq) at bedtime and to discontinue [MEDICATION NAME] 32 units sq at bedtime. Record review of the physicians handwritten and telephone orders from 11/18/15 to 11/30/15 revealed there were no Insulin orders written after the 11/18/15 order for [MEDICATION NAME] 40 units at bedtime. However, review of the December 2015 physicians orders revealed an order for [REDACTED]. Review of the December 2015 Medication Administration Record(MAR) revealed documentation that [MEDICATION NAME] 32 units was administered from 12/1/15 to 12/6/15. During an interview on 12/7/15 at 12:35 p.m. with Licensed Practical Nurse(LPN) KK revealed that the [MEDICATION NAME] 40 units sq at bedtime was not carried forward during the change over done at the end of every month He/she further revealed that the Unit Manager or another LPN does the change over from month to month. During an interview on 12/7/15 at 1:45 p.m. with the Director of Nursing (DON) he/she stated there was an error in the transcription from the November to December 2015 orders and MAR's during the change over at the end of November 2015. The DON further stated that the Unit Manager or person bringing over the orders signs the MAR indicated [REDACTED]. The DON confirmed the 11/18/15 telephone order for [MEDICATION NAME] 40 units sq at bedtime and to discontinue [MEDICATION NAME] 32 units sq at bedtime was not brought over to the December physician orders [REDACTED].# 18 not receiving the correct dose of [MEDICATION NAME] as ordered by the physician. During an interview on 12/9/15 at 8:40 a.m. with the resident's physician revealed it was his/her expectation that the physician's orders [REDACTED].",2018-05-01
5879,GOODWILL HEALTH AND REHAB,115486,4373 HOUSTON AVE.,MACON,GA,31206,2015-10-15,520,K,1,0,7J0Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have an effective Qaa Committee monitoring the Plan of Corrective Actions plans for continued compliance with federal regulations. Cross refer to F309 Findings include: A revisit was conducted on 8/26/15, in conjunction with complaint investigations during the revisit Substandard Quality of Care was cited based on actual harm to one (1) resident #1, when the facility failed to assure that supplies to measure blood glucose was present for treatment of [REDACTED]. Based on record review and staff interview the facility failed to follow physicians' orders related to sliding scale insulin coverage for ten (10) residents (#1, #3, #5, #6, #8, #11, #12, #13, #14, #20) of twenty-seven (27) sampled residents; failed to follow finger stick blood sugar (FSBS) assessments causing actual harm to one (1) resident (#1). Findings include: 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the residents' physician orders [REDACTED]. for FSBS of 150-199 = 2 units; for FSBS of 200-249 = 4 units; for FSBS of 250-299 = 6 units; for FSBS of 300-349 = 8 units; for FSBS of 350--400 = 10 units; for FSBS of greater than 400 = 12 units, notify MD; Accuchecks before meals with sliding scale coverage; Accu-check at bedtime without sliding scale coverage and notify MD if greater than 400 at 9:00 PM. Record review of the Medication Administration Record [REDACTED]. Continued review of the record review of a SBAR communication form and Progress Note revealed that on 8/4/15 the resident was clammy and lethargic with a Blood Pressure of 102/68 and pulse of 54 and respirations of 14. The emergency room History and Physical revealed that the chief complaint was [MEDICAL CONDITION] and unresponsive at 9:16 AM on 8/04/2015. The resident's blood sugar was recorded at >2000. 2. Record review of the physician orders [REDACTED]. Record review of the MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. 3. Review of the physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. Also, there was no documentation for the 8/4/15, 6:30 every AM blood sugar FSBS or Insulin given. 4. Review of the physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. Also, there was no documentation of the 8/5/15. FSBS and Insulin coverage (if any required). Record review for resident #8 revealed physician orders [REDACTED]. Record review of the Medication Record revealed no evidence of FSBS accuchecks at 9:00 PM on 8/7/15 and 8/15/15. Record review for resident #8 revealed physician order [REDACTED]. Review of the MAR indicated [REDACTED]. 5. Review of the physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. Also, there was no evidence of the 4:30 PM FSBS for 8/12/15 or Insulin given for that date. 6. Record review of resident #12 revealed a physician order [REDACTED]. Review of the MAR indicated [REDACTED]. 7. Review of the physician orders [REDACTED].> than 400 for the FSBS at both times. Review of the MAR for 8/3/15 and 8/5/15 revealed that the resident did not get his blood sugar checked at 9:00 PM for both dates. 8. Review of the physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. Also, on 8/4/15 at 6:30 AM there was no evidence of a FSBS or sliding scale Insulin administered. In addition, there was no FSBS documented or sliding scale Insulin given on 8/6/15 at 4:30 PM. 9. Review of physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. Also, on 8/12/15, the MAR indicated [REDACTED]. 10. Record review of the MAR for resident #3 revealed that the resident had physician orders [REDACTED]. A review of the Medication Record for 8/3/15 at 9:00 PM, revealed no evidence that an FSBS accuchecks was completed. Interview with Licensed Practical Nurse (LPN) AA on 8/18/15 at 12:00 noon, revealed that on 8/3/15 at 9:00 PM and 8/4/15 at 6:30 AM, there were not enough diabetic test strips in the building to perform finger sticks blood sugars. The staff nurse stated that she looked through out the building and on other medication carts, but could not find any diabetic test strips. The nurse further stated that she informed the Director of Nursing on 8/4/15 in the morning. Also, she stated in the interview that she did not call the physician and report to him that there were no diabetic finger test strips in the building on 8/3/15, 9:00 PM or 8/4/15, 6:30 PM, to test the resident's blood sugars as ordered by the physician. Interviews with the Interim Administrator and Interim Director of Nursing and both Unit Supervisors for Haven 1 and Haven 2 on 8/18/15, at 5:45 PM, confirmed the findings.",2018-05-01